How do you plot a partogram?

How to Plot a Partogram

A partogram should be plotted by obtaining serial observations of cervical dilatation and determining the rate of progress in cm/h, with documentation of fetal heart rate, maternal vital signs, and other key labor parameters to identify normal versus abnormal labor patterns. 1

Components of a Partogram

The partogram consists of three main sections:

1. Patient Information and Initial Assessment

   • General maternal data (name, age, parity, etc.)
   • Fetal position and presentation
   • Results of initial assessments (amnioscopy, cardiotocography)
   • Risk status assessment

2. Labor Progress Documentation

   • Cervical dilatation plotted against time
   • Fetal descent/station
   • Status of membranes and amniotic fluid
   • Uterine contractions (frequency, duration, strength)
   • Fetal heart rate monitoring
   • Maternal vital signs (BP, pulse, temperature)
   • Medications administered (especially oxytocin)

3. Delivery Information

   • Mode of delivery
   • Time of delivery
   • Newborn vital signs and Apgar scores

How to Plot Cervical Dilatation

1. Mark the time of admission or start of active labor on the x-axis
2. Plot cervical dilatation (in cm) on the y-axis
3. Record dilatation measurements with a "X" at each vaginal examination
4. Connect the points to visualize the labor curve
5. Compare progress against alert and action lines:
   • Alert line represents the slowest 10% of primigravid women's labor progress
   • Action line is placed 2-4 hours after the alert line to prompt intervention for slow progress 2

Normal Progress Parameters

• Nulliparous women: Cervical dilatation should progress at ≥1.2 cm/h
• Multiparous women: Cervical dilatation should progress at ≥1.5 cm/h 1

Abnormal Progress Identification

• Protracted active phase:
  • Nulliparas: <1.2 cm/h for >2-3 hours
  • Multiparas: <1.5 cm/h for >1 hour 1
• Arrest of active phase: No cervical change for 2 hours

Fetal Monitoring Documentation

Plot fetal heart rate (FHR) every:

• 15-30 minutes during active phase of first stage
• Every 5 minutes during second stage with pushing 1

Document FHR before and after:

• Admission
• Membrane rupture
• Vaginal examinations
• Administration of medications/analgesia
• Abnormal uterine activity 1

Uterine Contractions Documentation

• Record frequency, duration, and intensity
• Note if contractions are normal (≤5 contractions in 10 minutes) or tachysystole (>5 contractions in 10 minutes) 1
• Document resting tone between contractions

Interventions Based on Partogram Findings

When abnormalities are identified:

1. Change maternal position
2. Assess maternal vital signs
3. Discontinue oxytocin if in use
4. Consider oxygen administration
5. Perform vaginal examination
6. Administer IV fluids
7. Consider amnioinfusion for variable decelerations
8. Assess need for expedited delivery if abnormalities persist 1

Common Pitfalls and How to Avoid Them

1. Incorrect identification of labor phase

   • Remember that active phase can begin at various cervical dilatations, not just at 6 cm
   • Look for change in rate of dilatation from latent phase 1

2. Inadequate documentation frequency

   • Ensure regular cervical assessments during active labor
   • Document all interventions on the partogram

3. Failure to recognize patterns

   • Compare progress against established norms for nulliparous vs multiparous women
   • Identify deviations early to allow timely intervention

4. Over-reliance on partogram alone

   • Use partogram as a tool alongside clinical judgment
   • Consider maternal and fetal wellbeing indicators beyond just cervical dilatation

5. Inconsistent plotting technique

   • Ensure all staff use standardized approach to partogram completion
   • Compliance with partogram completion varies (65-84%) and requires training 3

While the Cochrane review found insufficient evidence to recommend routine partogram use 2, it remains a valuable visual tool for labor monitoring that helps identify abnormal labor patterns and guide appropriate interventions to improve maternal and fetal outcomes.