http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2015; 28(1): 82–87 ! 2015 Informa UK Ltd. DOI: 10.3109/14767058.2014.905908
ORIGINAL ARTICLE
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Assessment of labor using a new type partogram compared to the classical Fisher partogram Georgios Galazios1, Vlad Tica2, Nikolaos Vrachnis3, Georgios Vlachos1, Stefanos Zervoudis2, Iuliana Ceausu2, Grigorios Trypsianis1, Christos Zographou1, and Panagiotis Tsikouras1 1
Department of Obstetrics and Gynecology, Democritus University of Thrace, Alexandroupolis, Greece, 2Department of Obstetrics and Gynecology, University Ovidius, University Regional Emergency Hospital, Bucharest, Romania, and 32nd Department of Obstetrics and Gynecology, University of Athens Medical School, Athens, Greece Abstract
Keywords
Objective: To assess the quality of a new type partogram used to monitor labor. Methods: We compared efficacy using two types of partograms. The first was the classical WHO partogram (group A) and the second a new type in which we estimated and reported the sub of cervical dilatation and the position of the descending head (group B). Results: It was noted that there was a statistically significant decrease of the duration between the initiation of active phase of labor and the delivery time (dt1 + dt2 + dt3) (p50.001, A: mean: 318.4 ± 10.4 min, B: 246.56 ± 8.28 min). Also observed was early initiation in the acceleration stage of the active phase in the first phase of labor (dt1) (p50.001, A: 108.73 ± 5.29 min, B: 69.96 ± 4.99 min), shorter duration of the acceleration stage of the active phase in the first phase of labor (dt2) (p50.001, A: 136.93 ± 4.79 min, B: 91.89 ± 4.04 min) and early initiation in the second phase of labor in women who were studied with the new partogram (B). Conclusion: The new partogram is more helpful in the recognition of the initiation of the acceleration stage during the active phase of labor and in the timely use of appropriate actions in order to achieve a safer delivery.
Fisher partogram, labor progress, new type partogram
Introduction The partogram is a labor graph to evaluate the progress of the first stage of labor in combination with cervical dilatation, descent of head and labor duration time [1,2]. It is widely accepted as an essential component of labor care that serves as an early warning system and can significantly contribute to an early decision-making regarding augmentation and termination of labor [3,4]. The partogram is one of the methods used to decrease maternal mortality and morbidity, while simultaneously increasing the quality and regularity of all observations of the fetus and the mother in labor; it also aids early recognition of problems in either party [5,6]. Labor begins with uterine contractions that bring about demonstrable effacement and dilatation of the cervix [7]. Abnormal labor progression in the active phase is defined as cervical dilatation less than 1.2 cm/h in nulliparous and 1.5 cm/h in multiparous women. Obstructed labor is defined as no appreciable change in cervical dilatation for more than 2 h [7,8]. Friedman’s study in the 1950s introduced a labor curve using statistical observations with division of labor into Address for correspondence: Panagiotis Tsikouras, Assistant Professor, Department of Obstetrics and Gynecology, Democritus University of Thrace, Lysimachou /Petrina, Box 106, 6 km Alexandroupolis/Makri, Alexandroupolis 68100, Greece. E-mail: [email protected]
History Received 19 December 2013 Revised 5 March 2014 Accepted 16 March 2014 Published online 9 April 2014
first and second stages. It also defined the onset of labor as the point at which the woman perceives regular uterine contractions and provided definitions for the expected duration of the stages of labor [9–11]. Zhang and colleagues reported that the acceleration of cervical dilatation occurs after 6 cm and, compared with Friedman’s results, the labor progress is slower from 4 to 6 cm [12]. With proper use of the partogram, the details of labor are displayed, which allows the obstetrician to compare against the ideal labor progress in order to enable early identification of abnormal labor and prevention of obstetric complications [13]. Implementation of a self-directed learning program for midwives has been shown to increase midwives’ ability to interpret information from the partogram [14]. The partogram, a pictorial representation of labor progress contributes in enhancing early recognition of labor arrest and to avoid the cesarean section [15]. The purpose of this study was to evaluate the effect of a new type of partogram and compare this with the efficacy of the classical partogram in obstetric intervention and cesarean section rate.
Methods This was a retrospective study based on 277 laboring, term, singleton, vertex deliveries in two academic institutions, the
A new type of partogram and obstetric intervention
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Chinese University of Hong Kong on 02/23/15 For personal use only.
DOI: 10.3109/14767058.2014.905908
University Hospitals of Alexandroupolis (Greece) and Constanta (Romania). Criteria for the enrollment included: singleton pregnancies, gestation of at least 37 completed weeks, vertex presentation, no use of oxytocin in the first stage of labor, Bishop score below 6 and absence of additional abnormalities, complications or risk factors. Exclusion criteria were hypertension, antepartum hemorrhage and post-term pregnancy. The study partograms were divided into two groups: (1) Fisher’s partograms with two lines: cervical dilatation and action line; and (2) new type partograms with one line depending on three parameters cervical dilatation, actions and fetal head descent line (Figure 1). Management of labor was standardized using the clinical guidelines. The active phase of labor was defined when painful, regular contractions occurred every five minutes or less, lasting more than 40 s, with a cervical effacement more than 80% and with the cervix dilated three or more centimetres until complete cervical dilatation. The latent phase was defined as the time when the first cervical ripening agent was introduced until the time when cervical dilatation
83
reached 3 cm. Vaginal examination was performed by a dedicated doctor or midwife for every 1–2 h. Amniotomy was performed in the event of slow progress or arrest of cervical dilatation for over 1 h. Oxytocin was administrated for arrest of cervical dilatation for 2 h and when membranes ruptured. The duration of the first stage of labor was defined as the time prior to full dilatation. The second stage was defined as the time between the first active expulsion efforts and delivery. Data pertaining to participants who ended either in spontaneous delivery or in cesarean section were included up to the decision time for delivery or intervention and were recorded in a diagram concerning group A or group B as an alert line (Figure 2). In each study the following parameters were assessed and recorded in the partograms: cervical dilatation, fetal heart rate, blood pressure, maternal temperature and post-natal fetal outcome. These data were used to construct the representative partograms (Figures 1 and 2). Fisher’s exact test was used to assess the association between the quality of practical value of the two different partograms and perinatal results. Curves from the two partograms were compared via pairwise
Figure 1. New type partogram.
G. Galazios et al.
J Matern Fetal Neonatal Med, 2015; 28(1): 82–87
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Figure 2. Single graphic line evaluation of labor progress (Re-evaluation line).
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DOI: 10.3109/14767058.2014.905908
likelihood ratio tests by using a random effects model to adjust for obstetric interventions, with significance set at p50.05. Comparative analysis was performed using chisquare and Fisher’s exact tests. The parameters that were studied were the characteristics of the women, the time intervals (in minutes) and the Apgar scores in vaginal deliveries and in cesarean births according to the reading of the two partograms. Statistical analysis of the data was performed using the Statistical Package for the Social Sciences (SPSS), IBM SPSS 19.0 (IBM, Armonk, NY). The normality of quantitative variables was tested with the Kolmogorov–Smirnov test. All quantitative variables were expressed as frequencies (and percentages). The chi-square test and Student’s t test were used to assess differences in participants’ characteristics between the two groups of women. All tests were two-tailed and statistical significance was considered for p values less than 0.05.
A new type of partogram and obstetric intervention
Table 1. Characteristics of women according to the partogram (spontaneous labor).
Fisher
New type partogram
Number of women 75 122 Age (years; mean ± SD) 26.49 ± 5.25 27.39 ± 4.68 Parity [no (%)] Mulliparous 41 (54.7%) 58 (47.5%) Lultiparous 34 (45.3%) 64 (52.5%) Gestation 39.45 ± 0.92 38.89 ± 1.16 (weeks; mean ± SD) Weight (g; mean ± SD) 3394.80 ± 458.19 3346.39 ± 394.54 APGAR at 1 min 8.87 ± 0.38 8.89 ± 0.31 (mean ± SD) APGAR at 5 min 9.97 ± 0.16 10 (mean ± SD)
p value 0.213 0.331 0.573 0.433 0.590 0.159
Table 2. Characteristics of women according to the partogram (cesarean section).
Fisher
Results A total of 277 women were delivered during the study period and met the inclusion criteria. The maternity records were checked retrospectively: 197 (71.2%) spontaneous vaginal deliveries and 80 (28.8%) emergency cesarean births. Partograms of 106 grand multipara women (mean of two previous deliveries) were analyzed according to the Fisher partogram (total 40) and the new type partogram (total 76) and compared with the partograms of nullipara women Fisher partogram (total 65) and new type partogram (total 96) (Tables 1 and 2). The full-term pregnancies were normal and the vaginal deliveries were spontaneous and non-instrumental. Ninety-nine (99) nulliparous and 98 multiparous women had normal vaginal delivery, while 62 nulliparous and 18 multiparous underwent cesarean section (Tables 1 and 2). The maternal age, parity and gestational week were not statistically significant parameters between the two partogram groups. The statistical analysis confirms the following p values for the above-described parameters: p ¼ 0.213, p ¼ 0.31, p ¼ 0.73 in the spontaneous labor group (Table 1), and p ¼ 0.659, p ¼ 0.678 and p ¼ 0.791 in the cesarean section group, respectively (Table 2). No woman received epidural analgesia. The recorded values of fetal heart rate, blood pressure and maternal temperature were within normal limits. The condition of the neonatal babies was assessed using the APGAR score as there were no facilities for cord blood sampling in the study hospitals. The mean birth weight was similar in both groups (p ¼ 0.433 in the spontaneous labor group, Table 1; p ¼ 0.187 in the cesarean section group, Table 2). All babies were born alive. APGAR scores at 1 and 5 min after labor recorded in all studied participants were also similar between the two groups (p ¼ 0.590 and p ¼ 0.159 in the spontaneous labor group, Table 1; both p ¼ 1.000 in the cesarean section group, Table 2). The mean duration between the beginning of the active phase until the start of the acceleration phase (dt(1)) in the first phase of labor was significantly shorter (by 35.7%) in participants whose labor progress was evaluated with the new type partogram (B) (69.96 ± 4.99 min versus 108.73 ± 5.29 min using
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New type partogram
Number of women 30 50 Age (years; mean ± SD) 27.10 ± 4.15 27.56 ± 4.68 Parity [no (%)] Mulliparous 24 (80.0%) 38 (76.0%) Lultiparous 6 (20.0%) 12 (24.0%) Gestation 39.23 ± 0.86 39.18 ± 0.87 (weeks; mean ± SD) Weight (g; mean ± SD) 3624.17 ± 358.29 3603.40 ± 428.63 APGAR at 1 min 9 9 (mean ± SD) APGAR at 5 min 10 10 (mean ± SD)
p value 0.659 0.678 0.791 0.817 1.000 1.000
partogram A, p50.001; 95% CI of the difference, 23.78 to 53.76 min, Table 3). In the sequence, shorter duration (by 32.9%) of acceleration stage of active phase in the first phase of labor [start of acceleration phase – end of acceleration, dt(2)] phase was also associated with partogram B (91.89 ± 4.04 min versus 136.93 ± 4.79 min using partogram A, p50.001; 95% CI of the difference, 32.48 to 57.60 min, Table 3). Consequently, a statistically significant decrease (by 22.6%) of the duration between the initiation of active phase of labor and the delivery time [dt(1)] + [dt(2)] + [dt(3)] was observed in the second group (246.56 ± 8.28 min using partogram B versus 318.40 ± 10.40 min using partogram A, p50.001; 95% CI of the difference, 45.52 to 98.17 min, Table 3). On the other hand, in the cesarean section group the overall time from admission to the hospital till labor was longer (by 19.3%) in the participants whose labor progress was evaluated with the new type partogram (B) (512.00 ± 16.61 min versus 429.17 ± 15.34 min using partogram A, p ¼ 0.001; 95% CI of the difference, 33.97 to 131.69 min, Table 3).
Discussion For a more objective evaluation of labor protraction and arrest, a partogram may be a useful tool. However, the use of a partogram is controversial, especially in elective cesarean section cases, in which no advantages are observed as there is no labor [16]. The labor observations are recorded in the partogram with the aim of alerting obstetricians to an early
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G. Galazios et al.
J Matern Fetal Neonatal Med, 2015; 28(1): 82–87
Table 3. Time intervals (in minutes; expressed as mean ± standard error) in spontaneous labor and cesarean section, according to the different partograms.
Start of active phase – Start of acceleration phase [dt(1)] Start of acceleration phase – End of acceleration phase [dt(2)] End of acceleration phase – Labor [dt(3)] Start of active phase – Labor [dt(1) + dt(2) + dt(3)] Time of entrance in the hospital – Labor Start of active phase – Labor [cesarean section] Time of entrance in the hospital – Labor [cesarean section]
Fischer
New type partogram
p value
108.73 ± 5.29 136.93 ± 4.79 72.73 ± 2.79 318.40 ± 10.40 341.33 ± 11.86 344.50 ± 12.80 429.17 ± 15.34
69.96 ± 4.99 91.89 ± 4.04 84.71 ± 6.40 246.56 ± 8.28 350.25 ± 12.92 380.50 ± 15.19 512.00 ± 16.61
50.001 50.001 0.088 50.001 0.612 0.074 0.001
95% CI of the difference 23.78 32.48 25.76 45.52 46.25 79.79 131.69
to to to to to to to
53.76 57.60 1.80 98.17 98.17 7.79 33.97
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Start of active phase – Start of acceleration phase – [dt(1)]. Start of acceleration phase – End of acceleration phase – [dt(2)]. End of acceleration phase – Labor – [dt(3)]. Start of active phase – Labor – [dt(1)] + [dt(2)] + [dt(3)].
recognition of deviations from normality in labor progress as well as absence of fetal and/or maternal well-being. The use of the partogram reduces the risk of prolonged labor, cesarean sections and perinatal mortality [12,17–19]. The documentation of the partogram includes the administration of oxytocin and such procedures as amniotomy [17]. In the Fisher partogram, cervical dilatation and action line are the recorded parameters of the progress of labor, but the fetal head descent is not included [20]. The wide variation in the published records of labor observation suggests that midwives and some obstetricians prioritized cervical dilatation over the other parameters [20]. Possibly, not all parameters in the previous partogram are essential to ensure optimal outcome of labor [20,21]. However, it is of great importance to monitor the fetal condition intrapartum in order to achieve satisfactory fetal outcome [22], since substandard intrapartum fetal monitoring is strongly associated with poor fetal outcome (p50.001) [22]. In multiparous deliveries the delayed normal rotation of the fetal head from occiput transverse to occiput anterior position, resulting from delayed descent, has led to the assumption that fetuses are often delivered in a low transverse position of the head [23]. However, the slow head descent is caused by pelvic floor physiological changes and is not exclusively due to cephalopelvic disproportion [23]. According to our results, we found that the fetal head descent is an important labor progress parameter when it comes to decision-making concerning the delivery mode. While the classical Fisher partogram consists of two straight diagonal parallel lines and the action line is parallel and right of the alert line, in the new partogram under study the alert line is crossed only once and it is included as part of the single graphic line evaluation of labor progress (Figure 2). An alert line based on the low 10th centile of the local population is an attentive parameter and should perhaps be used in the management of labor [24]. When the alert line was crossed by the action line, it was followed by artificial or spontaneous rupture of membranes; the starting point in our partograms was at 6 cm of cervical dilatation to the point of full dilatation at the rate of 1 cm per hour. This indicates that attention is needed if cervical dilatation is slower than 1 cm per hour. In a partogram where the earliest deviation in labor progress may be slow until arrest of labor occurs, the alert line represents a prompt signal for early recognition and immediate intervention so as to correct the deviation [16].
In our study, we found that there is a shorter duration of acceleration in the active phase (first stage of labor) of the new type partogram (B). In cases using partogram B, dt(2) was 91.89 ± 4.04 min versus 136.93 ± 4.79 in cases using partogram A; p50.001, 32.48 to 57.60 (95% CI of the difference) (Table 3). Engagement of fetal head led to a shorter duration of the alert line [dt(2)] and influenced the course of labor. Based on our findings, we confirmed in the second group a statistically significant decrease in the duration between the initiation of active phase of labor and the delivery time [dt(1)] + [dt(2)] + [dt(3)] in cases where the labor progress was evaluated according to the new type partogram B. Partogram A was 318.40 ± 10.40 min versus 246.56 ± 8.28, respectively [p50.001, 45.52 to 98.17 (95% CI of the difference)] (Table 3). Since these differences appear to be clinically significant, their suboptimal documentation, especially that of the fetal head descent, hinders early detection of labor progress deviation, timely intervention of labor modus and prevention of obstetric complications. Failure of descent of the presenting part during the first stage of labor in addition to arrest of cervical dilatation was associated with a high cesarean section rate. This contributes to the support of multifactorial redefinition of labor curves, which are used widely in the management of labor. The partogram is a useful tool in appropriate labor management that can be used as a guide when interventions are undertaken during labor. On the basis of the findings of this study, we recommend further studies focusing on the routine use of the new type partogram that should form a component of standard labor management and may contribute further to satisfactory perinatal results and improved maternal outcomes.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
References 1. Cartmill RS, Thornton JG. Effect of presentation of partogram information on obstetric decision-making. Lancet 1992;339: 1520–2. 2. Bosse G, Massawe S, Jahn A. The partograph in daily practice: it’s quality that matters. Int J Gynaecol Obstet 2002;77:243–4.
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DOI: 10.3109/14767058.2014.905908
3. Dujardin B, De Schampheleire I, Sene H, Ndiaye F. Value of the alert and action lines on the partogram. Lancet 1992;339:1336–8. 4. Fatusi AO, Makinde ON, Adeyemi AB, et al. Evaluation of health workers’ training in use of the partogram. Int J Gynaecol Obstet 2008;100:41–4. 5. Lavender T, Wallymahmed AH, Walkinshaw SA. Managing labor using partograms with different action lines: a prospective study of women’s views. Birth 1999;26:89–96. 6. Azandegbe´ N, Testa J, Makoutode´ M. Assessment of partogram utilisation in Benin. Sante 2004;14:251–5. 7. Nelson DB, McIntire DD, Leveno KJ. Relationship of the length of the first stage of labor to the length of the second stage. Obstet Gynecol 2013;122:27–32. 8. Neilson JP, Lavender T, Quenby S, Wray S. Obstructed labour. Br Med Bull 2003;67:191–204. 9. Friedman EA. Classic pages in obstetrics and gynecology. The graphic analysis of labor. Am J Obstet Gynecol 1978;132:822–3. 10. Friedman EA. Evolution of graphic analysis of labor. Am J Obstet Gynecol 1978;132:824–7. 11. Friedman EA. A cervimeter for continuous measurement of cervical dilatation in labour – preliminary results. Br J Obstet Gynaecol 1978;85:638. 12. Zhang J, Landy HJ, Branch DW, et al.; Consortium on Safe Labor. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol 2010;116:1281–7. 13. Souberbielle BE, O’Brien ME. Use of WHO partogram in developing countries. Lancet 1994;344:193. 14. Theron GB. Effect of the maternal care manual of the perinatal education programme on the ability of midwives to interpret antenatal cards and partograms. J Perinatol 1999;19:432–5.
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15. Windrim R, Seaward PG, Hodnett E, et al. A randomized controlled trial of a bedside partogram in the active management of primiparous labour. J Obstet Gynaecol Can 2007; 29:27–34. 16. Leanza V, Leanza G, Monte S. A didactic protocol for labour and delivery: the partogram. Minerva Ginecol 2011;63: 325–32. 17. Orhue A, Aziken ME, Osemwenkha AP. Partograph as a tool for team work management of spontaneous labor. Niger J Clin Pract 2012;15:1–8. 18. Kidanto HL, Massawe SN, Nystrom L, Lindmark G. Analysis of perinatal mortality at a teaching hospital in Dar es Salaam, Tanzania, 1999–2003. Afr J Reprod Health 2006;10:72–80. 19. Hofmeyr GJ. Obstructed labor: using better technologies to reduce mortality. Int J Gynaecol Obstet 2004;85:S62–72. 20. Mathews JE, Rajaratnam A, George A, Mathai M. Comparison of two World Health Organization partographs. Int J Gynaecol Obstet 2007;96:147–50. 21. Nyamtema AS, Urassa DP, Massawe S, et al. Partogram use in the Dar es Salaam perinatal care study. Int J Gynaecol Obstet 2008; 100:37–40. 22. Sallam HN, Abdel-Dayem A, Sakr RA, et al. Mathematical relationships between uterine contractions, cervical dilatation, descent and rotation in spontaneous vertex deliveries. Int J Gynaecol Obstet 1999;64:135–9. 23. Juntunen K, Kirkinen P. Partogram of a grand multipara: different descent slope compared with an ordinary parturient. J Perinat Med 1994;22:213–18. 24. Van Bogaert LJ. Revising the primigravid partogram: does it make any difference? Arch Gynecol Obstet 2009;279:643–7.
ORIGINAL ARTICLE
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Chinese University of Hong Kong on 02/23/15 For personal use only.
Assessment of labor using a new type partogram compared to the classical Fisher partogram Georgios Galazios1, Vlad Tica2, Nikolaos Vrachnis3, Georgios Vlachos1, Stefanos Zervoudis2, Iuliana Ceausu2, Grigorios Trypsianis1, Christos Zographou1, and Panagiotis Tsikouras1 1
Department of Obstetrics and Gynecology, Democritus University of Thrace, Alexandroupolis, Greece, 2Department of Obstetrics and Gynecology, University Ovidius, University Regional Emergency Hospital, Bucharest, Romania, and 32nd Department of Obstetrics and Gynecology, University of Athens Medical School, Athens, Greece Abstract
Keywords
Objective: To assess the quality of a new type partogram used to monitor labor. Methods: We compared efficacy using two types of partograms. The first was the classical WHO partogram (group A) and the second a new type in which we estimated and reported the sub of cervical dilatation and the position of the descending head (group B). Results: It was noted that there was a statistically significant decrease of the duration between the initiation of active phase of labor and the delivery time (dt1 + dt2 + dt3) (p50.001, A: mean: 318.4 ± 10.4 min, B: 246.56 ± 8.28 min). Also observed was early initiation in the acceleration stage of the active phase in the first phase of labor (dt1) (p50.001, A: 108.73 ± 5.29 min, B: 69.96 ± 4.99 min), shorter duration of the acceleration stage of the active phase in the first phase of labor (dt2) (p50.001, A: 136.93 ± 4.79 min, B: 91.89 ± 4.04 min) and early initiation in the second phase of labor in women who were studied with the new partogram (B). Conclusion: The new partogram is more helpful in the recognition of the initiation of the acceleration stage during the active phase of labor and in the timely use of appropriate actions in order to achieve a safer delivery.
Fisher partogram, labor progress, new type partogram
Introduction The partogram is a labor graph to evaluate the progress of the first stage of labor in combination with cervical dilatation, descent of head and labor duration time [1,2]. It is widely accepted as an essential component of labor care that serves as an early warning system and can significantly contribute to an early decision-making regarding augmentation and termination of labor [3,4]. The partogram is one of the methods used to decrease maternal mortality and morbidity, while simultaneously increasing the quality and regularity of all observations of the fetus and the mother in labor; it also aids early recognition of problems in either party [5,6]. Labor begins with uterine contractions that bring about demonstrable effacement and dilatation of the cervix [7]. Abnormal labor progression in the active phase is defined as cervical dilatation less than 1.2 cm/h in nulliparous and 1.5 cm/h in multiparous women. Obstructed labor is defined as no appreciable change in cervical dilatation for more than 2 h [7,8]. Friedman’s study in the 1950s introduced a labor curve using statistical observations with division of labor into Address for correspondence: Panagiotis Tsikouras, Assistant Professor, Department of Obstetrics and Gynecology, Democritus University of Thrace, Lysimachou /Petrina, Box 106, 6 km Alexandroupolis/Makri, Alexandroupolis 68100, Greece. E-mail: [email protected]
History Received 19 December 2013 Revised 5 March 2014 Accepted 16 March 2014 Published online 9 April 2014
first and second stages. It also defined the onset of labor as the point at which the woman perceives regular uterine contractions and provided definitions for the expected duration of the stages of labor [9–11]. Zhang and colleagues reported that the acceleration of cervical dilatation occurs after 6 cm and, compared with Friedman’s results, the labor progress is slower from 4 to 6 cm [12]. With proper use of the partogram, the details of labor are displayed, which allows the obstetrician to compare against the ideal labor progress in order to enable early identification of abnormal labor and prevention of obstetric complications [13]. Implementation of a self-directed learning program for midwives has been shown to increase midwives’ ability to interpret information from the partogram [14]. The partogram, a pictorial representation of labor progress contributes in enhancing early recognition of labor arrest and to avoid the cesarean section [15]. The purpose of this study was to evaluate the effect of a new type of partogram and compare this with the efficacy of the classical partogram in obstetric intervention and cesarean section rate.
Methods This was a retrospective study based on 277 laboring, term, singleton, vertex deliveries in two academic institutions, the
A new type of partogram and obstetric intervention
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Chinese University of Hong Kong on 02/23/15 For personal use only.
DOI: 10.3109/14767058.2014.905908
University Hospitals of Alexandroupolis (Greece) and Constanta (Romania). Criteria for the enrollment included: singleton pregnancies, gestation of at least 37 completed weeks, vertex presentation, no use of oxytocin in the first stage of labor, Bishop score below 6 and absence of additional abnormalities, complications or risk factors. Exclusion criteria were hypertension, antepartum hemorrhage and post-term pregnancy. The study partograms were divided into two groups: (1) Fisher’s partograms with two lines: cervical dilatation and action line; and (2) new type partograms with one line depending on three parameters cervical dilatation, actions and fetal head descent line (Figure 1). Management of labor was standardized using the clinical guidelines. The active phase of labor was defined when painful, regular contractions occurred every five minutes or less, lasting more than 40 s, with a cervical effacement more than 80% and with the cervix dilated three or more centimetres until complete cervical dilatation. The latent phase was defined as the time when the first cervical ripening agent was introduced until the time when cervical dilatation
83
reached 3 cm. Vaginal examination was performed by a dedicated doctor or midwife for every 1–2 h. Amniotomy was performed in the event of slow progress or arrest of cervical dilatation for over 1 h. Oxytocin was administrated for arrest of cervical dilatation for 2 h and when membranes ruptured. The duration of the first stage of labor was defined as the time prior to full dilatation. The second stage was defined as the time between the first active expulsion efforts and delivery. Data pertaining to participants who ended either in spontaneous delivery or in cesarean section were included up to the decision time for delivery or intervention and were recorded in a diagram concerning group A or group B as an alert line (Figure 2). In each study the following parameters were assessed and recorded in the partograms: cervical dilatation, fetal heart rate, blood pressure, maternal temperature and post-natal fetal outcome. These data were used to construct the representative partograms (Figures 1 and 2). Fisher’s exact test was used to assess the association between the quality of practical value of the two different partograms and perinatal results. Curves from the two partograms were compared via pairwise
Figure 1. New type partogram.
G. Galazios et al.
J Matern Fetal Neonatal Med, 2015; 28(1): 82–87
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Chinese University of Hong Kong on 02/23/15 For personal use only.
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Figure 2. Single graphic line evaluation of labor progress (Re-evaluation line).
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Chinese University of Hong Kong on 02/23/15 For personal use only.
DOI: 10.3109/14767058.2014.905908
likelihood ratio tests by using a random effects model to adjust for obstetric interventions, with significance set at p50.05. Comparative analysis was performed using chisquare and Fisher’s exact tests. The parameters that were studied were the characteristics of the women, the time intervals (in minutes) and the Apgar scores in vaginal deliveries and in cesarean births according to the reading of the two partograms. Statistical analysis of the data was performed using the Statistical Package for the Social Sciences (SPSS), IBM SPSS 19.0 (IBM, Armonk, NY). The normality of quantitative variables was tested with the Kolmogorov–Smirnov test. All quantitative variables were expressed as frequencies (and percentages). The chi-square test and Student’s t test were used to assess differences in participants’ characteristics between the two groups of women. All tests were two-tailed and statistical significance was considered for p values less than 0.05.
A new type of partogram and obstetric intervention
Table 1. Characteristics of women according to the partogram (spontaneous labor).
Fisher
New type partogram
Number of women 75 122 Age (years; mean ± SD) 26.49 ± 5.25 27.39 ± 4.68 Parity [no (%)] Mulliparous 41 (54.7%) 58 (47.5%) Lultiparous 34 (45.3%) 64 (52.5%) Gestation 39.45 ± 0.92 38.89 ± 1.16 (weeks; mean ± SD) Weight (g; mean ± SD) 3394.80 ± 458.19 3346.39 ± 394.54 APGAR at 1 min 8.87 ± 0.38 8.89 ± 0.31 (mean ± SD) APGAR at 5 min 9.97 ± 0.16 10 (mean ± SD)
p value 0.213 0.331 0.573 0.433 0.590 0.159
Table 2. Characteristics of women according to the partogram (cesarean section).
Fisher
Results A total of 277 women were delivered during the study period and met the inclusion criteria. The maternity records were checked retrospectively: 197 (71.2%) spontaneous vaginal deliveries and 80 (28.8%) emergency cesarean births. Partograms of 106 grand multipara women (mean of two previous deliveries) were analyzed according to the Fisher partogram (total 40) and the new type partogram (total 76) and compared with the partograms of nullipara women Fisher partogram (total 65) and new type partogram (total 96) (Tables 1 and 2). The full-term pregnancies were normal and the vaginal deliveries were spontaneous and non-instrumental. Ninety-nine (99) nulliparous and 98 multiparous women had normal vaginal delivery, while 62 nulliparous and 18 multiparous underwent cesarean section (Tables 1 and 2). The maternal age, parity and gestational week were not statistically significant parameters between the two partogram groups. The statistical analysis confirms the following p values for the above-described parameters: p ¼ 0.213, p ¼ 0.31, p ¼ 0.73 in the spontaneous labor group (Table 1), and p ¼ 0.659, p ¼ 0.678 and p ¼ 0.791 in the cesarean section group, respectively (Table 2). No woman received epidural analgesia. The recorded values of fetal heart rate, blood pressure and maternal temperature were within normal limits. The condition of the neonatal babies was assessed using the APGAR score as there were no facilities for cord blood sampling in the study hospitals. The mean birth weight was similar in both groups (p ¼ 0.433 in the spontaneous labor group, Table 1; p ¼ 0.187 in the cesarean section group, Table 2). All babies were born alive. APGAR scores at 1 and 5 min after labor recorded in all studied participants were also similar between the two groups (p ¼ 0.590 and p ¼ 0.159 in the spontaneous labor group, Table 1; both p ¼ 1.000 in the cesarean section group, Table 2). The mean duration between the beginning of the active phase until the start of the acceleration phase (dt(1)) in the first phase of labor was significantly shorter (by 35.7%) in participants whose labor progress was evaluated with the new type partogram (B) (69.96 ± 4.99 min versus 108.73 ± 5.29 min using
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New type partogram
Number of women 30 50 Age (years; mean ± SD) 27.10 ± 4.15 27.56 ± 4.68 Parity [no (%)] Mulliparous 24 (80.0%) 38 (76.0%) Lultiparous 6 (20.0%) 12 (24.0%) Gestation 39.23 ± 0.86 39.18 ± 0.87 (weeks; mean ± SD) Weight (g; mean ± SD) 3624.17 ± 358.29 3603.40 ± 428.63 APGAR at 1 min 9 9 (mean ± SD) APGAR at 5 min 10 10 (mean ± SD)
p value 0.659 0.678 0.791 0.817 1.000 1.000
partogram A, p50.001; 95% CI of the difference, 23.78 to 53.76 min, Table 3). In the sequence, shorter duration (by 32.9%) of acceleration stage of active phase in the first phase of labor [start of acceleration phase – end of acceleration, dt(2)] phase was also associated with partogram B (91.89 ± 4.04 min versus 136.93 ± 4.79 min using partogram A, p50.001; 95% CI of the difference, 32.48 to 57.60 min, Table 3). Consequently, a statistically significant decrease (by 22.6%) of the duration between the initiation of active phase of labor and the delivery time [dt(1)] + [dt(2)] + [dt(3)] was observed in the second group (246.56 ± 8.28 min using partogram B versus 318.40 ± 10.40 min using partogram A, p50.001; 95% CI of the difference, 45.52 to 98.17 min, Table 3). On the other hand, in the cesarean section group the overall time from admission to the hospital till labor was longer (by 19.3%) in the participants whose labor progress was evaluated with the new type partogram (B) (512.00 ± 16.61 min versus 429.17 ± 15.34 min using partogram A, p ¼ 0.001; 95% CI of the difference, 33.97 to 131.69 min, Table 3).
Discussion For a more objective evaluation of labor protraction and arrest, a partogram may be a useful tool. However, the use of a partogram is controversial, especially in elective cesarean section cases, in which no advantages are observed as there is no labor [16]. The labor observations are recorded in the partogram with the aim of alerting obstetricians to an early
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Table 3. Time intervals (in minutes; expressed as mean ± standard error) in spontaneous labor and cesarean section, according to the different partograms.
Start of active phase – Start of acceleration phase [dt(1)] Start of acceleration phase – End of acceleration phase [dt(2)] End of acceleration phase – Labor [dt(3)] Start of active phase – Labor [dt(1) + dt(2) + dt(3)] Time of entrance in the hospital – Labor Start of active phase – Labor [cesarean section] Time of entrance in the hospital – Labor [cesarean section]
Fischer
New type partogram
p value
108.73 ± 5.29 136.93 ± 4.79 72.73 ± 2.79 318.40 ± 10.40 341.33 ± 11.86 344.50 ± 12.80 429.17 ± 15.34
69.96 ± 4.99 91.89 ± 4.04 84.71 ± 6.40 246.56 ± 8.28 350.25 ± 12.92 380.50 ± 15.19 512.00 ± 16.61
50.001 50.001 0.088 50.001 0.612 0.074 0.001
95% CI of the difference 23.78 32.48 25.76 45.52 46.25 79.79 131.69
to to to to to to to
53.76 57.60 1.80 98.17 98.17 7.79 33.97
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Start of active phase – Start of acceleration phase – [dt(1)]. Start of acceleration phase – End of acceleration phase – [dt(2)]. End of acceleration phase – Labor – [dt(3)]. Start of active phase – Labor – [dt(1)] + [dt(2)] + [dt(3)].
recognition of deviations from normality in labor progress as well as absence of fetal and/or maternal well-being. The use of the partogram reduces the risk of prolonged labor, cesarean sections and perinatal mortality [12,17–19]. The documentation of the partogram includes the administration of oxytocin and such procedures as amniotomy [17]. In the Fisher partogram, cervical dilatation and action line are the recorded parameters of the progress of labor, but the fetal head descent is not included [20]. The wide variation in the published records of labor observation suggests that midwives and some obstetricians prioritized cervical dilatation over the other parameters [20]. Possibly, not all parameters in the previous partogram are essential to ensure optimal outcome of labor [20,21]. However, it is of great importance to monitor the fetal condition intrapartum in order to achieve satisfactory fetal outcome [22], since substandard intrapartum fetal monitoring is strongly associated with poor fetal outcome (p50.001) [22]. In multiparous deliveries the delayed normal rotation of the fetal head from occiput transverse to occiput anterior position, resulting from delayed descent, has led to the assumption that fetuses are often delivered in a low transverse position of the head [23]. However, the slow head descent is caused by pelvic floor physiological changes and is not exclusively due to cephalopelvic disproportion [23]. According to our results, we found that the fetal head descent is an important labor progress parameter when it comes to decision-making concerning the delivery mode. While the classical Fisher partogram consists of two straight diagonal parallel lines and the action line is parallel and right of the alert line, in the new partogram under study the alert line is crossed only once and it is included as part of the single graphic line evaluation of labor progress (Figure 2). An alert line based on the low 10th centile of the local population is an attentive parameter and should perhaps be used in the management of labor [24]. When the alert line was crossed by the action line, it was followed by artificial or spontaneous rupture of membranes; the starting point in our partograms was at 6 cm of cervical dilatation to the point of full dilatation at the rate of 1 cm per hour. This indicates that attention is needed if cervical dilatation is slower than 1 cm per hour. In a partogram where the earliest deviation in labor progress may be slow until arrest of labor occurs, the alert line represents a prompt signal for early recognition and immediate intervention so as to correct the deviation [16].
In our study, we found that there is a shorter duration of acceleration in the active phase (first stage of labor) of the new type partogram (B). In cases using partogram B, dt(2) was 91.89 ± 4.04 min versus 136.93 ± 4.79 in cases using partogram A; p50.001, 32.48 to 57.60 (95% CI of the difference) (Table 3). Engagement of fetal head led to a shorter duration of the alert line [dt(2)] and influenced the course of labor. Based on our findings, we confirmed in the second group a statistically significant decrease in the duration between the initiation of active phase of labor and the delivery time [dt(1)] + [dt(2)] + [dt(3)] in cases where the labor progress was evaluated according to the new type partogram B. Partogram A was 318.40 ± 10.40 min versus 246.56 ± 8.28, respectively [p50.001, 45.52 to 98.17 (95% CI of the difference)] (Table 3). Since these differences appear to be clinically significant, their suboptimal documentation, especially that of the fetal head descent, hinders early detection of labor progress deviation, timely intervention of labor modus and prevention of obstetric complications. Failure of descent of the presenting part during the first stage of labor in addition to arrest of cervical dilatation was associated with a high cesarean section rate. This contributes to the support of multifactorial redefinition of labor curves, which are used widely in the management of labor. The partogram is a useful tool in appropriate labor management that can be used as a guide when interventions are undertaken during labor. On the basis of the findings of this study, we recommend further studies focusing on the routine use of the new type partogram that should form a component of standard labor management and may contribute further to satisfactory perinatal results and improved maternal outcomes.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
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