The Partograph & the WHO Labour Care Guide

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

The Partograph & the WHO Labour Care Guide — Monitoring Labour Progress

A partograph is a graphical record that plots the progress of labour — cervical dilatation and fetal descent — alongside contractions and maternal/fetal vital signs, all against time. Its purpose is simple: to turn "labour is taking a while" into an objective, visual signal that prompts action before labour becomes obstructed, not after. In 2020, WHO replaced the classic Alert/Action-line partograph described below with a new tool, the Labour Care Guide (LCG) — covered in its own section further down, alongside what's actually changed.

Know which tool your unit is using. The panels below on the Alert Line and Action Line describe the classic WHO partograph (in use since the 1990s, and still the correct tool wherever a facility hasn't yet transitioned). Further down, a dedicated section covers the WHO Labour Care Guide — the tool WHO now recommends globally, most recently detailed in its 2025 Labour Care Guide: Implementation Resource Package. The clinical goal is identical; the mechanics differ in real ways.

🎯 THE CLASSIC PARTOGRAPH — WHEN TO START PLOTTING

Plotting begins in the active phase of labour — cervix ≥4 cm dilated, with regular, painful contractions

Starting the plot too early, during the latent phase, creates a false impression of slow progress and can prompt unnecessary intervention

GREEN: the dilatation plot sits on or to the left of the Alert Line — labour is progressing normally

AMBER: the plot has crossed the Alert Line — increase surveillance, and consider referral if at a lower-resource facility

RED: the plot has crossed the Action Line — active reassessment and intervention are needed now

📋 WHAT GETS RECORDED, AND HOW OFTEN

Fetal heart rateEvery 30 minutes

Contractions (frequency & duration)Every 30 minutes

Maternal pulseEvery 30 minutes

Cervical dilatationEach vaginal exam (~4-hourly)

Per Abdminal Exam. Descent of the headEach vaginal exam

Liquor & mouldingEach vaginal exam

Blood pressure & temperatureEvery 4 hours

Urine (protein/acetone/volume)At each void

Moulding is graded 0 to +++ ; +++ (overlapping, not reducible) is a real warning sign of disproportion — don't record it as a routine box-tick.

📈 THE ALERT LINE & ACTION LINE

The Alert Line starts at 4 cm and rises at 1 cm per hour — the expected minimum rate of progress in active labour

The Action Line runs parallel, 4 hours to the right of the Alert Line

Alert Line (1 cm/hr)

Action Line (+4 hrs)

Actual dilatation plot

In this example, the plot falls behind early and drifts into the amber zone between the two lines — exactly the window meant for closer watching and reassessment, before anything crosses into the red action zone.

On/Left of Alert Line

Normal progress

Continue routine observation

Crossed Alert, Before Action

Caution zone — increase monitoring

Consider referral if resources are limited here

Crossed the Action Line

Active intervention required

Full reassessment before augmenting

Plateau (No Change ≥2 hrs)

Secondary arrest — reassess urgently

Applies regardless of alert/action line position

🚨 REASSESS URGENTLY — DON'T JUST KEEP PLOTTING

The plot has crossed the Action Line

No cervical change for 2+ hours despite adequate contractions

Moulding +++ or increasing caput — signs of possible disproportion

Any fetal heart rate abnormality (see our FHR Monitoring guide)

Descent not progressing despite apparently full dilatation

🛠️ WHEN THE ACTION LINE IS CROSSED

1

Full reassessment — contractions, fetal condition, and signs of obstruction (moulding, caput, descent)

2

Rule out cephalopelvic disproportion or malposition before augmenting

3

If contractions are inadequate and no disproportion — consider amniotomy (if membranes intact) and cautious oxytocin augmentation

4

If disproportion is suspected, or progress fails to improve — plan for operative delivery

5

Continuous fetal monitoring throughout; involve a senior obstetrician and document clearly

🆕 THE WHO LABOUR CARE GUIDE (LCG) — WHAT'S DIFFERENT

Launched by WHO in 2020 to replace the classic partograph, following WHO's 2018 update to its intrapartum care recommendations; a full Implementation Resource Package followed in 2025 to support the rollout

Active labour is now defined from 5 cm, not 4 cm — this alone shifts when monitoring formally begins

The fixed 1 cm/hour Alert Line and parallel Action Line are gone. In their place: evidence-based time limits at each centimetre of dilatation, based on the slower end of normal labours — progress is checked against a per-centimetre threshold, not a single diagonal line

An "Alert" column runs through every section of the chart — any parameter outside the expected range is flagged, and the provider must record what they actually did about it, not just that it was noted

Monitoring now explicitly continues into the second stage of labour, which the classic partograph didn't formally cover

Contraction strength/intensity is no longer recorded — it proved too subjective to standardize; frequency and duration remain

New sections for supportive care (companionship, hydration, mobility, pain relief) and shared decision-making — the LCG treats the birth experience, not just the labour curve, as something to actively monitor

The LCG has seven sections: admission details, supportive care, care of the baby, care of the woman, labour progress, medication, and shared decision-making — considerably broader in scope than the dilatation-and-descent focus of the classic chart.

⚖️ CLASSIC PARTOGRAPH vs THE LCG, SIDE BY SIDE

Classic Partograph

Active labour from 4 cm

Fixed 1 cm/hr Alert Line + Action Line

Focus: first-stage dilatation & descent

Contraction frequency, duration, and intensity

WHO Labour Care Guide

Active labour from 5 cm

Per-centimetre evidence-based time limits

Focus: first stage, second stage, mother, baby, and experience

Contraction frequency and duration only

Which one should your unit use? WHO's own guidance is pragmatic: use the LCG once staff are trained and the necessary charting and support systems are in place — but keep using the classic partograph, accurately and consistently, rather than abandon structured monitoring altogether while that transition is being planned. An imperfect tool used properly beats a better tool used badly or not at all.

🌍 WHY THIS MATTERS — WHICHEVER TOOL YOU USE

Catches prolonged and obstructed labour before it progresses unnoticed — directly reducing the risk of uterine rupture, obstetric fistula, postpartum haemorrhage, and stillbirth

Low-cost and low-tech — genuinely valuable anywhere continuous electronic monitoring isn't available

Standardizes handover — any clinician picking up the chart can see the whole labour trajectory at a glance, not just the current moment

🧠 COMMON PITFALLS IN PRACTICE — EITHER TOOL

Charting retrospectively: filling it in at the end of labour defeats its entire purpose as an early-warning tool

Infrequent or inaccurate vaginal exams degrade the reliability of the whole plot

A line is crossed, but nothing happens: the same "trigger without response" failure seen in early warning systems generally — a documented action line means nothing without action

Not using it at all in a busy unit — the tool only works when it's actually kept up, for every labouring woman

The Core Rule

1 cm Per Hour

4h

GAP BETWEEN
ALERT & ACTION LINES

In the classic partograph, the Alert Line assumes at least 1 cm of cervical dilatation per hour is normal progress in active labour. Falling behind that rate doesn't automatically mean intervention — it means watch more closely and reassess the whole picture. The LCG expresses this same idea differently (a time limit per centimetre), but the underlying discipline is identical.

The 4-hour gap between the Alert and Action Lines is deliberate — it gives time to correct reversible causes (inadequate contractions, dehydration, positioning) before committing to intervention

Either tool is only as good as how honestly and promptly it's filled in — real-time charting is the whole point

Every member of the team should be able to look at the chart and understand exactly where labour stands, at a glance

Reminder: whichever tool your unit uses, its entire value lies in turning a vague sense that "labour is taking a while" into an objective, visual, shared decision point — and then actually acting on it.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary for structured teaching and triage. LCG content reflects WHO's 2020 Labour Care Guide and its 2025 "Labour Care Guide: Implementation Resource Package"; exact chart formats, thresholds, and rollout status vary by country and institution — follow local protocol and confirm which tool your facility has adopted.