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.
Competent partogram use has two halves: demonstrate use and consider reasons/controversies. The first is to actually drive the tool — plot a cervix, recognise when a line is crossed, and act. The second is to 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 — driven by the very reasons the WHO abandoned the fixed 1 cm/hour alert line. 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. The partogram was therefore 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. They fall into natural groups, which is how the chart is filled:
- 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.