The Partogram

A partogram is used to monitor the progress of labour once the labour is established.
The onset of labour is defined as regular, painful uterine contractions resulting in progressive cervical
effacement and dilatation.
A. Maternal Vital Signs

Maternal Temperature
The maternal temperature should be monitored every 4 hours during labour. If the mother is pyrexic,
underlying infection should be suspected. Possible infections include chorioamnionitis, group B
streptococcus infection and urinary tract infection. Perform a full blood count (white blood count), CRP,
urine dipstick and blood culture to identify the source of the infection.

Chorioamnionitis is suspected when the maternal temperature is >38C and two of the following signs are
present :

WBC count >15,000 cells/mm3

Maternal tachycardia >100 beats per minute
Fetal tachycardia >160 beats per minute
Tender uterus
Foul smelling discharge

Maternal Respiratory Rate

The maternal respiratory rate could increase if the mother is pyrexic.

Maternal Blood Pressure

The maternal blood pressure should be monitored every 4 hours during labour, especially in those who
have pre-eclampsia. It is important to record the blood pressure after the delivery of the placenta as
excessive blood loss could lead to hypotension.

Maternal Pulse
The maternal pulse should be monitored every hour. Maternal pyrexia can cause an increase in both
maternal pulse rate and fetal heart rate.

B. Fetal Heart Rate

The fetal heart rate should be assessed every 15 minutes using either a Pinard stethoscope or Doppler
transducer. If non-reassuring or abnormal fetal heart rate (<100bpm or >180bpm) is recorded, the
suspicion of fetal distress should be raised and prompt actions should be taken to assess the fetal
condition.

Management of non-reassuring or abnormal fetal heart rate:

Start CTG monitoring

Oxygen - improved fetal oxygenation.
Maternal position - left lateral position reduces aortocaval compression, this increases cardiac output
and uterine blood flow.
 Intravenous fluid administration - increases blood volume and placental perfusion.
Oxytocin should be discontinued until the fetal heart rate and uterine activity return to acceptable
levels.
Fetal blood sampling should be considered when pathological features are shown on the continuous
electronic fetal monitoring. Urgent birth is often required when the fetal blood pH >7.20.

Pregnant women are encouraged to mobilise and adopt the most comfortable positions during labour.
Positions such as semi-recumbent, kneeling, or left lateral position tends to increase the dimensions of
pelvic outlet. They should not lie flat on their back because this will result in aortocaval compression
where the gravid uterus compresses the main blood vessels and reduces the cardiac output, leading to
maternal hypotension and fetal distress.

C. Urine / Liquor State

Urine:

Presence of protein in the urine could suggest pre-eclampsia or contamination by the liquor fluid.
Presence of glucose in the urine could suggest underlying diabetes mellitus during pregnancy.
Presence of ketones in the urine could suggest maternal starvation where the body cannot get
enough glucose to produce energy and body fats are utilised instead. This will lead to metabolic
acidosis which reduces the contractibility of the uterus, thus prolonging the labour.
Presence of blood in the urine could suggest urinary tract infection or obstructed labour.

Liquor State

Intact
Clear - indicates the membranes have ruptured
Meconium - might indicate fetal distress; advise continuous electronic fetal monitoring and fetal blood
sampling
Blood - might indicate placental abruption

The time of rupture of membranes is usually recorded on the partogram because the longer the time, the
higher the risk of ascending infection.

D. Indicators of Labour Progress

Fifths of palpable fetal head per abdomen

The mother's abdomen is palpated every 4 hours to assess the level of the fetal head. It is often used to
determine the likelihood of a fetus to be born vaginally by instrumental delivery, or by Caesarean section,
when there is slow progress in labour.

Position
 Position is the orientation of the fetal head in the maternal pelvis. It is assessed transvaginally by locating
the position of anterior fontanelle, sagittal suture and posterior fontanelle. Occipito-posterior position is
associated with difficult labour.

Moulding
Moulding is the overlapping of skull bones when the fetal head passes through the birth canal. It is normal
to have some degree of moulding during labour but excessive moulding might indicate cephalo-pelvic
disproportion and Caesarean section is then required.
Degree of moulding

1. The bones are separated normally

2. The bones are touching each other
3. The bones are overlapping but can be easily separated with digital pressure
4. The bones are overlapping and cannot be separated by digital pressure (sign of cephalo-pelvic
disproportion)

Caput
Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head caused by the
pressure during labour when the fetal head is forced down onto dilating cervix. The presence of caput
usually indicates prolonged length of labour.

Cervical Dilatation
The diameter of the internal os of the cervix is measured in centimetres by vaginal examination from 0cm
to 10cm, with 10cm corresponding to complete cervical dilatation. In the active phase of the first stage of
labour, cervical dilatation is usually at the rate of 1cm/hour in primigravida and 2cm/hour in multigravida.
Delay is suspected when the progress of cervical dilatation is less than 2cm in 4 hours.

Consider amniotomy if membranes intact.

Advise vaginal examination 2 hours later.
If the progress is less than 1cm, consider oxytocin for primigravida. In multigravida, abdominal
palpation and vaginal examination should be performed to determine the presentation and station
before starting the oxytocin to reduce the risk of uterine rupture.
Advise continuous electronic fetal monitoring once oxytocin is started.
Repeat the vaginal examination in 4 hours after oxytocin infusion and consider Caesarean section if
the progress is less than 2cm.

Station
The level of head descent can be assessed by transvaginal examination. It is crudely measured in
relation to the level of ischial spines. Station 0 means the head is at the level of ischial spines; station
+1cm means it is 1cm below and station -1cm means it is 1cm above the ischial spine level.

Contraction
The contraction of the uterus should be assessed every 30 minutes during labour. 3-5 regular, strong
contractions in 10 minutes are usually aimed for the second stage of labour.
E. Oxytocin Use

Syntocinon is a synthetic form of oxytocin indicated for the induction and augmentation of labour.
It should not be given as a large bolus because it can cause a marked transient fall in maternal blood
pressure.
It should be given as a dilute solution by continuous intravenous infusion or as an intramuscular
injection.
It is also given after the delivery of baby to reduce postpartum haemorrhage.
Oxytocin infusion should be discontinued when fetal distress or hyperstimulation of the uterus is
suspected.

F. Drug Dosage

Any analgesia given during labour should be recorded.

For example:

Inhaled Entonox
Intramuscular diamorphine
Intramuscular pethidine
Epidural analgesia

G. Fluid Balance

All intravenous fluid eg, normal saline, Hartmann's solution, that is administered should be recorded.
It is important to make sure the mother is not dehydrated during labour.
Check the frequency of bladder emptying, as a full bladder will often prevent the fetal head from
entering the pelvic brim, causing slow progress in labour.
Patients who are on epidural analgesia are particularly prone to urinary retention due to reduced
bladder sensation, and therefore catheterisation might be required.

H. Factors Determining Slow Progress In Labour

Power

3-5 regular, strong uterine contractions per 10 minutes, each lasting for one minute, are considered
satisfactory for labour.
Uterine activity can be assessed by manual palpation of the uterus per abdomen or using the
cardiotocography (detects the frequency but not the intensity of contraction).

Passenger

Ideally, the fetus should be in the longitudinal lie, cephalic presentation and occipito-anterior position
for vaginal delivery.
Large fetal size (macrosomia >4500g), malpresentation (breech, brow, face, or shoulder), abnormal
lie (transverse, oblique) and multiple pregnancies could result in slow progress in labour.
 Fetal size, presentation, lie and multiple pregnancies can be assessed by abdominal palpation and
ultrasound scans.

Passage

Gynaecoid pelvic type is the ideal pelvic shape for vaginal delivery. Android and platypelloid are the
less favourable pelvic types. Anthropoid pelvic type is often associated with delivery of fetus in the
occipito-posterior position.
Pelvic masses such as uterine fibroids and ovarian tumours could obstruct the birth canal, causing
slow progress in labour.
The likelihood of cephalo-pelvic disproportion could be assessed by trial of labour or clinical
pelvimetry where the parameters of pelvic inlet, midcavity and pelvic outlet are measured.

I. Lines drawn on the partogram

Alert line - It starts at the position where there is 3 or 4 cm of cervical dilation. It is then continued
diagonally at a rate of 1 cm per hour in primigravidae and 1.5 cm in multigravidae.
Action line - is parallel to the alert line, and is located 4 hours to the right of the alert line.
If the plot of cervical dilatation reaches the action line, indicating slow progress, then consideration
should be given to a number of different measures which aim to improve progress (ROM, mobility,
oxytocin).