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The WHO Partograph & Labor Care Guide (LCG):

Dr. Weqar Akram
Objectives:
 What is the partograph?
 The components of the partograph.
 What is the LCG?
 The similarities & differences between the partograph & LCG.

It is a graphical presentation of the progress of labor, and fetal and maternal condition during
labor. It is the best tool to help us to detect whether labor is progressing normally or
abnormally, and to warn us as soon as possible if there are signs of fetal distress or if the
mother’s vital signs deviates from the normal range. This record allows:
‫تقييم بصري فوري لتوسع عنق‬
Cervix  An instant visual assessment of cervical dilatation compared with an expected norm , ‫الرحم مقارنة باملعيار املتوقع‬
according to the parity of the woman, so that slow progress can be recognized early
and appropriate actions taken to correct it where possible.
Uterus  The frequency and strength of contractions.
Head descent  The descent of the head in fifth palpable and station.
Amniotic uid  The amount and color of the amniotic fluid draining.
‫حالة االم‬  Basic observations maternal wellbeing such as blood pressure, heart rate and
temperature.
 It had been shown that maternal and fetal complications due to prolonged labor were less
common when the progress of labor was monitored by the birth attendant using partograph.
For this reason, partograph should be used while attending a woman in labor, either at her
home or in the health post.

 The graph sections of the partograph:

The sections of the partograph are where you record the features of the fetus or the
mother in different areas of the chart and these sections are:

 The partograph has an identification section at the top where we write:

 The name and age of the mother.
 Her”gravida” and “para” status.
 The date and time when you first attended her for the delivery.
 The time the fetal membranes ruptured (her water broke).

 Immediately below the patients ID details, the fetal heart would be recorded initially
and then every 30 minutes. The scale for fetal heart rate covers the range from 80 to
200 beats -/minute.
 Below the FHR, there are two rows close together, the first of these is labeled liquor_
which is the medical term for the amniotic fluid, if the fetal membranes have ruptured,
the color of the fluid should be recorded initially and every 4 hours.
 The row below “liquor” Is labeled Moulding; this is the extent to which the bones of the
fetal skull are overlapping each other as the baby’s head is forced down the birth canal.
It should be assessed initially and every 4 hours.
 Below “moulding”, there is an area of partograph labelled cervix (cm) (Plot X) for
recording cervical dilatation, i.e. the diameter of the mother’s cervix in centimeters.
 In this area of the partograph, Descent of the head (Plot 0) is also recorded, which is
how far down the birth canal the baby’s head has progressed. These measurements are
recorded as either X or O, initially and every 4 hours.
 The next section is for recording contractions/10 minutes initially and every 30 minutes.
 Below that are two rows for recording administration of oxytocin during labor and the
amount given.
 The next area is labelled drugs and IV fluids given to the mother.
  Near the bottom of the partograph is where you record the mothers vital signs; Pulse,
BP, and Temp.
 At the very bottom recording of the mother’s urine characteristics: protein, acetone,
volume.
 The alert and action lines: in the section of cervical dilatation and fetal head descent,
there are two diagonal lines labelled Alert & 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 /hr. 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 us to take
action quickly if the labor is not progressing normally.

 Recording and interpreting the progress of labor:

A normal progress of labor is characterized by at least 1cm/hour cervical dilatation, once the
labor has entered the active first stage of labor.

An important point is that (unless maternal or fetal problems is detected), FH beats should be
counted every 30 minutes for one full minute, and uterine contractions for 10 minutes.
A digital vaginal examination should be done initially to assess:

 The extent of cervical effacement and dilatation.

 The fetal presenting part.
 The status of fetal membranes (intact or ruptured) and amniotic fluid.
 The relative size of maternal pelvis to check if the brim is wide enough for the baby to
pass through.
Thereafter, in every 4 hours assessment of the following points should be done:
 Cervical dilatation.
 Development of cervical edema (an initially thin cervix may become thicker if the
woman starts to push too early, or if the labor is too prolonged with minimal
change in cervical dilatation).
 Position if can be identified.
  Fetal head descent.
 Development of moulding and caput.
 Amniotic fluid color(if FM have already ruptured)
One partograph form should be used per each laboring mother and recording should be started
when the labor is in active first stage (cervical dilatation of 4cm and above).
The records should be clearly visible so that anybody who knows about the partograph can
understand and interpret the marks have be made. And if the laboring mother needs to be
referred to a higher level health facility, the partograph should be sent with her.

 Cervical dilatation: —-> digital vaginal examination

In the cervical dilation section of the partograph, down the left side, are the numbers 0-10.
Each number/square represent 1cm dilatation. Along the bottom of this section are 24 squares,
each representing 1 hour. The cervical dilatation 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 4 hours in advanced labor, because their
progress is likely to be faster than that in primigravida.

If progress of labor is satisfactory, the recording of cervical dilatation will remain on, or to the
left of the alert line.
If the membranes have been ruptured and the woman has no contractions, digital examination
should not be performed, as there is a risk of introducing infection.

Cervical dilatation (marked by X) and fetal head descent (marked by O)

 Fetal head descent:

For labor to progress well, cervical dilatation should be accompanied by descent of fetal head,
which is plotted on the same section of the partograph, but using O as the symbol. Estimation
of the progress of fetal head descent is by measuring the station of the fetal head. The station
can be determined by vaginal examination 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.
 Assessing the station of the fetal head in
relation to ischial spine

When the fetal head is at the same level of the ischial spine, this is called station 0. If the head
is higher up the birth canal than ischial spine, 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 -1it 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, it is able to see the presenting part
of the baby’s head bulging forward during labor contractions. At station +3 the baby’s head is
😂
crowning, i.e. visible at vaginal opening even between contractions. The cervix should be fully
dilated at this point.
In the section of partograph where cervical dilatation and descent of head are recorded, the
scale to the left has the values from 0 to 10. The values from 0 to 5 are used to record to level
of fetal descent.
This table shows corresponding positions of the fetal head station (determined by vaginal
examination) and the record of fetal descent on the partograph:

Station of fetal head Corresponding mark on partograph

-4 or -3 5
-2or -1 4
0 3
+1 2
+2 1
+3 0

 Assessing moulding and caput formation:

 Sutures and fontanels of newborn’s skull

The five separate bones of fetal skull are joined together by sutures, which are quite flexible
during the birth, and there are two large soft areas called fontanels. Movement in the sutures
and fontanels allow the skull bones to overlap each other’s to some extent as the head is forced
down the birth canal by the contractions of the uterus. The extent of the 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.

Normal variations in moulding of the newborn skull, which usually disappears

within 1-2 days after birth

Some baby’s skull have a swelling called a caput in the area that it was presented against the
cervix during labor. This is common even in a labor that is progressing normally. Whenever a
moulding or caput formation is detected, a careful maternal evaluation for a possible
cephalopelvic disproportion. A small pelvis is common in malnourished and is a frequent cause
of prolonged and obstructed labor.
A swelling on one side of the newborns 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 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.

 Suture opposed: this is when adjacent bones are touching each other, but are not
overlapping. This is called degree 1 moulding (+1).
 Sutures overlapped but reducible: this is when skull bone is overlapping another, but
when it is gently pushed, the overlapped bone goes back easily. This is called degree 2
moulding (+2).
 Sutures overlapped and reducible: this is when skull bone is overlapping another, but
when try to push the overlapped bone, it does not go back. This is called degree 3
moulding (+3). If +3 moulding is found with poor progress of labor, this may indicate
that the labor is at increased risk of becoming obstructed.
When we 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 finger.

+3 Bones are overlapping but cannot be separated easily with pressure by finger.
In the partograph, there is no specific space to document caput formation, however it should
be a part of assessment during each vaginal examination. Because it is subjective nature,
grading the caput as +1 or +3 simply indicates a “small” and a “large” caput respectively. The
degree of caput formation can be recorded at the back of partograph or on the mother’s health
record.

 Uterine contractions:
Good uterine contractions are necessary for good progress of labor. Normally contractions
become more frequent and last longer as labor progress. Contractions are recorded every 30
minutes on partograph on their own section. At the left hand side is written “contractions per
10min” and the scale is numbered from 1-5. Each square represent 1 contraction, so that if
2contractions are felt per 10 min, 2 squares should be shaded
On each shaded square, duration of each contraction is also indicated by using the symbols
shown below:

Tatitanic contraction

Different shading on
the squares you draw on the partograph indicate the strength and duration of
contractions.

 Assessment and recording of fetal wellbeing:

Fetal wellbeing can be assessed by the following:
 Counting FH beat every 30 minutes.
 Checking the color of amniotic fluid if the membranes are ruptured.
  The normal FHR at term is between 120-160 beats/minute. If FHR is either below
120beats/min or above 160 beats/min, it is a warning to count more frequently until
it has stabilized within the normal range.it is common for the FH to be a bit out of
the normal range for a short wwhile and then return to normal. However, fetal
distress during labor and delivery can be expressed as:
😂  FHB persistently (for 10 minutes or more) remains below 120 beats/minute (doctors call
this persistent fetal bradycardia)
 FHB persistently (for 10 minutes or more) remains above 160 beats/minute (doctors
call this persistent fetal tachycardia)
The fetus is dependent on good functioning 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
FHB deviating from the normal range. Counting of FHB every 30 minutes and recording it on
partograph, may help to detect the first sign of deviation for the normal range. Once detecting
any FH abnormality, should not be wait for another 30 minutes, count it as frequently as
possible and arrange referral quickly if persist for more than 10 minutes.
In normal progress of labor, FHR should be recorded every 30 minutes in the first stage of labor
and every 5 minutes in the second stage.

Below; is an example of FHR recorded on the partograph at 30 minutes interval

 Another indicator for fetal distress is meconium stained amniotic fluid (green or
blackish liquor). Lightly stained AF does not necessarily indicate fetal distress, unless
it is accompanied by persistent FH deviations outside the normal range. The
following observations are made at each VE and recorded on the partograph,
immediately below the FHR recording.
If fetal membranes are intact, write the letter “I”.
If membranes are ruptured and:
 Liquor is absent, write ‘A’ (for absent)
 Liquor is clear, write ‘C’ (for clear).
 Liquor is blood-stained, write ‘B’.
  Liquor is meconium-stained, write ‘M1’ for lightly stained, ‘M2’ for a little bit thick and
‘M3’ for very thick liquor.

 Assessment of maternal wellbeing:

Maternal evaluation is followed by measuring maternal vital signs: BP, pulse, temperature, and
urine output. BP is measured every 4 hours, pulse is recorded every 30 minutes. Temperature is
recorded every 2 hours & urine output is recorded every time urine is passed. If there is any
deviation from the normal range of any pf these measurements, refer the mother to a higher
health facility.

Since 2018, WHO began work on a “next generation” partograph, the WHO Labor Care Guide
(LCG). It has been made to reduce needless interventional use and over- and under- diagnosis
of problematic labor episodes, assist with audits and rising the standard of labor care. The old
WHO partogram failed to demonstrate any meaningful clinical effect. It is crucial that the LCG
can accommodate maternity care and professional’s needs and that is contains the proper
criteria for labor monitoring. The LCG was designed to care mothers and their newborns
throughout labor.