1. The Partogram
Dr. C. Savona-Ventura
MD, DScMed, FRCOG, Accr.Cert.OG,
MRCP
The Partogram
• A graphic representation of the progress of
labour
– Cervicograph
– Descent of Head [cf moulding]
– Uterine contractions
– Features that assist progress
[membranes/augmentation/drugs]
– Maternal condition [heart rate, BP, urinalysis]
– Fetal condition [heart rate, liquor]
1

2. Phases in progress of Labour
• LATENT PHASE:-
» Nullipara Multipara
» 8.6-20.6 hrs 5.3-13.6 hrs
• ACTIVE PHASE:-
– Acceleration Phase ] 4.9-11.7 hrs 2.2-5.2 hrs
– Phase of Maximum Slope ]
– Deceleration Phase 54 min-3.3 hrs 14 -53 min
• SECOND STAGE 57 min-2.5 hrs 18 -50 min
• THIRD STAGE up to 20 min
Labour progress - cervical
dilatation
10
2nd Stage
8
1st Stage of Labour
6
LATENT 1 cm/hr
4
PHASE ACTIVE
2
PHASE
0
0 5 10 15 20
2

3. Latent Phase
• Poor rate of cervical dilatation but general preparation of
cervix.
• Duration: Nullipara Multipara
» 8.6-20.6 hrs 5.3-13.6 hrs
• Assessed using Bishop Score 0 1 2 3
– Cervical dilatation 0 1-2 3-4 5-6+
– Cervical effacement [%] 0-40 40-60 60-80 80+
[cm] 3 2 1 0
– Cervical position Post Mid Ant
– Cervical consistency Firm Mod Soft
– Station re ischial spine [cm] -3 -2 -1,0 +1,+2
• The use of the partogram during the latent phase not of use
since this would chart only cervical dilatation. We should use a
cervicograph.
Prolonged Latent Phase
• Definition
– >20 hrs [nullipara]; >14 hrs [multipara]
• Aetiology
– Excessive sedation
– Unfavourable Cervix
– Idiopathic [forced induction]
– False Labour
• Outcome
– 14% will go into a Protracted Active Phase
3

4. Prolonged Latent Phase
• Management DIAGNOSIS
EVALUATE CAUSE
THERAPEUTIC REST
No Change
Membranes ruptured Membranes Intact
Progress to Active Phase
Augmentation False Labour
Active Phase
• Good rate of cervical dilatation; cervix fully effaced.
• Rate: Nullipara Multipara Lower limit of Normal
» ~3.0 cm/hr ~5.7 cm/hr ~1.0 cm/hr
• The use of the partogram during the active phase is
essential for good intrapartum management
• Draw ALERT & ACTION LINES at onset of active
phase
– At 2-3 cm dilatation with patient getting strong and regular
contractions. Slope at 1cm/hr; lines four hours apart
4

5. Partogram - cervical dilatation
10
9
CERVICAL DILATATION
8
7
6
5
4
3
2
1 ALERT LINE
0
TIME ACTION LINE
Uterine contractions
• Aim at:- strong & regular contractions
• ASSESS DURATION OF CONTRACTION
– mild moderate strong
– <20 sec 20-40 sec >40 sec
• ASSESS FREQUENCY OF CONTRATIONS
– Number of contractions in last 10 min of each ½ hr.
– increased frequency from 1:10 to 5:10 minutes
5

6. Descent of head in fifths per
abdomen
• Engagement at 2/5 and less
• If 3/5 or more than CPD [absolute or
relative] is present
Vaginal assessment in
relation to ischial spines not
useful to define engagement
since position of spines
dependant on type of pelvis.
Prolonged Active Phase
• Definition
– >6 hrs or >1.2 cm/hr [nullipara]; >5.2 hrs or >1.5 cm/hr [multipara]
• Aetiology
– CephaloPelvic Disproportion [often relative]
– Fetal head malposition: OP/OT
– Idiopathic [early ARM]
– Excessive sedation
• Outcome
– 39% Po & 13% P1+ will go into Secondary Arrest
6

7. Prolonged Active Phase
10
9
CERVICAL DILATATION
8
7
6
5
4
3
2 ALERT LINE
1 NORM AL
0
DYSFUNCTIONAL
TIME ACTION LINE
Prolonged Active Phase
• Management DIAGNOSIS
EVALUATE CAUSE
HYPOTONIA HYPERTONIA
Augment Augmented? CPD
Normal Progress Reduce Dose LSCS
Vaginal Delivery 2o Arrest
7

8. Secondary Arrest of Active
Phase
• Definition
– No change in cervical dilatation over a period of 2hrs+. Cervix becomes
oedematous. Can occur at 4-7 cm dilatation or as a protracted Deceleration
phase
• Aetiology
– CephaloPelvic Disproportion [often absolute]
– Fetal head malposition [OP/OT] or Malpresentation [breech]
– Insufficient uterine action
– Excessive sedation
• Outcome
– Will require LSCS. If protracted deceleration beware of shoulder
impaction
Partogram - cervical dilatation
10
9
CERVICAL DILATATION
8
7
6
5
4
3
2 ALERT LINE
1 NORM AL
0 2 ARREST
PROTRACTED
TIME ACTION LINE
8

9. Secondary Arrest of Active
Phase
• Management DIAGNOSIS
EVALUATE CAUSE
No CPD
head 2/5-
CPD
head 3/5+ Assess Uterine Activity
Optimal Sub-Optimal
head 2/5
Augment
LSCS
No Response Good Response
Vaginal Delivery
9