International Journal of Gynecology and Obstetrics (2007) 96, 147150

a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m

w w w. e l s e v i e r. c o m / l o c a t e / i j g o

SPECIAL ARTICLE

Comparison of two World Health Organization partographs

J.E. Mathews, A. Rajaratnam, A. George, M. Mathai
Department of Obstetrics and Gynecology, Christian Medical College, Vellore, India Received 23 June 2006; received in revised form 7 August 2006; accepted 22 August 2006

KEYWORDS
Partograph; Latent phase; User friendliness; World Health Organization

Abstract Objective: To compare two World Health Organization (WHO) partographs a composite partograph including latent phase with a simplified one without the latent phase. Method: Comparison of the two partographs in a crossover trial. Result: Eighteen physicians participated in this trial. One or the other partograph was used in 658 parturients. The mean (S.D.) user-friendliness score was lower for the composite partograph (6.2 (0.9) vs. 8.6 (1.0); P = 0.002). Most participants (84%) experienced difficulty bsometimesQ with the composite partograph, but no participant reported difficulty with the simplified partograph. While most maternal and perinatal outcomes were similar, labor values crossed the action line significantly more often when the composite partograph was used, and the women were more likely to undergo cesarean deliveries. Conclusion: The simplified WHO partograph was more user-friendly, was more to be completed than the composite partograph, and was associated with better labor outcomes. 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

The first World Health Organization (WHO) partograph [1], or composite partograph, covers a latent phase of labor of up to 8 h and an active phase beginning when cervical dilatation reaches 3 cm. The active phase is provided with an alert and an action line, drawn 4 h apart on the partograph, as aids to monitoring labor. This partograph

Corresponding author. Department of Making Pregnancy Safer, World Health Organization, CH 1211 Geneva 27, Switzerland. Tel.: +41 22 791 3210; fax: +41 22 791 5853. E-mail address: mathaim@who.int (M. Mathai).

enables staff attending women in labor to record the changes in maternal and perinatal variables, and the alert and action lines are meant to help the staff recognize alerts or initiate action (Fig. 1). However, since the composite partograph covers the latent as well as the active phase, when a woman admitted during the latent phase enters the active phase, an attendant must btransferQ her cervical dilatation value to the appropriate place by means of a broken line. This btransferQ has been difficult for some staff to understand, leading to mistakes when filling out partographs [2]. And since a prolonged latent phase is relatively

0020-7292/$ - see front matter 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2006.08.016

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J.E. Mathews et al.

Figure 1

The bcompositeQ WHO partograph.

Comparison of two World Health Organization partographs

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Figure 2

The bsimplifiedQ WHO partograph.

infrequent and not usually associated with poor perinatal outcome, the usefulness of recording the latent phase in the partograph has been questioned [2]. Moreover, differentiating the latent phase from false labor being difficult, diagnosis is often made in retrospect [3]; meanwhile, the staff is likely to intervene more actively than necessary [2]. The simplified partograph in the current WHO guideline [4] excludes the latent phase (Fig. 2) and recording begins with the active phase (with cervical dilatation now 4 cm). Alert and action lines are similar to those in the composite WHO partograph, but unlike in the composite version, descent of the fetal head is not recorded in the simplified one. The 2 WHO partographs were compared in a cross-over study of 3 months' duration. Physicians working in 12-hour shifts at this teaching hospital were instructed on the use of one of the partographs, which they then used for the next 10 days. After a week, the intervention was repeated with the other partograph. The order of use was randomized. Care was provided using WHO guidelines for the hospital setting [3]. Participants scored the 2 partographs for each of the following categories: user-friendliness (scores of 010), teachability (scores of 05) and overall usefulness (scores of 05). All partographs were checked for completeness, and the difficulties the physicians experienced while recording were documented.

In all, 658 women in labor were provided care by 18 physicians who used these partographs. While most maternal and perinatal outcomes were similar when labor was monitored using either partograph (Table 1), labor values crossed the action line significantly more often when the composite partograph was used, and the women were more likely to undergo cesarean deliveries. The composite partograph scored lower on userfriendliness (mean SD, 6.2 0.9 vs. 8.6 1.0; 2 > 10.1; P = 0.002). Most participants (83.4%) reported difficulty in using the composite partograph bsometimesQ but no participant reported difficulty using the simplified partograph (2 = 10.1; P = 0.001). Most participants (84%) gave the maximum score of 5 for the bteachabilityQ of the simplified partograph, but no participant gave the composite partograph the maximum score in that category. However, since the simplified partograph did not include the descent of the fetal head, it was considered less useful than the composite partograph (median scores of 3 and 4, respectively). Cervical dilatation was carefully recorded in both partographs, but recording was more thorough for other variables with the simplified partograph (contractions, 92% vs. 74%; fetal heart rate, 90% vs. 83%; pulse rate, 86% vs. 65%; and blood pressure, 92% vs. 49%). Overall, the simplified WHO partograph was more userfriendly, was more likely to be completed than the composite WHO partograph, and was associated with better labor outcomes.

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Table 1 Variable Labor crossing the alert line Nulliparas Multiparas Labor crossing action line Nulliparas Multiparas 2 vaginal examinations Nulliparas Multiparas Oxytocin use Nulliparas Multiparas Instrumental delivery Nulliparas Multiparas Cesarean delivery Nulliparas Multiparas Apgar score < 7 at 5 min Nulliparas Multiparas Mean birth weight, mean SD, g Nulliparas Multiparas Admission to NICU Nulliparas Multiparas User friendliness score, mean SD Difficulty reported in using the partograph, %

J.E. Mathews et al.

Comparison of labor outcomes and user satisfaction using the composite partograph and the simplified partograph Composite partograph 34 (19.4) 30 (16.1) 19 (10.9) 6 (3.2) 24 (13.7) 7 (3.8) 53 (30.3) 33 (17.7) 15 (8.6) 11 (5.9) 22 (12.6) 10 (5.4) 4 (2.3) 3 (1.6) 2933 504 3048 430 38 (21.7) 36 (19.3) 6.2 0.9 83.4 Simplified partograph 28 (17.9) 17 (12.1) 2 (1.3) 1 (0.07) 14 (9.0) 3 (2.1) 43 (27.6) 22 (15.6) 16 (10.3) 10 (7.1) 5 (3.2) 2 (1.4) 5 (3.2) 1 (0.07) 3025 949 2964 561 23 (14.7) 24 (17) 8.6 1.0 0 P value or RR (95% CI) 0.7 0.3 1.7 (1.432.02) 0.1 0.2 0.4 0.6 0.6 0.6 0.7 1.62 (1.312.0) 1.49 (1.141.96) 0.6 0.5 0.3 0.1 0.1 0.6 0.002 0.001

Abbreviations: CI, confidence interval; NICU, neonatal intensive care unit; RR, relative risk. There were 175 nulliparas and 186 multiparas in the composite partograph group and 156 nulliparas and 141 multiparas in the simplified partograph group; values are given as number (percentage) unless otherwise indicated. P values were not significant and RRs with 95% CIs were significant.

References
[1] World Health Organization Maternal Health and Safe Motherhood Programme. World Health Organization partograph in management of labour. Lancet 1994;343:1399404. [2] Dujardin B, De Schampheliere I, Kulker R, Bailey J. The partograph: is it worth including the latent phase? Trop Doct 1995;25:434. [3] World Health Organization. Managing complications in pregnancy and childbirth. Geneva, Switzerland: World Health Organization;

2000. Available at: http://www.who.int/making_pregnancy_ safer/publications/archived_publications/mcpc.pdf. [4] World Health Organization. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. Geneva, Switzerland: World Health Organization; 2003. Available at: http://www.who.int/making_pregnancy_safer/publications/ PCPNC_2006_03b.pdf.