This manual is designed to teach the use of the partograph in the management of labour. It does not
set out to teach the principles and physiology of labour.
The principles behind the partograph, particularly the partograph described in this series with its pre-
drawn alert and action lines, are described in Principles and Strategy (WHO document
WHO/FHE/MSM/93.8). It is assumed that a tutor working with this User's Manual for teaching
purposes will have acquired a working knowledge of these principles and can pass this information on
to the trainees as appropriate. Consequently this manual concentrates on the practical aspects of
using the partograph as a managerial tool in labour and not on theoretical aspects.
INTRODUCTION FOR USERS
This manual describes the use of the partograph as a tool to help in the management of labour. A
partograph is used to record all observations made on a woman in labour. Its central feature is a
graph, where dilatation of the cervix as assessed by vaginal examination is plotted. By noting the rate
at which the cervix dilates, it is possible to identify women whose labours are abnormal y slow and
who require special attention. These women are at risk of developing prolonged and obstructed labour
due to cephalopelvic disproportion (CPD), which may lead to serious problems, such as ruptured
uterus and death of the fetus. Other problems that may result from slow progress in labour include
postpartum haemorrhage and infection.
By helping to identify at an early stage those women whose labour is slow, the partograph should
prevent some of these problems. It is also a very clear way of recording al labour observations on one
chart, making it easy to detect any other abnormalities.
WHO SHOULD NOT HAVE A PARTOGRAPH IN LABOUR
Before describing how to use the partograph, it is important to realise that it is a tool for managing
labour only. It does not help to identify other risk factors which may have been present before labour
Only start a partograph when you have checked that there are no complications of the pregnancy that
require immediate action
OBJECTIVES OF THIS MANUAL
After studying this training manual, the physician and midwifery personnel should be able to:
" Understand the concept of the partograph.
• Record the observations accurately on the partograph.
• Understand the difference between the latent and the active phases of labour.
• Interpret a recorded partograph and recognize any deviation from the norm.
• Monitor the progress of labour, recognize the need for action at the appropriate time, and
decide on timely referral.
• Explain to mothers and other members of the community the significance of the partograph.
OBSERVATIONS CHARTED ON THE PARTOGRAPH (Figure II.1)
Observations and recordings will be explained in the following sequence:
The progress of labour
• Cervical dilatation
• Descent of the fetal head
Abdominal palpation of fifths of head felt above the pelvic brim
• Uterine contractions
Frequency per 10 minutes
Duration (shown by differential shading)
The fetal condition
• Fetal heart rate
• Membranes and liquor
• Moulding of the fetal skul
The maternal condition
• Pulse, blood pressure and temperature
• Urine (volume, protein, acetone)
• Drugs and IV fluids
• Oxytocin regime
5.1 The Progress of Labour
Latent and active phases of labour
The first stage of labour is divided into the latent and active phases.
Starting the Partograph
A partograph chart must only be started when a woman is in labour. You must be sore that she is
contracting enough to start a partograph.
In the latent phase
Contractions must be 2 or more in 10 minutes each lasting 20 seconds or more.
In the active phase
Contractions must be 1 or more in 10 minutes, each lasting 20 seconds or more.
The rate of cervical dilation changes from the latent to the active phase of labour.
• The latent phase (slow period of cervical dilatation) is from 0-2 cm with a gradual shortening of
• The active phase (faster period of cervical dilatation) is from 3 cm to 10 cm (ful cervical
In the centre of the partograph is a graph. Along the left side are numbers 0-10 against squares: each
square represents 1 cm dilatation. Along the bottom of the graph are numbers 0-24: each square
represents 1 hour.
Dilatation of the cervix is measured in centimetres (cm) and a diagram of a useful learning aid is found
in Annex 1.
The dilatation of the cervix is plotted (recorded) with an "X". The first vaginal examination, on
admission, includes a pelvic assessment and the findings are recorded. Thereafter, vaginal
examinations are made every 4 hours, unless contraindicated. However, in advanced labour, women
may be assessed more frequently, particularly the multipara.
Example: Plotting cervical dilatation when admission is in the active phase
Look at Fig. II.2. In the section label ed active phase there is an "alert" line, a straight line from 3-10
cm. When a woman is admitted in the active phase, the dilatation of the cervix is plotted on the alert
line and the clock rime written directly under the X in the space for time.
If progress is satisfactory, the plotting of cervical dilatation wil remain on or to the left of the alert line.
Observations on Fig. II.2
• Dilatation of the cervix was 4 cm: active phase.
• Dilatation is plotted on the alert line at 4 cm.
• The time of admission was 15:00.
• At 17:00 dilatation was 10 cm.
• Time in the first stage of labour in hospital was only 2 hours.
Example: Plotting cervical dilatation when admission is in the latent phase
Look at Fig. II.3. The latent phase normal y should not take longer than 8 hours. When admission is in
the latent phase, dilatation of the cervix is plotted at 0 time and vaginal examination made every 4
Observations on Fig. II.3
• Admission was at 9:00 and the cervix was 1 cm dilated.\
• At 13:00 the cervix was 2 cm dilated.
• At 17:00 the cervix was 3 cm dilated when she entered the active phase of labour.
• At 20:00 the cervix was 10 cm (ful y dilated).
• Latent phase lasted 8 hours and active phase lasted 3 hours.
Example: (Transfer from latent to active phase): Plotting cervical dilatation when admission is
in the latent phase and goes into active phase in less than 8 hours.
When dilatation is 0-2 cm, plotting must be in the latent phase area of the cervicograph. When labour
goes into the active phase, plotting must be transferred by a broken line to the alert line. The
recordings of cervical dilatation and time are plotted 4 hours after admission, then transferred
immediately to the alert line using the letters "TR", leaving the area between the transferred recording
blank. The broken transfer line is not part of the process of labour.
Observations on Fig. II.4
• Admission time was 14:00 and the dilatation was 2 cm.
• At 18:00 the dilatation was 6 cm - active phase.
• Time and dilatation were immediately transferred to the alert line.
• At 22:00 the cervix was 10 cm.
• She had a total of 3 vaginal examinations.
• The length of the first stage of labour in hospital was 8 hours.
Points to Remember
1. The latent phase is from 0-2 cm dilatation and is accompanied by gradual shortening of the
cervix. It should normal y not last longer than 8 hours.
2. The active phase is from 3-10 cm and dilatation should be at the rate of at least 1 cm/hour.
3. When labour progresses well, the dilatation should not move to the right of the alert time.
4. When admission to hospital takes place in the active phase, the admission dilatation is
immediately plotted on the alert line.
5. When labour goes from latent to active phase, plotting of the dilatation is immediately
transferred from the latent phase area to the alert line.
escent of the fetal head
For labour to progress well, dilatation of the cervix should be accompanied by descent of the head.
However, descent may not take place until the cervix has reached about 7 cm dilatation.
Descent of the head is measured by abdominal palpation and expressed in terms of fifths above the
pelvic brim (see Fig. II.5). It is found to be a more reliable way of gauging descent than vaginal
examination where large caput formation often leads the inexperienced to confuse scalp descent with
*sinciput; O = Occiput
Source: Philpott RH & Castle WM (1)
Descent of the head should always be assessed by abdominal examination immediately before doing
a vaginal examination.
For convenience, the width of the 5 fingers is a guide to the expression in fifths of the head above the
brim. A head that is mobile above the brim will accommodate the full width of 5 fingers (closed) (Figs.
II.6 and II. 6A).
As the head descends, the portion of the head remaining above the brim will be represented by fewer
fingers (4/5, 3/5, etc.)
It is generally accepted that the head is engaged when the portion above the brim is represented by 2
fingers width or less (Figs. II.7 and II. 7A).
Fig. II.6 Head is mobile above the brim = 5/5
Fig. II. 6A Head accommodates full width of 5 fingers
above the brim
Fig. II.7 Head is engaged = 2/5
Fig. II. 7A Head accommodates 2 fingers above the brim
Example: Plotting descent of the fetal head
Look at Fig. II.8. On the left-hand side of the graph is the word "descent" with lines going from 5-0.
Descent is plotted with an "O" on the partograph (Fig. II.8).
Observations on Fig. II.8
• On admission at 13:00, the head was 5/5 above the pelvic brim and the cervix was 1 cm
• After 4 hours at 17:00, the head was 4/5 above the brim and the cervix was 5 cm dilated.
• Labour is now in the active phase. Cervical dilatation, is transferred to the alert line; descent of
head and time are transferred to the vertical line downwards from 6 cm.
• After 3 hours, the head was only 1/5 above the pelvic brim and the cervix was 10 cm dilated.
• The length of the first stage of labour observed in the unit was 7 hours.
Points to Remember
1. Assessing descent of the head assists in detecting progress in labour.
2. Descent is assessed abdominal y in fifths felt above the pelvic brim.
3. Immediately before a vaginal examination, an abdominal examination must always be done.
For labour to progress well, there must be good uterine contractions. In normal labour they usual y
become more frequent and last longer as labour progresses.
Observing uterine contractions
Observations on the contractions are made every hour in the latent phase of labour and every half-
hour in the active phase.
There are two observations made of the contractions:
1. The frequency: How often are they felt?
2. The duration: How long do they last?