Among the five major causes of maternal mortality in developing countries like Ethiopia (hypertension, haemorrhage, infection, obstructed labour and unsafe abortion), the middle three (haemorrhage, infection, obstructed labour) are highly correlated with prolonged labour. To be specific, postpartum haemorrhage and postpartum sepsis (infection) are very common when the labour gets prolonged beyond 18–24 hours. Obstructed labour is the direct outcome of abnormally prolonged labour; you will learn about this in detail in Study Session 9 of this Module. To avoid such complications, a chart called a partograph will help you to identify the abnormal progress of a labour that is prolonged and which may be obstructed. It will also alert you to signs of fetal distress.
In this study session, you will learn about the principles of using the partograph, the interpretation of what it tells you about the labour you are supervising, and what actions you should take when the recordings you make on the partograph deviate from the normal range. When the labour is progressing well, the record on the partograph reassures you and the mother that she and her baby are in good health.
When you have studied this session, you should be able to:
4.1 Define and use correctly all of the key terms printed in bold. (SAQs 4.1 and 4.3)
4.2 Describe the significance and the applications of the partograph in labour progress monitoring. (SAQs 4.1 and 4.2)
4.3 Describe the components of a partograph and state the correct time intervals for recording your observations and measurements. (SAQs 4.1 and 4.3)
4.4 Describe the indicators in a partograph that show good progress of labour, and signs of fetal and maternal wellbeing. (SAQ 4.3)
4.5 Identify the indicators in a partograph for immediate referral to a hospital during the labour. (SAQ 4.3)
The partograph is a graphical presentation of the progress of labour, and of fetal and maternal condition during labour. It is the best tool to help you detect whether labour is progressing normally or abnormally, and to warn you as soon as possible if there are signs of fetal distress or if the mother’s vital signs deviate from the normal range. Research studies have shown that maternal and fetal complications due to prolonged labour were less common when the progress of labour was monitored by the birth attendant using a partograph. For this reason, you should always use a partograph while attending a woman in labour, either at her home or in the Health Post.
In the study sessions in this Module, you have learned (or will learn) the major reasons why you need to monitor a labouring mother so carefully. Remember that a labour that is progressing well requires your help less than a labour that is progressing abnormally. Documenting your findings on the partograph during the labour enables you to know quickly if something is going wrong, and whether you should refer the mother to the nearest health centre or hospital for further evaluation and intervention.
The partograph is actually your record chart for the labouring mother (Figure 4.1). It has an identification section at the top where you write the name and age of the mother, her ‘gravida’ and ‘para’ status, her Health Post or hospital registration number, the date and time when you first attended her for the delivery, and the time the fetal membranes ruptured (her ‘waters broke’).
What is the difference between a woman who is a multigravida and one who is a multipara?
A multigravida is a woman who has been pregnant at least once before the current pregnancy. A multipara is a woman who has previously given birth to live babies at least twice before now.
On the back of the partograph (if you are not using another chart), you can also record some significant facts, such as the woman’s past obstetric history, past and present medical history, any findings from a physical examination and any interventions you initiate (including medications, delivery notes and referral).
The graph sections of the partograph are where you record key features of the fetus or the mother in different areas of the chart. We will describe each feature, starting from the top of Figure 4.1 and travelling down the partograph.
You learned about giving IV (intravenous) fluid therapy to women who are haemorrhaging in Study Session 22 of the Antenatal Care Module.
What can you tell from the colour of the amniotic fluid?
If it has fresh bright red blood in it, this is a warning sign that the mother may be haemorrhaging internally; if it has dark green meconium (the baby’s first stool) in it, this is a sign of fetal distress.
In the section for cervical dilatation and fetal head descent, there are two diagonal lines labelled Alert and Action. The Alert line starts at 4 cm of cervical dilatation and it travels diagonally upwards to the point of expected full dilatation (10 cm) at the rate of 1 cm per hour. The Action line is parallel to the Alert line, and 4 hours to the right of the Alert line. These two lines are designed to warn you to take action quickly if the labour is not progressing normally.
You should refer the woman to a health centre or hospital if the marks recording cervical dilatation cross over the Alert line, i.e. indicating that cervical dilation is proceeding too slowly. (The Action line is for making decisions at health-facility level.)
As you learned in Study Session 1 of this Module, a normally progressing labour is characterised by at least 1 cm per hour cervical dilatation, once the labour has entered the active first stage of labour.
Another important point is that (unless you detect any maternal or fetal problems), every 30 minutes you will be counting fetal heart beats for one full minute, and uterine contractions for 10 minutes.
You should do a digital vaginal examination initially to assess:
Thereafter, in every 4 hours you should check the change in:
You should record each of your findings on the partograph at the stated time intervals as labour, progresses. The graphs you plot will show you whether everything is going well or one or more of the measurements is a cause for concern. When you record the findings on the partograph, make sure that:
If you have to refer the mother to a higher level health facility, you should send the partograph with your referral note and record your interpretation of the partograph in the note.
Without looking back over the previous sections, quickly write down the partograph measurements that you must make in order to monitor the progress of labour.
Compare your list with the partograph in Figure 4.1. If you are at all uncertain about any of the measurements, then re-read Sections 4.2 and 4.3.
As you learned in Study Session 1 of this Module, the first stage of labour is divided into the latent and the active phases. The latent phase at the onset of labour lasts until cervical dilatation is 4 cm and is accompanied by effacement of the cervix (as shown in Figure 1.1 previously). The latent phase may last up to 8 hours, although it is usually completed more quickly than this. Although regular assessments of maternal and fetal wellbeing and a record of all findings should be made, these are not plotted on the partograph until labour enters the active phase.
Vaginal examinations are carried out approximately every 4 hours from this point until the baby is born. The active phase of the first stage of labour starts when the cervix is 4 cm dilated and it is completed at full dilatation, i.e. 10 cm. Progress in cervical dilatation during the active phase is at least 1 cm per hour (often quicker in multigravida mothers).
In the cervical dilatation section of the partograph, down the left side, are the numbers 0–10. Each number/square represents 1 cm dilatation. Along the bottom of this section are 24 squares, each representing 1 hour. The dilatation of the cervix is estimated by vaginal examination and recorded on the partograph with an X mark every 4 hours. Cervical dilatation in multipara women may need to be checked more frequently than every 4 hours in advanced labour, because their progress is likely to be faster than that of women who are giving birth for the first time.
In the example in Figure 4.2, what change in cervical dilatation has been recorded over what time period?
The cervical dilatation was about 5 cm at 1 hour after the monitoring of this labour began; after another four hours, the mother’s cervix was fully dilated at 10 cm.
If progress of labour is satisfactory, the recording of cervical dilatation will remain on, or to the left, of the alert line.
If the membranes have ruptured and the woman has no contractions, do not perform a digital vaginal examination, as it does not help to establish the diagnosis and there is a risk of introducing infection. (PROM, premature rupture of membranes, was the subject of Study Session 17 of the Antenatal Care Module.)
For labour to progress well, dilatation of the cervix should be accompanied by descent of the fetal head, which is plotted on the same section of the partograph, but using O as the symbol. But before you can do that, you must learn to estimate the progress of fetal descent by measuring the station of the fetal head, as shown in Figure 4.3. The station can only be determined by examination of the woman’s vagina with your gloved fingers, and by reference to the position of the presenting part of the fetal skull relative to the ischial spines in the mother’s pelvic brim.
As you can see from Figure 4.3, when the fetal head is at the same level as the ischial spines, this is called station 0. If the head is higher up the birth canal than the ischial spines, the station is given a negative number. At station –4 or –3 the fetal head is still ‘floating’ and not yet engaged; at station –2 or –1 it is descending closer to the ischial spines.
If the fetal head is lower down the birth canal than the ischial spines, the station is given a positive number. At station +1 and even more at station +2, you will be able to see the presenting part of baby’s head bulging forward during labour contractions. At station +3 the baby’s head is crowning, i.e. visible at the vaginal opening even between contractions. The cervix should be fully dilated at this point.
Now that you have learned about the different stations of fetal descent, there is a complication about recording these positions on the partograph. In the section of the partograph where cervical dilatation and descent of head are recorded, the scale to the left has the values from 0 to 10. By tradition, the values 0 to 5 are used to record the level of fetal descent. Table 4.1 shows you how to convert the station of the fetal head (as shown in Figure 4.3) to the corresponding mark you place on the partograph by writing O. (Remember, you mark fetal descent with Os and cervical dilatation with Xs, so the two are not confused.)
When the baby’s head starts crowning (station +3), you may not have time to record the O mark on the partograph!
Station of fetal head (Figure 4.3)
|Corresponding mark on the partograph|
|–4 or –3||5|
|–2 or –1||4|
What does crowning mean and what does it tell you?
Crowning means that the presenting part of the baby’s head remains visible between contractions; this indicates that the cervix is fully dilated.
The five separate bones of the fetal skull are joined together by sutures, which are quite flexible during the birth, and there are also two larger soft areas called fontanels (Figure 4.4). Movement in the sutures and fontanels allows the skull bones to overlap each other to some extent as the head is forced down the birth canal by the contractions of the uterus. The extent of overlapping of fetal skull bones is called moulding, and it can produce a pointed or flattened shape to the baby’s head when it is born (Figure 4.5).
Some baby’s skulls have a swelling called a caput in the area that was pressed against the cervix during labour and delivery (Figure 4.6); this is common even in a labour that is progressing normally. Whenever you detect moulding or caput formation in the fetal skull as the baby is moving down the birth canal, you have to be more careful in evaluating the mother for possible disproportion between her pelvic opening and the size of the baby’s head. Make sure that the pelvic opening is large enough for the baby to pass through. A small pelvis is common in women who were malnourished as children, and is a frequent cause of prolonged and obstructed labour.
A swelling on one side of the newborn’s head is a danger sign and should be referred urgently; blood or other fluid may be building up in the baby’s skull.
To identify moulding, first palpate the suture lines on the fetal head (look back at Figure 1.4 in the first study session of this Module) and appreciate whether the following conditions apply. The skull bones that are most likely to overlap are the parietal bones, which are joined by the sagittal suture, and have the anterior and posterior fontanels to the front and back.
You need to refer the mother urgently to a health facility if you identify signs of an obstructed labour. You will learn more about this in Study Session 9.
When you document the degree of moulding on the partograph, use a scale from 0 (no moulding) to +3, and write them in the row of boxes provided:
0 Bones are separated and the sutures can be felt easily.
+1 Bones are just touching each other.
+2 Bones are overlapping but can be separated easily with pressure by your finger.
+3 Bones are overlapping but cannot be separated easily with pressure by your finger.
In the partograph, there is no specific space to document caput formation. However, caput detection should be part of your assessment during each vaginal examination. Like moulding, you grade the degree of caput as 0, +1, +2 or +3. Because of its subjective nature, grading the caput as +1 or +3 simply indicates a ‘small’ and a ‘large’ caput respectively. You can document the degree of caput either on the back of the partograph, or on the mother’s health record (if you have it).
Imagine that you are assessing the degree of moulding of a fetal skull. What finding would make you refer the woman in labour most urgently, and why?
If you found +3 moulding and the labour was progressing poorly, it may mean there is uterine obstruction.
You already know that good uterine contractions are necessary for good progress of labour (Study Session 2). Normally, contractions become more frequent and last longer as labour progresses. Contractions are recorded every 30 minutes on the partograph in their own section, which is below the hour/time rows. At the left hand side is written ‘Contractions per 10 mins’ and the scale is numbered from 1–5. Each square represents one contraction, so that if two contractions are felt in 10 minutes, you should shade two squares.
On each shaded square, you will also indicate the duration of each contraction by using the symbols shown in Figure 4.7.
How do you know that the fetus is in good health during labour and delivery? The methods open to you are limited, but you can assess fetal condition:
The normal fetal heart rate at term (37 weeks and more) is in the range of 120–160 beats/minute. If the fetal heart rate counted at any time in labour is either below 120 beats/minute or above 160 beats/minute, it is a warning for you to count it more frequently until it has stabilised within the normal range. It is common for the fetal heart rate to be a bit out of the normal range for a short while and then return to normal. However, fetal distress during labour and delivery can be expressed as:
There are many factors that can affect fetal wellbeing during labour and delivery. You learned in the Antenatal Care Module (Study Session 5) that the fetus is dependent on good functioning of the placenta and good supply of nutrients and oxygen from the maternal blood circulation. Whenever there is inadequacy in maternal supply or placental function, the fetus will be at risk of asphyxia, which is going to be manifested by the fetal heart beat deviating from the normal range. Other factors that will affect fetal wellbeing, which may be indicated by abnormal fetal heart rate, are shown in Box 4.1.
You learned about hypertensive disorders of pregnancy, maternal anaemia and placental abruption in Study Sessions 18, 19 and 21 of the Antenatal Care Module, Part 2.
Placental blood flow to the fetus is compromised, which commonly occurs when there is:
With that background in mind, counting the fetal heart beat every 30 minutes and recording it on the partograph, may help you to detect the first sign of any deviation for the normal range. Once you detect any fetal heart rate abnormality, you shouldn’t wait for another 30 minutes; count it as frequently as possible and arrange referral quickly if persists for more than 10 minutes.
The fetal heart rate is recorded at the top of the partograph every half hour in the first stage of labour (if every count is within the normal range), and every 5 minutes in the second stage. Count the fetal heart rate:
Each square for the fetal heart on the partograph represents 30 minutes. When the fetal heart rate is in the normal range and the amniotic fluid is clear or only lightly blood-stained, you can record the results on the partograph, as in the example in Figure 4.8. When you count the fetal heart rate at less than 30 minute intervals, use the back of the partograph to record each measurement. Prepare a column for the time and fetal heart rate.
Another indicator of fetal distress which has already been mentioned is meconium-stained amniotic fluid (greenish or blackish liquor). Lightly stained amniotic fluid may not necessarily indicate fetal distress, unless it is accompanied by persistent fetal heart rate deviations outside the normal range. The following observations are made at each vaginal examination and recorded on the partograph, immediately below the fetal heart rate recordings.
If the fetal membranes are intact, write the letter ‘I’ (for ‘intact’).
If the membranes are ruptured and:
Refer the woman in labour to a higher health facility as early as possible if you see:
During labour and delivery, after your thorough initial evaluation, maternal wellbeing is followed by measuring the mother’s vital signs: blood pressure, pulse, temperature, and urine output. Blood pressure is measured every four hours. Pulse is recorded every 30 minutes. Temperature is recorded every 2 hours. Urine output is recorded every time urine is passed. If you identify persistent deviations from the normal range of any of these measurements, refer the mother to a higher health facility.
In Study Session 4, you have learned that:
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.
Read Case Study 4.1 and then answer the questions that follow it.
Bekelech is a gravida 5, para 4 mother, whose current pregnancy has reached the gestational age of 40 weeks and 4 days. When you arrive at her house, she is already in labour. During your first assessment, she had four contractions in 10 minutes, each lasting 35–40 seconds. On vaginal examination, the fetal head was at –3 station and Bekelech’s cervix was dilated to 5 cm. The fetal heart rate at the first count was 144 beats/min.
Give two reasons for using a partograph.
Two key reasons for using a partograph are because: