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Barbara Kwast
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Abstract
The objective was to study the frequency and mode of delivery of
women admitted in the latent and active phase of labour in St.
Lukes Catholic Hospital in Wolisso, Southwest Shoa Zone, Oromia
Regional State, Ethiopia. It was a descriptive, retrospective
design. Admission phases of labour and mode of delivery were
collected for seven months.
The modified World Health Organization (WHO) partograph
was introduced in Wolisso in January 2007. Analysis of mode
of delivery of women admitted in the latent and active phase,
showed that women admitted in the latent phase had more
operative (both abdominal and vaginal) deliveries as labour
progressed to the right of the alert line in active phase compared
to women admitted in the active phase of labour. Partographs
were generally plotted very well, with 86% of those eligible
for partography available for analysis. Application of the
management protocol needs to improve as the average monthly
C/S rate is 22.5% and augmentation of labour is rarely applied.
It is recommended that a management protocol for women
admitted in the latent phase is formulated and applied. Space
for these women needs to be organized closer to the labour ward
for regular observation in the latent phase and earlier diagnosis
of the onset of the active phase of labour. Considering the mean
number of 5.857 hours until the active phase was diagnosed,
re-introduction of the latent phase on the WHO partograph
remains a controversial subject. However, development of,
and adherence to, a management protocol for these women is
strongly recommended. One-third of the women were admitted
in the second stage of labour which means that frequency of
partograph use should not be used as a quality of care indicator
in management information systems but criterion-based audits
would definitely improve management of labour.
described elsewhere (WHO, 1993a and 1993b). The WHO
conducted a multi-centre trial of this partograph between
1990 and 1991 in south-east Asia comprising 35 484 women
(WHO, 1994a and 1994b).
In 2000, the modified version of the WHO partograph
was introduced after the publication of the Integrated
Management of Pregnancy and Childbirth or IMPAC
Barbara E. Kwast is International Consultant Maternal Health
and Safe Motherhood, Senior Adviser AMDD, Leusden, The
Netherlands; Pia Poovan is Senior Surgeon; Edita Vera is Director
of Nursing Services; Elaine Kohlsis General Manager, St. Luke
Hospital, Wolisso, Ethiopia
143
Regular observations in
the latent phase of labour
may give the woman the
advantage of an earlier
observed labour in active
phase.
Methods
Intervention
The introduction of the modified WHO partograph in
St. Luke Hospital in January 2007 coincided with the
conduct of a number of Safe Motherhood and Emergency
Obstetric Care workshops for students of the College of
Nursing, tutors and all staff of the delivery unit of the
hospital. Two days in-service training was conducted on
the modified partograph with simultaneous introduction
of the new partograph in the labour ward and the development of a management protocol. Ongoing supervision in
the labour ward could be provided during the workshop
and at night and thus questions and problems could be
solved simultaneously.
Two weeks after the implementation, a modified criterion-based audit was performed with all staff of the labour
ward to look at labour management issues. Teaching posters
were displayed in the labour ward and one copy of IMPAC
was left as a reference with ten more copies available in the
144
Data collection
In February 2008, a descriptive, retrospective study was
designed with the permission and participation of the senior
staff involved with labour ward management. The objective
was to gain an understanding of the frequency of women
admitted in the latent and active phases of labour and to
compare these with the mode of delivery related to alert and
action lines for those women having reached or been admitted in the active phase of labour.
The register in the delivery room was available for the
last six months of 2007 and the first months of 2008.
All data were abstracted and entered by hand on tally
sheets designed for the study. The register was used to
record age and parity, the phase of labour on admission
and mode of delivery and outcome for all women during these eight months. All case notes of admissions in
January 2008 were pulled from the records department
for an in-depth analysis of progress of labour and mode of
delivery of those women admitted in the latent and active
phases related to alert and action lines on the partographs.
Parameters for documentation of specific elements of
the partographs were not analyzed separately. If labour
progress was plotted inconsistently, the partographs were
considered unassessable. Anonymity was guaranteed and
neither names of women nor staff were recorded anywhere
on the tally sheets.
Analysis
Data for all births during the seven months from July
2007 to January 2008 were analyzed. Tabulations between
phase of labour on admission and mode of delivery were
made for 1 318 women. Case records for 226 women
who delivered in January 2008 were retrieved from the
records department and an in-depth analysis was made
related to progress of labour in the latent and active
phases and mode of delivery related to alert and action
lines on the partograph. Frequency tables were generated;
means and standard deviations (SD) were calculated for
variables related to hours in latent phase before entering
active phase and dilatation on first examination in latent
and active phase of labour. Analysis was conducted using
PEPI software CHISQ and EXACT2XK programs
(Abramson and Gahlinger, 2001).
Partograph analysis
Of the 226 women, a total of 127 (56.2%) were eligible
for partography: 21 of 32 latent phase admissions who
entered the active phase <9 cm, and 106 of 196 of active
phase admissions. 117 women had assessable partographs:
18 of 21 (86%) and 99 of 106 (93.4%) admitted in latent
Latent
phase
24(13)
18(11)
14(9)
13(8)
24(15)
15(8)
32(14)
140
(11.2)
Active
1st stage
74(41)
65(41)
70(45)
89(52)
63(40)
93(47)
124(55)
578
(46.4)
2nd stage
NK
Total
68(38)
15(8)
181(100)
51(32)
25(16)
159(100)
55(36)
15(10)
154(100)
51(30)
17(10)
170(100)
60(38)
11(7)
158(100)
65(33)
25(12)
198(100)
55(24)
15(7)
226(100)
405
123
1246*
(32.5)
(9.9)
(100)
Wolisso, July 2007January 2008
Latent phase
140(100)
Active phase
1178(100)
Total
1318(100)
55(39.5)
22(15.8)
661(56.1)
126(10.6)
716(54.2)
148(11.2)
58(41)
00)
0(0)
234(19.9)
10(0.8)
15(1.3)
292(22.3)
10(0.8)
15(1.1)
2(1.4)
3(2.2)
17(1.4)
7(0.6)
19(1.4)
10(0.8)
0(0)
108(9.2)
108(8.2)
Wolisso, July 2007 January 2008
145
Course of labour
Total women*
18
100
99
100
38.9
67
69.8
27.8
18
18.8
33.3
14
14.1
Progress
On or left of Between alert
alert line
& action line
67(67.7)
18(18.2)
of labour
At or beyond
action line
Total
14(14.1)
99(100)
1(9.1)
8(61.5)
54(77.1)
1
2
1(1.6)
6(54.5)
11(100)
2(15.4)
13(100)
5(7.2)
70(100)
1
2(100)
2(100)
1(100)
3
Wolisso, January 2008
4(36.4)
3(23.1)
11(15.5)
146
Mode of delivery was as follows: spontaneous vertex delivery 119 (60.7 %); caesarean section 35 (17.9 %); vacuum
delivery 25 (12.8 %); twins: 9 (4.6 %); breech 3 (1.5%);
laparotomy for ruptured uterus 3 (1.5%); destructive
operation 2 (1.0 %).
Discussion
No study to date, to our knowledge, has described what
happens to women admitted in the latent phase of labour
when the modified WHO partograph without the latent
phase is applied. During the last decade there has been a
desire to simplify the partograph by deleting the latent phase
of labour as confusion was created when dilatation had to be
transferred from the latent phase on to the alert line once the
active phase was reached (Dujardin et al, 1992; Matthews
et al, 2007; Odberg Pettersson et al, 2000). Mathews and
colleagues (2007) have shown results of progress of labour
and outcomes comparing the original composite WHO
partograph with an even more simplified WHO partograph
(WHO, 2006).
The present analysis in a rural area in Ethiopia of seven
months from July 2007 to January 2008 shows a consistent
pattern of about 11.1% of admissions in the latent phase of
labour. This is lower compared to 27% in urban settings in
three south-east Asian countries (WHO, 1994b). The indepth analysis of 226 women in January 2008 shows that
92.6% of latent phase admissions had the first examination in
active phase after a mean of 5.85 hours in labour at a mean of
5.84 cms dilatation (range 410 cm). The WHO multi-centre
trial (1994a and 1994b) showed that 95.3% of latent phase
admissions progressed to active phase within eight hours.
Since 50% of latent phase admissions were at 3 cm dilatation,
the question arises whether the alert line in the modified par-
Management of labour
Management of labour requires special skills and patience,
particularly managing primigravidae in order not to send
too many back home to remote areas with an unnecessary
caesarean section scar, which may prove fatal in the next pregnancy. Seffah and colleagues (1994) showed the usefulness
of the partograph in a trial of labour (TOL) in prior C/S in
Ghana. The most significant finding was that the partograph
enabled the use of level of head measured abdominally in 5th
above the symphysis pubis as well as the initial rate of cervical
dilatation to predict the outcome of TOL. In Africa, where
tragedies of obstructed labour, ruptured uterus and vesicovaginal fistula are daily occurrences, measurement of level
of head in 5th must be retained on the partograph as failure
of the head to descend is an extremely important marker of
obstructed labour. After more than 40 years struggle with
implementation of the partograph worldwide, serious action
needs to be taken to manage labour better and at all levels of
the health system as Nyamtema and colleagues (2008) have
clearly emphasized in a study in Dar es Salaam.
Of the 107 women with an active phase of labour plotted
adequately on the partograph, 63.6% remained on or left of
the alert line, 21.4% moved to the right of the alert line and
15% reached or crossed the action line. In south-east Asia
these findings were 72.8%, 17.3% and 9.9% respectively
(Lennox and Kwast, 1995). The higher number dilating
slower than 1cm/hr in Africa may well indicate a higher
degree of cephalo-pelvic disproportion in Ethiopia with
concomitant higher C/S rates. Mathews and colleagues
(2007) data show labours moving to the right of the alert
line but not reaching action line on the composite and simplified partograph as 17.8% and 15% respectively, and for
those crossing the action line as 7% and 0.7% respectively.
147
retrieval of case records is acknowledged. Dr. Patsy Bailey, Senior Scientist and
Dr. Conrad Otterness, Research Analyst of Family Health International(FHI),
Research Triangle Park, NC, USA are thanked for help with statistical analysis.
Conclusions
Labour can be managed without the latent phase being plotted on a partograph, provided that a labour management
protocol for the latent phase is instituted with clear guidelines
on frequency of observations as women with <4 cm dilatation
on admission are more likely to end up with complicated
deliveries. Many women who come early give us a warning
sign of underlying problems, particularly cephalo-pelvic disproportion. In addition, many nulliparous women and those
with previous C/S who present in the latent phase deserve
a careful trial of labour. Regular observations in the latent
phase of labour may give the woman the advantage of an
earlier observed labour in active phase. This requires space to
accommodate women who are presenting in the latent phase
and encouragement to report back regularly to the labour
ward if a woman is sent to a waiting area or other ward. One
limitation of this study may be the small numbers, but in
this perspective some results are not new. It is intriguing that
results in this small study are remarkably similar to the WHO
multi-centre trial even though it was conducted in a different
population in Asia.
More research is recommended on the outcomes of the
modified WHO partograph and more needs to be known
about the parameters for a fetal heart rate between 100
and 180. In spite of the high prevalence of prolonged and
obstructed labour in Africa, hospital C/S rates should be kept
within reasonable limits and regular criterion-based audits of
partographs and C/S are an excellent quality improvement
tool as they are objective and confidential.
AJM
Acknowledgements
The authors wish to express gratitude to Dr. Fabio Manenti, Medical Director
at that time for permission to implement the modified WHO partograph in St.
Luke hospital and to the following staff: Dr. Woldegabriel Jofore, surgeon; Sr.
Stella Varghese, SSps, matron in 2007; all midwives, nurses and doctors working in the delivery room and in particular Sr. Sagaya Mari, Sr. Florence Utah,
Hanna Petros and Desta Mamo. The support of the records department for
Key Points
n Prolonged/obstructed labour is a leading cause of maternal
mortality and morbidity in Ethiopia with 9 000 new cases of
obstetric fistula occurring annually.
n During the last decade there has been a desire to simplify the
partograph by deleting the latent phase of labour.
n The new model partograph has been introduced in several
countries, but for many midwives and obstetricians who were
very confident with the original model, reservation remains.
n It is evident from the data analysis that women who were
admitted in the latent phase of labour progressed more slowly
in the active phase of labour and required more operative
vaginal and abdominal delivery.
n Labour can be managed without the latent phase being plotted
on a partograph, provided that a labour management protocol
for the latent phase is instituted with clear guidelines.
148