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WHO modified partograph descent of head plotting fifths palpable

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Descent of the Fetal Head on the WHO (Modified) Partograph

What "descent of head" means
On the partograph, "descent of the head" refers to how far the fetal head has descended into the maternal pelvis — i.e., the degree of engagement of the presenting part. It is one of the three parameters used to monitor the progress of labour (the other two being cervical dilatation and uterine contractions), while fetal heart rate, liquor colour, and moulding monitor fetal condition.
Descent is expressed using the "rule of fifths": the examiner estimates how many fifths of the fetal head are still palpable above the pelvic brim on abdominal examination.
  • 5/5 — head is entirely above the brim, freely mobile (not engaged)
  • 4/5 — most of the head is above the brim; only a small part felt
  • 3/5 — head is at the brim; sinciput easily felt, occiput just felt (this level, 3/5, is generally taken as the point of "engagement")
  • 2/5 — head is mostly below the brim; only a small part above
  • 1/5 — very little head felt above the brim
  • 0/5 — head is entirely below the pelvic brim, not palpable abdominally (deeply engaged, near the perineum)
Importantly, WHO guidance emphasises that descent should be assessed by abdominal palpation (not just vaginal examination), immediately before doing the vaginal exam. This is because caput succedaneum or excessive moulding on vaginal exam can give a falsely low (i.e., falsely advanced) impression of station, whereas abdominal palpation of fifths above the brim is more reliable. A high head with increasing moulding is a warning sign of cephalopelvic disproportion.
How it is plotted
  • The left-hand vertical axis of the partograph carries a scale from 0 to 5 (fifths palpable), running alongside the cervical dilatation scale (0-10 cm).
  • At each assessment (recommended every 4 hours, alongside the vaginal exam for dilatation), the descent value is marked with the symbol "O" on the grid, at the corresponding time column.
  • Successive "O" points are joined with a straight line, producing a descent curve running alongside the cervical dilatation curve (marked with "X").
  • Normally, as labour progresses, dilatation (X) rises while descent (O) falls — the two lines tend to move in opposite directions, X trending up and O trending down toward 0/5 as the head engages and descends through the pelvis.
  • In the original WHO composite partograph, dilatation was plotted from the latent phase and transferred to the alert line on entering the active phase at 4 cm. In the WHO-modified partograph (2000), the latent phase was removed entirely — plotting begins at 4 cm cervical dilatation, and the alert/action line framework and the descent-of-head recording (O, rule of fifths) otherwise remained unchanged.
(Note: WHO's more recent Labour Care Guide, introduced around 2020-2021, has largely superseded the classic partograph in updated WHO intrapartum guidance, though the modified partograph described above is still what is taught and used widely in many settings and exams.)
  • The Partograph in Childbirth: An Absolute Essentiality or a Mere Exercise? - PMC, Fig. 1, 3, 6
  • WHO Partograph for Beginner - contemporaryobgyn.net
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