10/9/13!

Physiologic partograph to improve birth safety and outcomes among low-risk, nulliparous women with spontaneous labor onset

Presentation Overview

Jeremy L. Neal PhD, CNM, RN

Assistant Professor The Ohio State University

! Background & Signicance! ! Introduction to Partograph! ! Partograph Use Examples!

To start!
Birth should be recognized as a normal physiologic process ! Providers should advocate for non-intervention in the absence of complications ! Scientic evidence should be incorporated into clinical practice !

Background and Significance

Why Nulliparous Women? ! Term, nulliparous women carrying singleton, cephalic

Labor
! The presence of uterine contractions of sufcient
frequency, duration, and intensity to cause demonstrable effacement and dilation of the cervix (ACOG, 2003)
!

presenting fetuses are of particular interest when strategizing to improve obstetrical care quality and outcomes (CDC, 2012;
ACOG, 2000; Boyle et al, 2012; Main et al, 2004, 2006; Cleary et al, 1996)!

! 40% of all U.S. births are to nulliparous women; 1.6 million in

2011 (Martin et al, 2013)!

! ~97-98% of the variation in overall cesarean rates between

institutions is d/t variation in cesareans to low-risk, nulliparous women (Brennen et al, 2009, 2011) ! management of subsequent labors!

! 1
!

st

Stage = contraction onset full dilatation!

!! Latent phase = contraction onset active dilation onset! !! Active phase = active dilation complete dilatation!

! The course of the 1labor largely dictates the course and

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Friedmans Active Phase: Nulliparae

4.9 3.4 hrs (mean) (1955)! 4.6 3.6 hrs (mean) (1971, 1978)! 11.7 hrs (mean+2 SD) !
(1955, 1971, 1978)!

Nulliparous Labor Curve From Active Labor Onset

7.3 hrs ! (median)! 13.7 hrs (90th %)! 16.4 hrs (95th %)!

10 9 8 7

Deceleration Phase (~9-10 cm) = 0.84-0.9 hr!

10 9 8

cm 6
5 4 3 2 0 5

Phase of Max Slope (~4-9 cm) = Phase 3.0-3.7 ! of cm/hr Max Slope ! [**computes to 1.35-1.67 hrs] ! = 1.2 cm/hr! (~4-9 cm) 1 cm/hr rule! Acceleration Phase (~2.5-4 cm) 2.1-2.4 hrs!

cm 6
5 4 3 2 0
(Friedman, 1955, 1971, 1978)! Dilatations associated with active labor onset (Cunningham et al, 2010; Gabbe et al, 2007;Varney et al, 2004)!

Hrs

10

15

Hrs

10
(Zhang, Troendle et al, 2002)! (Zhang, Landy et al, 2010)!

15

(Friedman, 1955, 1978; Friedman & Kroll, 1971)!

(Zhang, Troendle et al, 2010)!

Nulliparous Active Labor

Cervicograph (adapted)

! Peisner & Rosen (1986) (n = 1060)!

!!

Using Friedmans 1.2 cm/hr criteria, low-risk, term, nulliparas with intact membranes, cephalic presentation, and spontaneous labor were evaluated:! ! At 3 cm, 75% were not active! ! At 4 cm, 50% were not active! ! At 5 cm, 25% were not active!

! !

Alert line = dilation expectation of ! 1 cm/hr meant to represent the slowest 10% (based on Friedman work)! Action line = if crossed, consider aggressive interventions (e.g., oxytocin)!
Alert line Action line

10 8

! Neal et al (In review) (n = 216)!

!!

78.2% (n=488)
hr m/ 4c

10.9% (n=68)

10.9% (n=68)

cm
6
0.6

Using criteria put forth by the SOGC (1995), i.e., at > 3 cm dilatation, adequate labor involves average dilation of > 0.5 cm/hr over any 4 hr time window:! ! 52.8% did not meet this expectation in the rst 4 hrs after admission (average dilatation at admission ~3.5 cm)!

4 3 0 2 4 6 8

Low-risk, Rhodesian primigravidae at ! 3 cm at admission (n = 624) ! Hrs

10 12 14 16

(Philpott, 1972; Philpott & Castle, 1972a, 1972b)

WHO Partograph

WHO Partograph (adapted)

! !

Evaluated in large, multicenter trial in 1990s (n = 35,484)! Reported on subgroup of low-risk, term, nulliparous women with spontaneous labor onset admitted in active labor, i.e., ! 3 cm dilatation + contractions (n = 2397)!
10 8

Alert line

Action line

69.1% (n=1656)
4 0.6 cm ! /hr

19.2% (n=460)

11.7% (n=281)

cm
6

4 3 0 2 4 6 8 10 12 14 16

Hrs

(WHO, 1994)!

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WHO Partograph (adapted)

Nulliparous women assessed via partographs with alert and 4-hr action lines
Study! Country! Earliest partograph initiation!
3 cm! 3.4 0.6 cm*! 3 cm!

In 2007, the WHO changed their denition of active labor onset from 3 cm to 4 cm (WHO, 2007)!
10 8

n!

Alert line

Action line

Alert Line Crossed ! (< 1cm/hr)!

21.8%! 56.3%! 30.9%!

Action Line Crossed ! (< 0.64 cm/hr)!

10.9%! 32.3%! 11.7%!

Philpott et al. (1972)! Drouin et al. (1979)! WHO (1994)!

Zimbabwe! Cameroon! Indonesia, Thailand, & Malaysia! England! England! South Africa! England!

624! 480! 2397!

65.3% (n=169)
0c hr! m/

16.2% (n=42)

18.5% (n=48)

Lavender et al. (1998)! Lavender et al. (1999)! Pattinson et al. (2003)!

3 cm! 3 cm! 4 cm! 3 cm! 3 cm! 4 cm ! 4 cm! 3 cm!

311! 171! 350! 1485! 175! 156! 259! 1595!

Not reported! Not reported! 49.7%! Not reported! 19.4%! 17.9%! 34.8%! 34.4%!

38.1%! 37.4%! Not reported! 45.3%! 10.9%! 1.3%! 18.5%! 10.1%!

cm
6
0. 6

4 3 0 2 4 6 8

Low-risk, term, Nigerian nulliparas at ! 4 cm at admission (n = 259) ! Hrs

10 12 14 16

Lavender et al. (2006)!

Mathews et al. (2007)! India! Orji (2008)! van Bogaert (2009)! Nigeria! South Africa!

*! Mean dilatation at active phase onset! 2 partographs with 4-hr action lines were tested in this study!

(WHO, 2007; Orji, 2008)!

Active Management of Labor (AML)

! Multifaceted labor management program aimed

to shorten nulliparous labor (ODriscoll et al, 1973, 1993)!

Studies of Spontaneous Nulliparous Labor ( oxytocin, anesthesia)

! Kilpatrick & Laros (1989) (n = 2302)!

!! !! !! !! !! !!

regular, painful contractions " full dilatation = 8.1 4.3 hrs!

! Albers, Schiff, & Gorwoda (1996) (n = 347)! ! Albers (1999) (n = 806)! ! Jones & Larson (2003) (n = 120)!
0.8-1.0 cm/hr at the mean! 0.3-0.5 cm/hr at the statistical limit!

! Components:!
!!

4 cm " 10 cm = 7.7 5.9 hrs (95th %ile = 19.4 hrs)!

Antenatal childbirth preparation; strict diagnosis of spontaneous labor onset; 1-on-1 labor support ; routine amniotomy; routine cervical assessments; oxytocin if dilation is < 1 cm/hr; peer review of assisted deliveries!

4 cm " 10 cm = 7.7 4.9 hrs (95th %ile = 17.5 hrs)!

! 55-62% receive oxytocin under AML (ODriscoll

et al, 1973; Brown et al, 2008)!

4 cm " 10 cm = 6.2 3.6 hrs (95th %ile = 13.4 hrs)!

! Average dilation rates in these studies range from:!

Slowest-Yet-Normal Dilation Rate for Nulliparous Women

Clinical Dilemma

! Summary: Existing literature indicates that

!Either many nulliparous women are admitted

and/or !

10-18% of low-risk nulliparous women with spontaneous labor onset dilate <0.5-0.64 cm/hr, on average, even after 3 or 4 cm !
(Zhang et al, 2002, 2010; Philpott & Castle, 1972a, 1972b; WHO, 1994; Orji, 2008; Perl & Hunter, 1992; Albers et al, 1996; Albers, 1999; Jones & Larson, 2003)!

prior to progressive (active) labor yet held to dilation expectations of active labor !

!Common expectations of active labor dilation

rates (e.g. 1 cm/hr) are unrealistically fast!

! The problem: Clinician expectation of active

labor dilation is often much faster than the above rates!

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Consequences of Earlier Admission after Spontaneous Labor Onset

! Admissions at < 3 cm (vs. > 3 cm)! #!In-hospital labor time, oxytocin use, epidural use, dystocia $!Satisfaction with birth experience!
!
diagnoses, & cesarean deliveries!

! Low-risk, nulliparas at ! 37 wks with a singleton, cephalic fetus ! Women in pre-active labor were more likely to undergo:!
!! !! !! !! 114 (52.8%) were admitted in pre-active labor! 102 (47.2%) were admitted in active labor!

Timing of Admission to Hospital After Spontaneous Labor Onset

admitted for spontaneous labor onset by their provider (n = 216)!

!(McNiven et al., 1998; Impey et al., 2000; Rahnama et al., 2006)

! Admissions at < 4 cm (vs. > 4 cm)! #!In-hospital labor time, oxytocin use, epidural use, active
!
!

! In addition:!

Oxytocin augmentation (84.2% v. 45.1%, respectively; OR 6.5, 95% CI 3.43-12.27)! Cesarean delivery (15.8% v. 6.9%, respectively; OR 2.6, 95% CI 1.02-6.37)!

phase arrest, & cesarean deliveries!

!(Holmes et al., 2001; Bailit et al., 2005; Mikolajczyk et al., 2008)!

!! All cesareans for dystocia (n = 10) were in pre-active group (p < 0.01) (7 of 10 were performed at " 5 cm)! !! In-hospital labor time >4 hrs longer in pre-active group (p < 0.001)! !! Max temps during labor were higher in pre-active group (p = 0.026)!

p < 0.01 for all ndings!

Neal et al (In review)!

Consequences of Unrealistically Fast Cervical Dilation Expectations

Dystocia

!diagnoses of dystocia, i.e., slow, abnormal progression

of labor (ACOG, 2003)!

! Slow, abnormal progression of labor (ACOG, 2003)! ! In practice, diagnoses of dystocia are most often based on
ambiguously dened delays in dilation beyond which labor augmentation is deemed justied! diagnosed (Cunningham et al, 2010) !

!intervention(s) to accelerate labor with inherent risks! !unnecessary cesareans!

!
!

! Consequence: Dystocia is known to be over! Leading indication for primary cesareans accounting for as
much as 50% of all nulliparous cesareans (ACOG, 2000, 2003;
Cunningham et al, 2010)!

Oxytocin augmentation

! Dystocia over-diagnosis largely explains why

et al, 2006) !

! U.S. cesarean rates among term, low-risk, nulliparous women with ! Dystocia accounts for 50% of these (~13%) (ACOG, 2000, 2003;
Cunningham et al, 2010)!

Cesareans

approximately 50% of nulliparous women with spontaneous labor onset receive oxytocin augmentation during labor (Zhang et al, 2002, 2010; Treacy et al, 2006; Oscarsson

vertex fetus = 26.4% (CDC, 2013)!

! 90% of primary cesareans are followed by repeats, thus, the majority

of all cesareans are attributable to the diagnosis of dystocia that lead to the rst (CDC, 2013) !
Highest rate = Louisiana (39.9%); Lowest rate = Alaska (22.4%)! Minnesota (26.8%); Ohio (31.2%)!

! This is concerning because oxytocin: !

!! !! !! is a high-alert medication (ISMP, 2008)! is the intervention most commonly associated with preventable adverse perinatal outcomes (Clark et al, 2008, 2009) ! misuse is involved in half of all paid obstetric litigation claims (Clark, 2008) !

! Total cesarean rate in U.S. = 32.8% (Martin et al, 2013)!

!! !!

! Any overuse of oxytocin imposes unnecessary risk on

the mother and fetus during labor !

! The concern: the best birth outcomes occur with cesarean rates of
2010) !

5-10% while rates higher than 15% are associated with excessive morbidities and mortality (WHO, 1995; Villar et al, 2006, 2007; Lumbiganon et al,

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! Neal JL, Lowe NK, Ahijevych KL, Patrick TE, Cabbage LA,
!! !!

Another look at dilation rates in active labor

Nulliparous Labor from Criteria Associated with Active Labor Onset

6.0 2.0 hrs (mean)! (n = 7009)! 13.4 hrs (mean+2 SD)! (n = 4300)!

Corwin EJ. J Midwifery Womens Health 2010,55:308-318.! Aim: to describe labor duration and dilation rates beginning with clinical criteria often used as prospective evidence of active labor onset (i.e. 3 5 cm dilatation + regular contractions) 10 cm! Databases: MEDLINE & CINAHL!
! Cross-searched specic keywords, e.g.,!
nulliparous / nulliparous with labor (labour) length / labor (labour) duration / active phase / active labor (labour)!

10 9 8 7
1.2 cm r /h !

c 0.6

m/h

r!

cm 6
5 4 3 2 0
(Friedman, 1955, 1971, 1978)!

! !!

Limited to: 1990 2008; English (yield = 375 articles)! Low-risk, nulliparous women at ! 36 wks with a singleton, cephalic presenting fetus admitted for spontaneous labor onset between 3-5 cm!

!! Qualifying Publications (n = 25)!

Hrs
(Zhang et al, 2002)!

10
(Neal et al, 2010)!

15

Problem with Linear Expectation of Dilation

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,( ) F/B@;6!:76;>5<!#;B3!!E! D7<3;#!$6523

Physiologic (non-linear) expectation of dilation

95th percentile of cumulative duration of labor from admission among singleton, term, nulliparous women with spontaneous labor onset, vaginal delivery, and normal neonatal outcomes (n = 27,170)!

10 8

/0

* + & ' % , . % '

!
!

D7<3;#!$6523!E!F/B@;6! :76;>5<!#;B3

cm
6

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&

4 0 2 4 6 8

Zhang et al, 2002 hyperbolic dilation curve (n = 1162) ! Zhang et al, 2002 hyperbolic curve linearly conceptualized !

Hrs

10

12

14

16

18

(Zhang, Landy et al, 2010)

Physiologically-Based Partograph

! Our research team has developed a partograph for inIntroduction to the Partograph

hospital use in assessing the labors of nulliparous women with spontaneous labor onset (Neal & Lowe, 2012)!

! We hypothesize that partograph use will:!

!! safely limit diagnoses of dystocia during the rst stage of labor to only the slowest 10% ! !! ! oxytocin augmentation rates by ! 50%! !! ! cesareans performed for dystocia by ! 50%!

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Principles of Partograph
Principle 1.! Active labor onset must be accurately diagnosed before the rate of cervical dilation (cm/hr) is used to assess labor progression.! Expectations of cervical dilation (cm/hr) for the population must be appropriately-dened.! ! Cervical dilation rates progressively accelerate throughout the majority of active labor.! ! The time duration necessary to dilate from one centimeter to the next is more variable in earlier active labor than in more advanced active labor.!

Criteria for Partograph Use!

! Spontaneous labor onset !

!! !! !! !!

Principle 2.!

regular, painful contractions (" 2 in 10 min)! complete or near complete effacement! membranes intact or ruptured! bloody show absent or present !

! Initiated with labor and a qualifying cervical exam!

Principle 3.!

!! at 4 cm dilatation if being preceded by cervical change over time (i.e., ! 1 cm in " 2 hr window) = earliest start ! !! at ! 5 cm regardless of the rate of previous cervical change = direct start!

Principle 4.!

! Initiated and continued only when no complications

requiring urgent attention through intervention exist!

Partograph for Low-Risk, Nulliparous Women with Spontaneous Labor Onset"

Documenting Cervical Examinations

! Cervical exams are crude assessments that rely solely on

x o o x

the clinical experience and proprioceptive skill of the examiner!

! Clinicians accurately determine actual cervical dilatation

in only half of all cases (Buchmann et al, 2007; Huhn et al, 2004;
Phelps et al, 1995; Tuffnell et al, 1989) !
3
4:00pm

0
1:00pm

1
2:00pm

2!
3:00pm 3:15pm

4
5:00pm

5!
6:00pm

6
7:00pm

7
8:00pm

8
9:00pm

!! Accurate to 1 cm in 90% of cases!

! On partograph: dilatations reported as a range are

rounded down to the nearest integer dilatation, e.g., 4-5 cm is rounded to 4 cm.!

Example 1: Labor remaining left of the dystocia line without delay

Partograph Use Examples

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Example 2: Labor moving right of the dystocia line

Example 3: Labor remaining left of the dystocia line with delay

The Big Picture

! More than enough research evidence exists to support

the revision of existing active labor dilation rate expectations! safety and outcomes by safely:!

! Such physiologically-based revision should improve birth

!! ! diagnoses of dystocia during the rst stage of labor ! !! ! oxytocin augmentation rates! !! ! cesareans performed for dystocia!

! Midwives can take a lead in this area and our Hallmarks

of Midwifery can be the guide !

References
ACNM. Core Competencies for Basic Midwifery Practice, June 2007. Available at http://www.midwife.org ! ACOG Practice Bulletin Number 49, December 2003: Dystocia and augmentation of labor. Obstet Gynecol 2003;102(6):1445-1454.! ACOG. Evaluation of Cesarean Delivery / [Developed Under the Direction of the Task Force on Cesarean Delivery Rates, Roger K. Freeman ... et al.]. Washington, D.C.: ACOG; 2000.! Bailit JL, Dierker L, Blanchard MH, Mercer BM. Outcomes of women presenting in active versus latent phase of spontaneous labor. Obstet Gynecol 2005; 105:77-9.! Battista LR, Wing DA. Abnormal labor and induction of labor. In: S. G. Gabbe, J. R. Niebyl and J. L. Simpson, editors. Obstetrics: Normal and Problem Pregnancies. Philadelphia:Churchill Livingstone; 2007.! Boyle A, Reddy UM. Epidemiology of cesarean delivery: the scope of the problem. Semin Perinatol 2012;36:308-314.! Brennan DJ, Robson MS, Murphy M, et al. Comparative analysis of international cesarean delivery rates using 10group classication identies signicant variation in spontaneous labor. Am J Obstet Gynecol 2009;201:e1-e8.! Brennan DJ, Murphy M, Robson MS, et al. The singleton, cephalic, nulliparous woman after 36 weeks of gestation: contribution to overall cesarean delivery rates. Obstet Gynecol 2011;117:273-279.! Brown HC, Paranjothy S, Dowswell T, Thomas J. Package of care for active management in labour for reducing caesarean section rates in low-risk women. Cochrane Database Syst Rev 2008:CD004907.!

References
Bugg GJ, Siddiqui F, Thornton JG. Oxytocin versus no treatment or delayed treatment for slow progress in the rst stage of spontaneous labour. Cochrane Database Syst Rev . 2011:CD007123.! Buchmann EJ, Libhaber E. Accuracy of cervical assessment in the active phase of labour. BJOG 2007;114(7):833-837. ! CDC. Healthy People 2020. Accessed August 1, 2013.! CDC. Healthy People 2020 Summary of Objectives. Available at: http://www.healthypeople.gov/2020/topicsobjectives2020/pdfs/MaternalChildHealth.pdf. Accessed January 10, 2012. ! CDC. Rates of cesarean delivery United States, 1993. MMWR 1995; 44(15):1-4.! Clark SL, Simpson KR, Knox GE, Garite TJ. Oxytocin: new perspectives on an old drug. Am J Obstet Gynecol . 2009;200:35.e1-35.e6. ! Clark SL, Belfort MA, Dildy GA, Meyers JA. Reducing obstetric litigation through alterations in practice patterns. Obstet Gynecol . 2008;112:1279-1283. ! Cleary R, Beard RW, Chapple J, Coles J, Grifn M, Joffe M et al. The standard primipara as a basis for inter-unit comparisons of maternity care. Br J Obstet Gynaecol 1996; 103:223-9.! Cunningham, FG, Leveno, KJ, Bloom, SL, Hauth, JC, Rouse, DJ, Spong, CY, editor. Williams obstetrics. 23rd ed. New York: McGraw-Hill; 2010.! Friedman EA, editor. Labor: Clinical evaluation and management. 2nd ed. New York: Appleton-Century-Crofts; 1978.! !

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References
Friedman EA, Kroll BH. Computer analysis of labor progression. III. Pattern variations by parity. J Reprod Med 1971; 6:179-83.! Friedman EA. Primigravid labor: a graphicostatistical analysis. Obstet Gynecol 1955; 6:567-89.! Holmes P, Oppenheimer LW, Wen SW. The relationship between cervical dilatation at initial presentation in labour and subsequent intervention. BJOG 2001; 108:1120-4.! Huhn KA, Brost BC. Accuracy of simulated cervical dilation and effacement measurements among practitioners. Am J Obstet Gynecol 2004;191(5):1797-1799. ! Impey L, Hobson J, O'Herlihy C. Graphic analysis of actively managed labor: Prospective computation of labor progress in 500 consecutive nulliparous women in spontaneous labor at term. Am J Obstet Gynecol 2000; 183:438-43.! Institute for Safe Medication Practices. ISMP's list of high-alert medications. 2008; Available at: http://www.ismp.org/tools/highalertmedications.pdf. Accessed July 28, 2011.! Lumbiganon P, Laopaiboon M, Glmezoglu AM, Souza JP, Taneepanichskul S, Ruyan P, et al. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08. Lancet 2010;375(9713):490-499.! Main EK, Moore D, Farrell B, Schimmel LD, Altman RJ, Abrahams C et al. Is there a useful cesarean birth measure? assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. Am J Obstet Gynecol 2006; 194:1644-1652.!

References
Main EK, Bloomeld L, Hunt G. Development of a large-scale obstetric quality-improvement program that focused on the nulliparous patient at term. Am J Obstet Gynecol 2004; 190:1747-1756.! Martin JA, Hamilton BE, Sutton PD,Ventura SJ, Menacker F, Kirmeyer S. Births: nal data for 2004. Natl Vital Stat Rep 2006; 55(1): 1-102. ! Martin JA, Hamilton BE,Ventura SJ, Osterman MJK, Mathews TJ. Births: Final data for 2011. Natl Vital Stat Rep. 2013;62(1):1-90.! McNiven PS, Williams JI, Hodnett E, Kaufman K, Hannah ME. An early labor assessment program: A randomized, controlled trial. Birth 1998; 25:5-10.! Mikolajczyk R, Zhang J, Chan L, Grewal J. Early versus late admission to labor/delivery, labor progress and risk of caesarean section in nulliparous women. Am J Obstet Gynecol 2008; 199:S49.! Neal JL, Lamp JM, Buck JS, Lowe NK, Gillespie SL, Ryan SL. Outcomes of nulliparous women with spontaneous labor onset admitted to hospitals in pre-active versus active labor. Journal of Midwifery & Womens Health (In review).! Neal JL, Lowe NK, Ahijevych KL, Patrick TE, Cabbage LA, Corwin EJ. (2010). Active labor duration and dilation rates among low-risk, nulliparous women with spontaneous labor onset: a systematic review. Journal of Midwifery & Womens Health, 55(4), 308-318.! Neal JL, Lowe NK, Patrick TE, Cabbage LA, Corwin EJ. (2010). What is the slowest yet normal cervical dilation rate among nulliparous women with spontaneous labor onset? Journal of Obstetric Gynecologic and Neonatal Nursing, 39(4), 361-369.! ! !

! !

References
Neal JL, Lowe NK. (2012). Physiologic partograph to improve birth safety and outcomes among low-risk, nulliparous women with spontaneous labor onset. Medical Hypotheses, 78(2), 319-326.! O'Driscoll K, Meagher D, Boylan P, editors. Active management of labor: The Dublin experience. 3rd ed. Aylesbury, England: Mosby; 1993.! O'Driscoll K, Stronge JM, Minogue M. Active management of labour. Br Med J 1973; 3:135-7.! Orji E. Evaluating progress of labor in nulliparas and multiparas using the modied WHO partograph. Int J Gynaecol Obstet 2008; 102:249-52.! Oscarsson ME, Amer-Whlin I, Rydhstroem H, Klln K. Outcome in obstetric care related to oxytocin use. A population-based study. Acta Obstet Gynecol Scand 2006;85(9):1094-1098. ! Peisner DB, Rosen MG. Transition from latent to active labor. Obstet Gynecol 1986; 68:448-51.! Perl FM, Hunter DJ. What cervical dilatation rate during active labour should be considered abnormal? Eur J Obstet Gynecol Reprod Biol 1992; 45:89-92.! Phelps JY, Higby K, Smyth MH, Ward JA, Arredondo F, Mayer AR. Accuracy and intraobserver variability of simulated cervical dilatation measurements. Am J Obstet Gynecol 1995;173(3):942-945. ! Philpott RH. Graphic records in labour. Br Med J 1972; 4:163-5.! Philpott RH, Castle WM. Cervicographs in the management of labour in primigravidae. I. The alert line for detecting abnormal labour. J Obstet Gynaecol Br Commonw 1972; 79:592-8.! Philpott RH, Castle WM. Cervicographs in the management of labour in primigravidae. II. The action line and treatment of abnormal labour. J Obstet Gynaecol Br Commonw 1972; 79:599-602.! ! !

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Rahnama P, Ziaei S, Faghihzadeh S. Impact of early admission in labor on method of delivery. Int J Gynaecol Obstet 2006; 92:217-20.! Society of Obstetricians and Gynaecologists of Canada. Policy statement number 40: Dystocia. 1995.! Suzuki R, Horiuchi S, Ohtsu H. Evaluation of the labor curve in nulliparous Japanese women. Am J Obstet Gynecol . 2010;203:226.e1-226.e6. ! Treacy A, Robson M, O'Herlihy C. Dystocia increases with advancing maternal age. Am J Obstet Gynecol 2006;195(3):760-763.! Tuffnell DJ, Bryce F, Johnson N, Lilford RJ. Simulation of cervical changes in labour: reproducibility of expert assessment. Lancet 1989;2(8671):1089-1090. ! Varney H, Kriebs JM, Gegor CL.Varney's Midwifery. Boston:Jones and Bartlett Publishers, Inc.; 2004.! Villar J,Valladares E, Wojdyla D, Zavaleta N, Carroli G,Velazco A, et al. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet 2006;367(9525): 1819-1829. ! Villar J, Carroli G, Zavaleta N, Donner A, Wojdyla D, Faundes A, et al. Maternal and neonatal individual risks and benets associated with caesarean delivery: multicentre prospective study. BMJ 2007;335(7628):1025-1025.! World Health Organization Health. Department of Reproductive Health and Research. Integrated management of pregnancy and childbirth. managing complications in pregnancy and childbirth: A guide for midwives and doctors. 2007.! ! ! !

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