Navneet Magon. Gynaecologist, Obstetrician & Endoscopic Surgeon, Air Force Hospital, Kanpur.
International Journal of Clinical Cases and Investigations 2011. Volume 3 (Issue 1), 1:6, 6th August, 2011
Might sound strange to many, but the ancient Greek legacy relates itself to the understanding of current labour care practices. It was Plato who positioned mind as superior which resulted in a belief that bodily processes as liable to error and breakdown. Reproduction has suffered under this belief since times immemorial, both in relation to sexual behaviour and childbirth. Labour has been considered as bodily process and its surveillance has therefore been subject to planning, monitoring and regulation. Indeed, it was man midwives and subsequently male obstetricians who were instrumental in the medicalisation of childbirth and the evolution and regulation of the midwifery profession1. It was in the 17th century that the process of childbirth migrated from the private to public domain. The man midwives saw an opportunity to profit from this wealth by offering childbirth services and subsequently barred lay midwives to provide support in childbirth who were doing so probably since the beginning of human evolution2. This was more so in case of wealthy women. Slowly but steadily, childbirth was viewed as an arena only to be managed by professionals.
We, the generation Y Obstetricians, are vastly influenced by the kind of education and training we have had. We have been taught a ‘surveillance’ orientation to labour management. We are programmed to judge labour progress in the background knowledge of what should happen when. Childbirth has been medicalised3 and labour is divided into three stages that may bear little resemblance to narrative accounts by women4. Each stage is required to be framed in chronological time and illustrated in the partographs across the world.
Ever since Professor Philpott published his landmark papers in 19725,6,7, it has been demonstrated many a times that use of the Partograph, or partogram as many call it, reduces maternal and fetal morbidity and mortality8,9. Philpott’s work was5 was inspired by Friedman’s cervicograph.10 Emanuel Friedman was the first to provide a realistic tool for the study of human labour. This was done so as to rationalize the use of maternity services in Africa where paucity of resources required prioritization of cases which required specialized obstetric care. An alert line and an action line were placed on the cervicograph. In his own words: ‘The alert line joins points representing 1 cm dilatation at zero time (admission) and full dilatation (10 cm) 9 hours later, a rate of 1 cm per hour...The action line is arbitrarily drawn 4 hours later’6,7. And, ‘Progress [from 3 cm] is charted on the composite graph with the alert line regarding the time at 3 cm as zero time’5. Should a woman’s cervical dilatation cross the action line, 2 h to the right of the alert line, then arrangements were made to transfer her from a peripheral unit to the central unit where prolonged labour could be managed more effectively.
Philpott and Castle7 recommend pelvic reassessment to rule out cephalopelvic disproportion when the action line is reached followed by a trial of oxytocin, adequate hydration, and a caesarean delivery if there is fetal distress or if augmentation fails. WHO also recommends the same8,11. Since the initial publications on Partogram, the issue of the latent phase has always been an issue of controversy12. Philpott’s partograph does not depict the latent phase, probably because Philpott did most of his work on African women who were admitted in active labour. The World Health Organisation collaborative study reported that only a small number of women experience a prolonged latent phase8, and that a prolonged latent phase does not affect the caesarean section rate. Now the million dollar question is that should the latent phase remain as a part of the partogram? Perhaps for those who want to maintain, I feel reasonable compromise would be to chart the observations on a separate sheet. One must keep in mind the risk of inappropriate intervention if undue attention is paid to the latent phase13. According to Gifford et al., contrary to the WHO claim, 24% of caesarean deliveries done for of lack of progress of labour are done in the latent phase 14.
Each year, more than 200 million women become pregnant and about 500,000 will die as a result of the complications of pregnancy or childbirth15. In 1987, WHO launched the Safe Motherhood Initiative, which aimed to reduce maternal morbidity and mortality by 50% by the year 2000. The initiative did not succeed but maternal health has always been a major focus of WHO effort. The current WHO initiative16 is to reduce maternal mortality to 75% of the 1990 level by 2015. If this is to be successful, the problem of obstructed labour will need to be addressed effectively.
Obstructed labour occurs when there is a significant disproportion between the dimensions of the fetal presentation and the mother’s pelvis during labour. Information on the incidence of and mortality from prolonged and obstructed labour is incomplete and patchy. The reported incidence of obstructed labour varies widely; from as low as 1% in some populations to up to 20% in others17. About 8% of all maternal deaths in 2000 were estimated to be due to obstructed labour. However, there often is paucity of vital registration data in settings where obstructed labour and maternal deaths are common18. Moreover, when a woman dies as a result of obstructed labour, the death may not be so classified under the final cause of death; and may be reported as caused by sepsis, ruptured uterus or hemorrhage rather than owing to the underlying cause, which may be cephalopelvic disproportion. Obstructed labour is an important cause of maternal morbidity. An estimated 2,951,000 disability adjusted life years were lost in 2000 owing to obstructed labour17. Prolonged and obstructed labour is also associated with fetal hypoxia, birth trauma and infection resulting in intrapartum or early newborn deaths and perinatal morbidity. Therefore, prevention of obstructed labour is an important intervention towards reducing maternal and perinatal mortality and morbidity, and in achieving the Millennium Development Goals 4 and 5.
The literature suggests that in many countries, maternal mortality due to this cause is almost as prevalent today as it was 30 years ago. The partogram provides health professionals with a pictorial overview of the labour to allow early identification and diagnosis of the pathological labour. The World Health Organization recommends using the partogram to follow labour and delivery, with the objectives to improve health care and reduce maternal and fetal morbidity and death11. The partogram consists of a graphic representation of labour and is an excellent visual resource to analyze cervical dilation and fetal presentation in relation to time.
WHO partographs are the best known in most countries. Since the 1990, WHO has published 3 different types of the partograph. The first of these partographs8 also called as the composite partograph includes a latent phase of 8 hours and an active phase starting at 3 cm cervical dilatation. It has an alert line with a slope of 1 cm per hour which commences at 3 cm dilatation and the action line is 4 hours to the right of and parallel to the alert line. It also provides space for recording descent of the fetal head, indicators of maternal and fetal well-being and medications administered. This partograph was been tested successfully in an international study of over 35000 women in South East Asia8.
WHO modified the partograph for use in hospitals in 2000.19 The latent phase was excluded in this partograph. The active phase commences at 4 cm dilatation. The other features are the same as the composite WHO partograph. The reason for excluding the latent phase were that interventions are more likely if the latent phase is included and because staff reported difficulties in transferring from latent to active phase. The choice of 4 cm was made to reduce the risk of interventions in multiparous women with patulous cervices who were not yet in labour. A study of the modified WHO partograph in Ethiopia concluded that labour could be managed without the latent phase being plotted on a partograph.20 WHO further modified the paragraph for the third time, this time for use by skilled attendants in health centers.21 This simplified partograph is colour coded. The area to the left of the alert line in the cervicograph is coloured green, representing normal progress. The area to the right of the action line is coloured red, indicating dangerously slow progress in labour. The area in between the alert and action line is coloured amber, indicating the need for greater vigilance. In a cross over trial in Vellore, India; the composite partograph was rated as less user-friendly than the simplified partograph.22
The WHO claimed that the use of the partograph reduces the caesarean section rate; however, the paper shows that this was not a significant result. Only reductions in prolonged labour, augmented labours and post-partum sepsis reached statistical significance. The authors reported that the proportion of labours requiring oxytocin augmentation was reduced by 54%—from 20.7 to 9.1%. It is difficult to come to any conclusion except that the previous rate of augmentation was probably unnecessarily high. If this be so, then the partograph is simply correcting a poor standard of care, rather than making childbirth safer per se. But that itself is no small feat achieved. It must be understood that the majority of trials of partography have taken place in hospital settings where most maternal deaths occur among women admitted with severe complications and often neglected labour.23
Much has changed in obstetric care in recent decades, and many of the changes have arisen from questioning; and in some cases discarding, of many interventions which had previously been considered apt. The author herein encourages health professionals and policy-makers to join the questioning process. This is the only way for the medicine to evolve. In view of the author, despite the limitations and non conclusive evidence on reduction in maternal morbidity, the partogram as of today is probably the simplest and yet the most effective aid to logical management of labour that has ever been devised. The idea of a graphical representation of the progress of a labour which seems so very obvious to us now, was not so until the 1960s that it began to be used in obstetric practice. The underlying principles of the partogram are that it is a method of displaying progress in cervical dilatation as a continuous graph, while at the same time; displaying as many other features of the state of the mother, the fetus and the labour as possible in graphic form. It is this combination of features which makes the partogram so very worthwhile. This value is apparent for all health workers from the least to the most experienced, and for all health care environments from the least to the most sophisticated.
Although the partograph is a simple and inexpensive tool, it is not as widely implemented, as it should be. Studies from Nigeria did report that only 25% to 33% of caregivers surveyed were using partograph for routine monitoring.24,25 Use of the partograph was more in tertiary level facilities and less at primary and secondary levels whereas ideally it should have been perhaps more important in the later. Caregivers may resist using the tool if they have insufficient knowledge and do not fully understand why they have been asked to use the tool. Non-availability of preprinted partographs has also been reported as a cause for nonutilization.24 Filling the partograph is also seen as an additional chore for a busy health worker in such a situation and may not be motivated to complete the partograph. However, the challenges to the implementation of the partograph, including insufficient knowledge, nonavailability of preprinted partographs and workload pressure, can all be addressed with further education on the purpose of the partograph and local managerial support.
The issue of the latent phase of labour is a difficult one. The partogram recognizes it and allows for it, but it is not at all clear what the solution is for a prolonged latent phase. This is one of many unanswered questions in labour management. Two articles in this issue, one on Partograph by Magon N and another on Latent Labour by Magon N & Singh S shall definitely help in defining the clinical practice on these issues. Let us all, who have stakes in the women’s health instigate a learning and teaching itinerary to make all those who are involved in ‘labour surveillance’ develop an attitude towards humanism of pregnancy rather than medicalisation of the same. We all know there is no substitute for medical knowledge, but hope, honesty, love, and compassion are the universal language of healing. We know that we all practice Obstetrics in difficult times. The unending litany of negatives includes medico-legal liability, violence against physicians, damage to life & property, decreased reimbursements and the potential loss of the doctor patient relationship. It is enough to even depress the most die-hard optimists. There are even those naysayers who feel that we have become so obsessed with the monetary aspects of medicine that we have forgotten the real business of medicine. This climate of cynicism has prompted the question “Is the humanism of medicine dead or alive?” The humanism of medicine is in our hands. Let’s permit it to fly! The real business of medicine is immutable and is fixed in human condition. And as Marley once said, “Mankind is our business. The common welfare is our business. Charity, mercy, forbearance and benevolence are all our business.” A physician must evolve to become a true Healer. My concept of a Healer is one who injects elegance into the art and science of medicine. Healer is the person who can apply reason to the practice of medicine. And nowhere is this truer than in the practice of Obstetrics. The word “practice” is purposely chosen by me because Obstetrics is a continual practice that requires constant diligence and a life-long, never ending learning. Use what is available and evolve what is not. Partogram is one such powerful tool available in our hands. Let’s put it to use.
- Donnison J. Midwives and Medical Men. London, Historical Publications: 2008
- Rosenberg K, Trevathan W. Birth, obstetrics and human evolution. BJOG: 109(11): 1199–206
- Van Teijlingen E, Lowis J, McCaffery P, Porter M. Midwifery and the Medicalisation of Childbirth: Comparative Perspectives. London, Nova Medical: 2000
- Walsh D. Improving Maternity Service. Small is Beautiful: Lessons for Maternity Services from a Birth Centre. Oxford, Radcliffe Publishing: 2007
- Philpott RH. Graphic records in labour. BMJ 1972; 4: 163-165.
- Philpott RH, Castle WM. Cervicographs in the management of labour in primigravidae. I.The alert line for detecting abnormal labour. J Obstet Gynaecol Br Cwlth 1972; 79: 592-598.
- 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 Cwlth 1972; 79: 599-60.
- World Health Organisation. World Health Organisation partograph in the management of labour. Lancet 1994; 343: 1399-1404.
- Bosse G, Massawe S, Jahn A. The partograph in daily practice: it’s quality that matters. Int JGynaecol Obstet 2002; 77: 243-244.
- Friedman EA. Primigravid labor. A graphicostatistical analysis. Obstet Gynecol 1955; 6: 567-589.
- World Health Organisation. Preventing Prolonged Labour: A Practical Guide. The Partograph. Part I: Principles and Strategy. Geneva: WHO, 1993
- Hendricks CH, Brenner WE, Kraus G. Normal cervical dilatation pattern in late pregnancy and labor. Am J Obstet Gynecol 1970; 106: 1065-1082.
- Cartmill RSV, Thornton JG. Effect of presentation of partogram information on obstetric decision-making. Lancet 1992; 339: 1520-1522.
- Gifford DS, Morton SC, Fiske M, Keesey J, Keeler W, Kahn KL. Lack of progress in labor as a reason for cesarean. Obstet Gynecol 2000; 95: 589-595.
- McCarthy M. What’s going on at the World Health Organization? Lancet 2002; 360: 1108–10
- McCarthy M. A brief history of the World Health Organization. Lancet 2002; 360: 1111–2
- World Health Organization. The World Health Report 2005: Make Every Mother and Child Count. Geneva: World Health Organization; 2005
- World Health Organization, UNICEF, UNFPA, The World Bank. Maternal Mortality in 2005: Estimates Developed by WHO, UNICEF, UNFPA and The World Bank. Geneva: World Health Organization; 2008.
- World Health Organization. Managing Complications in Pregnancy and Childbirth. Geneva: World Health Organization; 2000.
- Kwast BE, Poovan P, Vera E, et al. The modified WHO partograph: do we need a latent phase. Afr J Midwifery Women Health. 2008;2:143–148.
- World Health Organization. Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice. Geneva: World Health Organization; 2006.
- Mathews JE, Rajaratnam A, George A, et al. Comparison of two World Health
- Lennox CE, Kwast BE. The partograph in community obstetrics. Trop Doct 1995; 25: 56–63
- Umezulike AC, Onah HE, Okaro JM. Use of the partograph among medical personnel in Enugu, Nigeria. Int J Gynecol Obstet. 1999;65:203–205.
- Fawole AO, Hunyinbo KI, Adekanle DA. Knowledge and utilization of the partograph among obstetric care givers in South West Nigeria. Afr J Reprod Health. 2008;12:22–29