Midwife Licensure Exam Independent Delivery & Emergency Obstetric Care — Partograph Use & Referral Decision-MakingConcept Map

Concept

What the Partograph Records

Sub Concepts

• Fetal Condition (FHR, amniotic fluid, moulding)
• Progress of Labor (cervical dilatation, descent, contractions)
• Maternal Condition (pulse, BP, temperature, urine)

Relationship To Central

Foundation—defines the three data families plotted on the chart

Concept

Recording Frequency & Timing

Sub Concepts

• FHR every 30 minutes in first stage
• Cervical dilatation every 4 hours by vaginal exam
• Contractions, maternal pulse, temperature, urine per protocol
• Active phase begins at 4 cm dilatation

Relationship To Central

Ensures accurate, timely plotting that keeps the picture trustworthy

Concept

Alert Line vs Action Line

Sub Concepts

• Alert line: 1 cm/hour expected progress from 4 cm
• Crossing alert line = warning → arrange referral
• Action line: 4 hours right of alert line
• Reaching action line = must be in CEmONC facility

Relationship To Central

The decision engine—defines when to refer (alert) and when action is mandatory (action)

Concept

Detecting Abnormal Labor Patterns

Sub Concepts

• Prolonged latent phase (>8 hours, no progress)
• Protraction (dilatation right of alert line)
• Arrest of dilatation (no change 2+ hours in active phase)
• Arrest of descent (head not descending despite good contractions)
• Excessive moulding (+++) with slow progress

Relationship To Central

Uses the partograph plot to identify prolonged, obstructed, or arrested labor early

Concept

Fetal and Maternal Danger Signs

Sub Concepts

• Abnormal FHR (<110 or >160 bpm)
• Meconium-stained (M) or blood-stained (B) liquor
• Rising maternal pulse, temperature
• Hypertension (≥140/90) with proteinuria
• Tonic/retracted uterus, Bandl's ring

Relationship To Central

Plotted on the partograph; trigger immediate detection and referral

Concept

When to Refer (Referral Triggers)

Sub Concepts

• Dilatation crosses alert line or reaches action line
• Fetal distress (abnormal FHR, meconium)
• Prolonged or obstructed labor, arrest of dilatation/descent
• Malpresentation or malposition
• Antepartum or intrapartum hemorrhage
• Pre-eclampsia, infection, ruptured membranes with no progress

Relationship To Central

Midwife's core responsibility—recognizes complications and activates referral system

Concept

Referral Essentials—the R Checklist

Sub Concepts

• Recognize the problem early (partograph + danger signs)
• Refer promptly (do not wait for crisis)
• Resuscitate/stabilize (IV, positioning, first-response care)
• Records (completed referral form + partograph)
• Ride/accompany (safe transport + skilled escort)
• Ring ahead (communicate with receiving facility)

Relationship To Central

Operationalizes the referral decision in the Philippines context (RHU → BEmONC → CEmONC)

Concept

Plotting Symbols & Codes

Sub Concepts

• X = cervical dilatation (0–10 cm)
• O = descent of fetal head (5/5 to 0/5 fifths)
• Contractions: stippling (weak), diagonal (moderate), solid (strong)
• Amniotic fluid: I, C, M, B, A
• Moulding: 0, +, ++, +++

Relationship To Central

Standardized visual language that makes the chart readable at a glance

Concept

Safe Midwifery Practice with the Partograph

Sub Concepts

• Start plotting in active phase (4 cm dilatation)
• Act at the alert line, not the action line (use the transfer zone)
• Never manage obstructed labor—detect and refer
• Timely referral prevents maternal/fetal death and severe morbidity
• Works within Philippine systems: BHS → RHU → CEmONC

Relationship To Central

Integrates partograph use into the broader BEmONC/community midwifery context

To

What the Partograph Records

From

Partograph as Decision Tool

Strength

strong

Relationship

The partograph contains three data families that are plotted simultaneously: fetal condition, labor progress, and maternal condition. These three streams of information together create the complete clinical picture.

To

Fetal Condition (FHR, amniotic fluid, moulding)

From

What the Partograph Records

Strength

strong

Relationship

FHR is plotted every 30 minutes (normal 110-160 bpm); amniotic fluid is recorded with a code (I, C, M, B, A); moulding is graded (0 to +++). These three observations detect fetal stress and obstruction.

To

Progress of Labor (cervical dilatation, descent, contractions)

From

What the Partograph Records

Strength

strong

Relationship

Cervical dilatation (X) and fetal descent (O) are plotted against time on the grid; contractions are shaded by strength and duration. These three track whether labor is progressing at the expected rate.

To

Maternal Condition (pulse, BP, temperature, urine)

From

What the Partograph Records

Strength

strong

Relationship

Maternal vital signs and urine findings are recorded at intervals. Rising pulse, fever, hypertension, or proteinuria are signs of infection, dehydration, obstruction, or pre-eclampsia—all complications requiring recognition and referral.

To

Alert Line vs Action Line

From

Progress of Labor (cervical dilatation, descent, contractions)

Strength

strong

Relationship

The alert line represents the expected slowest-normal rate of cervical dilatation (1 cm/hour from 4 cm). When the plotted dilatation crosses to the right of the alert line, it signals protraction. The action line (4 hours right of alert) marks the point where operative intervention is needed.

To

Detecting Abnormal Labor Patterns

From

Alert Line vs Action Line

Strength

strong

Relationship

The alert and action lines provide the visual mechanism for detecting protraction (dilatation right of alert line), arrest (no progress for 2+ hours), and obstruction (reaching action line). Without these lines, prolonged labor would be invisible until crisis.

To

When to Refer (Referral Triggers)

From

Detecting Abnormal Labor Patterns

Strength

strong

Relationship

Abnormal labor patterns (protraction, arrest, excessive moulding, poor descent) are the primary triggers for referral. Detection via partograph makes the decision objective and timely, before emergency develops.

To

When to Refer (Referral Triggers)

From

Fetal and Maternal Danger Signs

Strength

strong

Relationship

Danger signs (abnormal FHR, meconium, fever, hypertension) detected on the partograph are independent reasons to refer, even if cervical progress appears normal. These signs indicate fetal compromise or maternal complications.

To

Referral Essentials—the R Checklist

From

When to Refer (Referral Triggers)

Strength

strong

Relationship

Once a referral trigger is identified, the R-checklist provides the structured protocol: Recognize early, Refer promptly, Resuscitate/stabilize, Records complete, Ride safe, Ring ahead. This ensures safe, effective referral.

To

Philippine Context Applied

From

Referral Essentials—the R Checklist

Strength

strong

Relationship

The R-checklist is operationalized within the Philippine health system: BHS midwife refers to RHU, RHU refers to CEmONC. Safe referral follows the EINC/Unang Yakap model: normal birth at community, early detection and timely referral of complications.

To

What the Partograph Records

From

Recording Frequency & Timing

Strength

moderate

Relationship

Consistent, timely recording (FHR every 30 min, dilatation every 4 hours, contractions/vitals per protocol) keeps the partograph current and trustworthy. Poor recording obscures the picture.

To

Alert Line vs Action Line

From

Active Phase Definition

Strength

strong

Relationship

The alert line begins at 4 cm dilatation (the start of the active phase) with an expected progression of 1 cm/hour. The active phase is when partograph plotting and the alert/action line decision system apply.

To

What the Partograph Records

From

Plotting Symbols & Codes

Strength

moderate

Relationship

Standardized symbols (X for dilatation, O for descent, letters I/C/M/B/A for liquor, grades 0/+/++/+++ for moulding) make the chart readable at a glance and reduce errors in communication.

To

Alert Line vs Action Line

From

Safe Midwifery Practice with the Partograph

Strength

strong

Relationship

Safe practice means acting at the alert line (arranging early, safe referral) rather than waiting for the action line (urgent/crisis referral). The transfer zone between the two lines provides the safety buffer.

To

Detecting Abnormal Labor Patterns

From

Safe Midwifery Practice with the Partograph

Strength

strong

Relationship

The midwife's role is to recognize abnormal patterns early on the partograph and refer promptly. She does NOT manage obstructed labor; she detects it and refers it before emergency develops.

To

Transfer Zone

From

Alert Line vs Action Line

Strength

strong

Relationship

The 4-hour space between the alert and action lines is the transfer zone. It is the designed safety window: if the mother is recognized at the alert line and referred promptly, she will reach CEmONC while still stable enough to be transported safely.

To

Detecting Abnormal Labor Patterns

From

Prolonged Latent Phase (>8 hours, no progress)

Strength

moderate

Relationship

A latent phase that exceeds 8 hours without progression is a problem pattern. It indicates ineffective contractions or maternal exhaustion and may warrant referral for assessment and rest or augmentation.

To

Detecting Abnormal Labor Patterns

From

Excessive Moulding (+++) with slow progress

Strength

strong

Relationship

Excessive, non-reducible moulding combined with slow cervical progress or arrest is a sign of cephalopelvic disproportion and obstruction. It is a high-priority danger sign requiring urgent referral.

To

Fetal and Maternal Danger Signs

From

Abnormal FHR (<110 or >160 bpm)

Strength

strong

Relationship

Abnormal FHR is a sign of fetal distress. The midwife responds by repositioning the mother to the left, ensuring hydration, and referring for fetal monitoring and assessment at a CEmONC facility.

To

Fetal and Maternal Danger Signs

From

Meconium-stained (M) or blood-stained (B) liquor

Strength

strong

Relationship

Meconium or blood-stained amniotic fluid signals possible fetal compromise, especially if accompanied by abnormal FHR or poor descent. Combined with abnormal progress, it triggers referral.

To

Fetal and Maternal Danger Signs

From

Hypertension (≥140/90) with proteinuria

Strength

strong

Relationship

Elevated blood pressure combined with proteinuria indicates pre-eclampsia. If accompanied by headache, visual changes, or epigastric pain, it is a life-threatening emergency requiring urgent referral for assessment and management.

To

Referral Essentials—the R Checklist

From

Recognize the problem early (partograph + danger signs)

Strength

strong

Relationship

Recognition is the first step: using the partograph and knowing danger signs. The midwife must be able to read the chart and spot abnormal patterns before they become crises.

To

Referral Essentials—the R Checklist

From

Refer promptly (do not wait for crisis)

Strength

strong

Relationship

The second step is acting fast. Once a problem is recognized, referral should be initiated immediately. Waiting for the situation to deteriorate defeats the purpose of early detection.

To

Referral Essentials—the R Checklist

From

Resuscitate/stabilize (IV, positioning, first-response care)

Strength

strong

Relationship

Before or while arranging transfer, the midwife provides first-response emergency care: left lateral positioning, IV access and fluids, oxygen if needed, and drugs if within BHS/RHU scope (e.g., oxytocin, magnesium sulfate, antibiotics).

To

Referral Essentials—the R Checklist

From

Records (completed referral form + partograph)

Strength

strong

Relationship

The partograph and a written referral letter must accompany the mother. These documents give the CEmONC team the clinical context and history, ensuring safe, informed decision-making and continuity of care.

To

Referral Essentials—the R Checklist

From

Ride/accompany (safe transport + skilled escort)

Strength

strong

Relationship

Arranging safe transport and ensuring a trained attendant accompanies the mother is essential. The escort must monitor vital signs, be ready for emergencies (hemorrhage, convulsion), and communicate with the receiving facility.

To

Referral Essentials—the R Checklist

From

Ring ahead (communicate with receiving facility)

Strength

strong

Relationship

Calling the CEmONC facility ahead gives them warning, time to prepare, and assurance that the mother is en route. It also confirms the facility is ready to receive and has the needed capability (OR, ICU, blood bank).

To

Recording Frequency & Timing

From

Active Phase Definition

Strength

moderate

Relationship

Plotting on the partograph grid only begins when the active phase (4 cm dilatation with regular contractions) is reached. Prior to that, observations are recorded but not plotted on the alert/action line grid.