Clinical overview
The partogram is a single sheet of paper that converts the long, variable, frightening process of labour into a graphical record you can read across a room. It plots the progress of labour against time, overlaying maternal and fetal observations on the same page, so that a midwife at 3 a.m. in a district labour ward, a registrar called to review, and a consultant on the phone are all looking at the same picture and reaching the same decision. In South Africa it is mandatory documentation for every woman in established labour at every level of care, and the National Integrated Maternal and Perinatal Care Guidelines for South Africa (NDoH, 2024) (the "Maternity Guideline") prescribes its use as a core element of safe intrapartum monitoring and of the referral chain between district, regional and tertiary facilities.
This objective is weighted HOTS and the verb is deliberately double-barrelled: demonstrate use and consider reasons/controversies. So you are not being asked to recite a list of partogram columns. You are being asked to (1) actually drive the tool — plot a cervix, recognise when a line is crossed, and act — and (2) hold an honest, evidence-aware position on whether the partogram, and especially its action and alert lines, does what it was designed to do. That second half matters because the international evidence base is genuinely contested, and the WHO Labour Care Guide (2020) has, for many settings, replaced the classic partograph altogether. A registrar who can plot a partogram but cannot say why the WHO abandoned the fixed 1 cm/hour alert line will lose marks. Read this chapter alongside normal-labour, complicated-labour, ctg-interpretation and fetal-monitoring-methods — the partogram is the spine onto which all intrapartum monitoring hangs.
Core knowledge
What the partogram is and where it came from
The partogram (partograph) is a pre-printed chart for the graphical recording of labour. Its conceptual ancestry is Friedman's cervicographic work of the 1950s, which described the sigmoid cervical dilatation curve and the concept of latent and active phases. Philpott and Castle, working in what was then Rhodesia (now Zimbabwe) in the early 1970s, added the practical innovation that made the partogram a frontline tool in Africa: the alert line and, parallel and to its right, the action line. Their purpose was explicitly for under-resourced settings — to let a midwife in a peripheral unit identify slow progress early and transfer the woman to a facility with caesarean capability before obstructed labour, ruptured uterus or fistula occurred. This origin story is worth carrying into the exam: the partogram was designed to drive timely referral, not primarily to drive augmentation.
The WHO adopted and modified the partograph through the 1990s. The widely-taught "modified WHO partograph" begins plotting at the active phase (historically taken as 4 cm), with an alert line drawn at a rate of 1 cm/hour and an action line 4 hours to the right of the alert line. In 2020 the WHO published the WHO Labour Care Guide (2020), a fundamentally redesigned tool that abandons the single fixed alert line in favour of individualised reference thresholds and prompts — discussed under controversies below.
Anatomy of the chart — what each part records
A complete partogram records, on one time axis, several streams of observation. Learn them as groups because that is how you fill the chart and how examiners test it:
- Patient identifiers and labour landmarks — name, parity, time of admission, time of membrane rupture, and the agreed time of onset of established/active labour (the reference point for the graph).
- Fetal condition — fetal heart rate (plotted/recorded at intervals), the colour of the liquor (recorded as intact membranes, clear, meconium grades, or blood), and moulding of the fetal skull (graded 0/none, 1 = sutures apposed, 2 = sutures overlapping but reducible, 3 = overlapping and not reducible). Caput may also be noted.
- Progress of labour — cervical dilatation (cm, the central plot, against the alert and action lines), descent of the head (assessed abdominally in fifths palpable above the pelvic brim, the recommended SA method, and plotted on the same vertical scale), and uterine contractions (number per 10 minutes and duration, conventionally shaded by intensity: dots for <20 s, diagonal hatching for 20–40 s, solid for >40 s).
- Maternal condition — pulse, blood pressure, temperature, urine output and urinalysis (volume, protein, ketones/acetone), and drugs/IV fluids given.
- Oxytocin — concentration and dose (drops or mU/min) titrated against contractions, recorded over time.
The deliberate design point is co-location: a deteriorating fetal heart, meconium, increasing moulding, and a cervix crossing the action line are all on the same page at the same time-point, so the gestalt of obstructed labour or fetal compromise is hard to miss.
The alert and action lines — and the 4 cm problem
In the classic modified WHO partograph the alert line is a straight diagonal representing cervical dilatation at 1 cm/hour from the active-phase start. Crossing to the right of the alert line means progress is slower than this reference rate and is a signal to heighten surveillance and (in a peripheral unit) to arrange transfer. The action line, 4 hours further right, is the threshold at which active intervention is conventionally mandated — reassess fully, consider amniotomy/augmentation if appropriate, and escalate toward operative delivery if obstruction is present.
The "active phase begins at 4 cm" assumption that underpins the classic alert line has not survived contemporary labour-progress research. Zhang's large contemporary cohorts and the WHO's own evidence review showed that (a) the latent-to-active transition is commonly nearer 5–6 cm than 4 cm, (b) cervical dilatation in the active phase is frequently much slower than 1 cm/hour in normally progressing nulliparae without any adverse outcome, and (c) labour curves are not the smooth sigmoid Friedman drew but are highly variable. The practical consequence is that a rigid 1 cm/hour line over-diagnoses "delay", and acting on it risks unnecessary oxytocin and caesarean — the central controversy this objective wants you to engage with.
Figure I14.1 — The partogram as a single dashboard: plotting cervical dilatation and descent against the alert and action lines, with the fetal and maternal observations recorded alongside.
Assessment
Using the partogram in real time — the demonstration the examiners want
To "demonstrate use" you must be able to talk an examiner through filling and reading the chart on a real case. The workflow:
- Decide the woman is in established/active labour and start the partogram from that reference time. Do not plot the latent phase on the active-phase graph — premature plotting is the single commonest error and manufactures false "delay".
- Perform and plot the baseline assessment — a full abdominal and vaginal examination: cervical dilatation, effacement, station/fifths palpable, presentation and position, membranes/liquor, moulding and caput, and the contraction pattern. Record fetal heart, maternal vitals and urinalysis.
- Set the observation frequency. Standard teaching and the SA Maternity Guideline structure: fetal heart at least every 15–30 minutes in the active first stage (and after each contraction in the second stage), contractions half-hourly, vaginal examination and cervical plot approximately 4-hourly unless a concern prompts earlier review, maternal pulse half-hourly to hourly, blood pressure and temperature regularly (more often in hypertension or prolonged labour or ruptured membranes). Treat these intervals as standard teaching consistent with the guideline rather than memorising a single number — examiners accept a sensible, justified schedule.
- Plot consistently — cervix as a single character (often X), descent as O, on the shared scale; shade contractions by duration; mark interventions (amniotomy, oxytocin start, analgesia) on the time axis.
- Read the trend, not the point. Ask three questions every time you look: Is the fetus well (heart rate pattern, liquor, moulding trend)? Is progress adequate (cervix and descent versus the line)? Is the mother well (vitals, hydration, bladder, pain)? Crossing the alert line is a prompt to think and to ensure escalation capacity is in place; reaching the action line is a prompt to act and decide.
Reading the lines correctly
A cervix tracking on or left of the alert line is progressing at or faster than the reference rate — reassure and continue. Crossing into the alert-to-action zone is the "think and prepare" zone: in a clinic or midwife obstetric unit (MOU) this is the trigger to arrange referral to a facility with caesarean capability before the action line is reached, because transport in South Africa can itself consume hours. Reaching the action line demands a full reassessment for the cause of delay using the classic framework of the three Ps — Power (inadequate contractions), Passenger (malposition, malpresentation, big baby, moulding) and Passage (cephalopelvic disproportion, obstructed labour). The combination that should make you reach for theatre rather than oxytocin is arrest of descent + increasing moulding (grade 2–3) + a cervix across the action line: that is obstructed labour until proven otherwise.
The WHO Labour Care Guide approach to assessment
Where the WHO Labour Care Guide (2020) is in use, assessment is reframed away from a single pass/fail line. The LCG presents, for each centimetre of dilatation, a column with a reference threshold (the slowest acceptable progress) and embeds explicit "alert" cells that prompt review when an observation is abnormal, plus structured first- and second-stage time limits. It also foregrounds supportive-care reminders (companionship, mobility, oral intake, pain relief). Functionally it asks the same three questions — fetus, progress, mother — but replaces the rigid 1 cm/hour rule with dilatation-specific thresholds that tolerate the slower-but-normal early active phase.
Management
Acting on the partogram
The partogram does not treat anyone; it tells you when and what to assess so that you can act. Management flows from the cause of any abnormality the chart reveals.
- Slow progress with inadequate contractions (Power), intact membranes, no malposition/CPD and a reassuring fetus — consider amniotomy and then oxytocin augmentation, titrated against contractions and fetal heart, per the SA Maternity Guideline protocol. Re-examine to confirm progress within a defined interval; persistent failure to progress despite adequate contractions changes the working diagnosis toward disproportion.
- Malposition (Passenger) — occipito-posterior/transverse positions are a common reason a cervix drifts toward the action line; many resolve with time, adequate contractions and maternal position changes. This is precisely the scenario where a rigid alert line over-calls "delay".
- Obstructed labour / suspected CPD (Passage) — arrest of descent, a non-advancing cervix, increasing moulding, a Bandl's ring, haematuria or maternal distress — stop or withhold oxytocin and deliver by caesarean section. Do not augment a possibly obstructed labour.
- Fetal compromise on the chart — a rising or falling fetal heart, new significant meconium, or an abnormal CTG triggers the ctg-interpretation and fetal-monitoring-methods pathways; intrauterine resuscitation and expedited delivery follow as indicated.
The peripheral-unit referral drill (make this unmistakable)
The partogram earns its keep in district and MOU settings as a referral trigger. The drill, aligned to the SA levels-of-care system:
Cervix crosses the ALERT line in a clinic/MOU without caesarean capability →
- Call for senior help and notify the receiving facility immediately — do not wait for the action line; SA inter-facility transfer can take hours.
- Arrange emergency transfer with the appropriate ambulance priority; send the partogram and notes with the woman.
- In transit, optimise: position left-lateral, IV access and fluids, continue monitoring fetal heart and maternal vitals, and withhold oxytocin during transfer.
- At the receiving regional/tertiary unit: immediate reassessment for obstructed labour and caesarean section if confirmed. Delay here is the audited mechanism behind ruptured uterus, intrapartum fetal death and obstetric fistula.
This sequence — alert line in a unit without theatre means start moving the woman now — is the single most examinable SA application of the partogram, because it maps directly onto the avoidable-death and avoidable-fistula findings of the Saving Mothers (NCCEMD) reports. Obstetric haemorrhage and the consequences of prolonged obstructed labour remain leading, largely avoidable contributors to SA maternal morbidity and mortality, and audited cases repeatedly cite absent or poorly-used partograms and late referral.
Figure I14.2 — "Alert line = move early": the peripheral-unit referral drill, the 3-P assessment of the cause, and the arrest-of-descent-plus-moulding rule for obstructed labour.
Red flags / pitfalls
- Plotting the latent phase on the active-phase graph. This manufactures false delay and drives unnecessary oxytocin and caesarean. Only start the active-phase plot once you have decided the woman is in established active labour.
- Treating the alert/action line as a diagnosis rather than a prompt. Crossing a line means assess and think, not automatically augment or section. The cause (the three Ps) determines the action.
- Augmenting a possibly obstructed labour. Oxytocin given when moulding is increasing and descent has arrested risks uterine rupture — a catastrophic, audited SA event. When in doubt, examine for obstruction and escalate, do not push contractions.
- Missing the slow-but-normal nullipara. Contemporary labour curves show many normal women dilate well under 1 cm/hour; over-reading the classic alert line is a recognised driver of avoidable caesarean. This is the controversy made clinical.
- The chart is filled but not read. A complete partogram with no acted-upon trend is a documentation exercise, not safe care. The legal and audit value of the partogram is also a trap: a blank or back-filled partogram is a serious medico-legal liability.
- Forgetting the bladder, hydration and position. A full bladder, dehydration and supine positioning all slow progress and are reversible — check these before labelling "delay".
- Not sending the partogram with a transferred woman. The receiving unit loses the entire labour trend; continuity is the whole point of the chart.
- Using the wrong tool for the wrong setting. Know whether your institution uses the classic modified WHO partograph or the WHO Labour Care Guide — the thresholds and prompts differ, and the SA Maternity Guideline (NDoH, 2024) is the local arbiter of which to follow.
Evidence anchors
- National Integrated Maternal and Perinatal Care Guidelines for South Africa (NDoH, 2024) (NDoH; Knowledge Hub release 23 October 2024) — the SA source of truth for intrapartum monitoring, partogram use, observation frequency and the district→regional→tertiary referral chain.
- Saving Mothers / NCCEMD (triennial) — audited SA maternal-death reports that repeatedly identify poor partogram use and late referral among avoidable factors in deaths from obstructed labour and its sequelae; cite the latest triennium.
- WHO Labour Care Guide (2020) — the redesigned intrapartum tool that, for many contexts, supersedes the classic partograph; replaces the fixed 1 cm/hour alert line with dilatation-specific reference thresholds and structured prompts.
- NICE NG235 — Intrapartum care (2023) — care of healthy women and babies in labour, including the assessment of progress in the first and second stages.
- NICE NG229 — Fetal monitoring in labour (2022) — continual risk assessment and the fetal-condition observations that sit alongside the progress plot.
Standard, non-guideline-bound facts stated here as classical teaching (hedged in text): the Friedman cervical curve and latent/active phases; the Philpott–Castle alert/action-line origin in 1970s Rhodesia; the modified WHO partograph geometry (active phase historically from 4 cm, alert line 1 cm/hour, action line 4 hours to the right); moulding/contraction grading conventions; and Zhang-type contemporary evidence that the active phase often begins nearer 5–6 cm and progresses slower than 1 cm/hour. These are textbook canon, not line-itemed in VERIFIED-SOURCES — see notes.