You are on page 1of 7

See

discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/272555179

The modified WHO partograph: Do we need a latent


phase?
Article July 2008
DOI: 10.12968/ajmw.2008.2.3.30714

CITATIONS

READS

620

4 authors, including:
Barbara Kwast
Independent Researcher
36 PUBLICATIONS 809 CITATIONS
SEE PROFILE

All in-text references underlined in blue are linked to publications on ResearchGate,


letting you access and read them immediately.

Available from: Barbara Kwast


Retrieved on: 17 October 2016

RESEARCH & EDUCATION

The modified WHO partograph:


do we need a latent phase?
By Barbara E. Kwast, Pia Poovan, Edita Vera and Elaine Kohls

thiopia is a country of great geographic, ethnic and


cultural diversity. Mortality due to pregnancy and
childbirth is the leading cause of death in Ethiopia,
where approximately 24 000 women die during pregnancy
and childbirth every year with a maternal mortality ratio
(MMR) of 720 per 100 000 live births (Countdown Coverage
Writing Group, 2008).
Prolonged/obstructed labour is a leading cause of maternal
mortality and morbidity in Ethiopia with 9 000 new cases of
obstetric fistula occurring annually and about 44 000 waiting
for operation. An overwhelming majority of births (94%) are
taking place at home without skilled attendance (CSA and
ORC Macro, 2006). The challenge of maternal and neonatal
mortality reduction related to Millennium Development
Goals 4 and 5 (UN Millennium Project, 2005), has received
increasing attention from Federal and Regional governments
in Ethiopia in recent years. Particular attention has gone
into policy and programming to increase skilled attendance
at delivery as well as access to emergency obstetric care to
treat complications in pregnancy and childbirth. One of the
targets is to increase the proportion of births attended by
skilled health personnel either at home or in a health facility
to 60% by 2015 from the current 6% (Ministry of Health
[Ethiopia], 2006).
St. Luke Catholic Hospital and College of Nursing is
situated in Wolisso Town, the capital of the Southwest Shoa
Zone, Oromia Regional State. It is the only hospital in the
Zone serving a population of over 1 200 000. Coverage for
births in the Zone is 6% in health facilities, the met need
for treatment of direct obstetric complications is 5% and
the population-based caesarean section (C/S) rate is 0.8%
(UNICEF, UNFPA, WHO, 1997; Kohls; 2008). The average
hospital C/S rate for 2007 was 22.5%.
The partograph as designed by Philpott and Castle
(1972) in the early 1970s was introduced in The Tikur
Anbessa (Black Lion) Hospital Department of Obstetrics
and Gynaecology in Addis Ababa in the early 1980s. It is
not as yet widely implemented in Ethiopia. Since 1987, as
part of the Safe Motherhood Initiative, the World Health
Organization (WHO) have produced and promoted the
WHO partograph which is similar to Philpott and Castles
original description, retaining the alert and action line in
the active phase of labour. The central part of the partograph, the cervicograph plots cervical dilatation against time.
Distinction was made between a latent phase of labour, up to
3cm cervical dilatation, and the active phase when progress
of dilatation is expected at a rate of at least 1cm per hour (the
alert line). The action line is drawn four hours parallel to the
alert line. The main principles of the WHO partograph are

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

AFRICAN JOURNAL OF MIDWIFERY AND WOMENS HEALTH, JULYSEPTEMBER 2008, VOL 2, NO 3

143

RESEARCH & EDUCATION

Regular observations in
the latent phase of labour
may give the woman the
advantage of an earlier
observed labour in active
phase.

(WHO, 2000). The latent phase of labour was removed in


the new partograph and the active starts with the alert line
at 4cm dilatation. The action line is retained, four hours
parallel to the alert line. This 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 on implementation of
the new model (personal communication). Furthermore,
the parameters for a normal fetal heart rate (FHR) were
changed from between 120160 to 100-180 beats per
minute. The International Federation of Gynaecologists
and Obstetricians (FIGO) recommends the classification
of FHR features by the National Institute for Health and
Clinical Excellence (2007) as follows: reassuring baseline
is 110160, non-reassuring FHR is between 100109 and
161180 and abnormal is <100 and >180.
St. Luke Hospital was using the original WHO partograph but it was not applied consistently and there was
no management protocol. In January 2007, the modified
WHO partograph was introduced by consensus together
with a participatory developed management protocol. The
objective of this study was to assess how many women
are actually admitted in the latent and active phases and
second stage of labour and what mode of delivery terminated their labour comparing latent and active phase
admissions.

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

College of Nursing library. Much emphasis was placed on


assessment of cervical dilatation against a wooden board
with set circles representing diameters from 110 cm. The
notion that dilatation in fingers can be multiplied to centimeters is a difficult habit to break and can give rise to
disagreement between staff while this is the most critical
observation to start a partograph correctly on the alert line
in active phase.
During a return visit for further workshops in October
2007, partographs were reviewed and the management protocol rediscussed. The labour ward is run by a few midwives
and clinical nurses who call surgeons for help with difficult
cases. The midwives and nurses carry a great responsibility
and conduct most abnormal deliveries, including vacuum
deliveries.

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).

AFRICAN JOURNAL OF MIDWIFERY AND WOMENS HEALTH, JULYSEPTEMBER 2008, VOL 2, NO 3

RESEARCH & EDUCATION


Findings
Between July 2007 and January 2008, 1 318 women were
delivered in St. Luke Hospital. Of 1 246 women admitted
in labour (excluding women with emergency caesarean
section (C/S) on admission), 140 (11.2%) were admitted in latent phase of labour, 578 (46.4%) in active first
stage, 405 in second stage (32.5%), and for 123 (9.9%)
the stage of labour was not available from the delivery
room register (Table 1). The number of women admitted
in first and second stage of labour in January 2008 differed significantly from the distribution within the other
six months (Pearsons Chi-square: p=0.004). Comparison
with case records showed that several women admitted at
9 cm dilatation were recorded as second stage of labour in
the delivery room register.
Table 2 shows the mode of delivery by latent and active
phase admissions. A greater percentage of women admitted in the latent phase had an operative vaginal delivery or
C/S (15.8% and 41% respectively) compared to women
who were admitted in the active phase of labour, (10.6%
and 19.9% respectively). There was a statistically significant difference between singleton vaginal deliveries and
caesarean section between latent and active phase admissions (Pearsons Chi-square: p=<0.001).
An in-depth analysis was made for 226 women who
delivered in January 2008. The mean age of 221 women
was 25.16 years (SD 5.824) (age unknown for five
women). Ten women (4.5%) were <17 years. 43.4%
were nulliparous, 41.2% parity 14, 13.7% parity five or
more, and 1.7% parity unknown. Of the 107 admissions
in active first stage who did not have an emergency C/S
on admission the admission dilatations were as follows:
47.7%: 45 cm; 27.4%: 67 cm; 12.1%: 8 cm and 13.1%:
9 cm. Second stage admissions were 24%; 1.3% had a
ruptured uterus on admission and 8.8% an emergency
C/S on admission.
The mode of delivery for 226 women was: Spontaneous
vertex: 129 (57.1%); caesarean section: 49 (21.7%);
operative vaginal: 30 (13.3%); twins: 9 (3.9%); breech:
4 (1.8%); laparotomy for ruptured uterus: 3 (1.3%) and
destructive operation: 2 (0.9%). Only four women were
augmented in labour, one within 8 hours of latent phase
and three in active phase after crossing the action line.
Active management of the third stage was performed for
all women with a spontaneous delivery. One postpartum
haemorrhage occurred and a manual removal of placenta
was performed. There were six sets of twins resulting in a
total of 232 infants. There were 13 were stillbirths; in 11
cases the fetus was dead on admission and the other two
died within five minutes of birth. The number of first
week neonatal deaths was not available. There was no
maternal death.

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

Table 1. Distribution of women by stage of labour


on admission
Month
July-07
Aug-07
Sept-07
Oct-07
Nov-07
Dec-07
Jan-08**
Total
per cent

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

Results show number of women (percentages in parentheses).


*Number does not total 1 318 deliveries as induction of labour,
elective and emergency C/S on admission are excluded (72 women)
** p-value is 0.004

Table 2. Mode of delivery by admission in latent and active


phase
Mode of delivery
Total women
Singleton deliveries
SVD/vaginal breech
Vacuum extraction/forceps
delivery
Caesarean section
Craniotomy
Laparotomy for ruptured
uterus
Multiple deliveries
Both vaginal
At least one caesarean
section
Type unknown

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

Results show number of women (percentages in parentheses)


p-value is <0.001

and active phase respectively. In 17% of partographs one


or more observations were missing but for the majority this applied to status of membranes, spontaneous or
artificial rupture of membranes and colour of liquor. In
the event of augmentation, oxytocin dosage and infusion
rate were not recorded on the partograph but in the case
records.

Latent phase admissions


Thirty-two women were admitted in the latent phase of
labour and the mean cervical dilatation on first examination was 2.41 cm (SD.615). Mode of delivery was as follows:
caesarean section 15 (46.8%); spontaneous vertex delivery 11
(34.4%); vacuum delivery 5 (16.7%) and breech: 1 (3.3%).
Of these, six were delivered within the eight-hour latent

AFRICAN JOURNAL OF MIDWIFERY AND WOMENS HEALTH, JULYSEPTEMBER 2008, VOL 2, NO 3

145

RESEARCH & EDUCATION

phase; three had an emergency C/S on admission, one was


diagnosed as a face presentation 1.5 hours after admission and
two had a C/S due to no progress at 2 cm within eight hours
latent phase of labour. Of the remaining 26 women, the mean
cervical dilatation on admission was 2.38 cm (SD.637). The
mean number of hours from first latent phase dilatation to the
start of plotting the partograph in active phase was 5.857 hrs
(SD 3.006). There were five women whose first examination
in the active phase was at full dilatation of the cervix. The
mean cervical dilatation of the remaining 21 women on first
examination in the active phase starting on the alert line was
5.84 cm (SD 2.11).

Active phase admissions


One hundred and ninety-four women were admitted in
the active phase of labour with a mean cervical dilatation
of 6.03 cm (SD 1.736). For 121 of 124 women admitted
in active first stage admission dilatation was as follows:
45 cm: 47%; 67 cm: 28%; 8 cm: 13% and 9 cm: 12%.
Table 3. Comparison of women admitted in latent and active
phase of labour by course of labour

Course of labour

Admitted in latent phase


and progressed to active
phase
No.
%

Admitted in active phase


No.
%

Total women*

18

100

99

100

38.9

67

69.8

27.8

18

18.8

33.3

14

14.1

Delivered on or left of alert line


Total

Delivered between alert and action line


Total

Delivered on or past action line


Total

Wolisso, January 2008


*Total who had an assessable partograph in active phase
p-value is 0.0187

Table 4: Course of labour by mode of delivery


and augmentation among women admitted
in active phase(48 cm) with a partograph
Mode of delivery
and augmentation
Total cases
Delivery
Caesarean section
Operative vaginal
Spontaneous vertex
Breech
Twins (sets)
Other
Augmented labour*

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)

Results show number of women (percentages in parentheses)


*Not counted in total number of women
p-value is <0.0001

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 %).

Comparison of women admitted in latent and


active phase by progress of labour and type of
delivery
Womens course of labour was analyzed for 18 women admitted in latent phase who had an assessable partograph in active
phase and 99 admissions in active phase between 48 cm
who had an assessable partograph (Table 3). Given the total
distribution, a significantly higher proportion of active phase
admissions (70%) delivered on or left of the alert line compared to 39% of latent phase admissions (Fischers exact test:
p=0.0187). The differences of the other two proportions
delivered between alert and action line, and delivered on
or past action lineare not statistically different: 0.578 and
0.099 respectively. Table 4 shows the course of labour by
mode of delivery among the active phase admissions. The
more labour deviated from normal progress on the alert line
to between alert and action line and beyond action line, the
higher the proportion of C/S deliveries and the lower the proportion of operative vaginal and spontaneous vertex deliveries
(Fischers exact test: p<0.0001). The general pattern was the
same for women admitted in latent phase. C/S and operative
vaginal deliveries increased and spontaneous vertex deliveries decreased as labour progressed right of the alert line, but
numbers were small and need to be interpreted with caution
(data not shown).

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-

AFRICAN JOURNAL OF MIDWIFERY AND WOMENS HEALTH, JULYSEPTEMBER 2008, VOL 2, NO 3

RESEARCH & EDUCATION

tograph should be retained at 4 cm at the detriment of losing


a mean of 5.86 hours observation of these women in labour.
In these women the C/S rate was 36% which gives rise to
concern. Admittedly, oxytocin augmentation of labour was
rarely applied compared to the study in India where overall
oxytocin use during active phase was 24% and 21.6% for
women managed on the composite and simplified partograph
respectively (Mathews et al, 2007). Oxytocin use in India was
very much higher compared to the WHO multi-centre trial
in south-east Asia where overall labour augmentation was
reduced from 20.7% to 9.1%. 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.
Similar results have been shown in the multi-centre trial of
the WHO partograph (WHO, 1994a and 1994b).
Having deleted the latent phase shows the importance for
development of a protocol for care and assessment of women
in the latent phase especially as the majority of these women
give a signal by coming early and thus problems can be
diagnosed in good time and disasters prevented. It is a great
advantage that both midwives and nurses are performing
vacuum extractions in St. Lukes Hospital, Wolisso, thereby
preventing unnecessary caesarean section and enhancing the
womans future obstetric career.

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.

The midwives and nurses


... felt that the modified
partograph was helpful
and enabled them to
interpret progress of
labour for management
decisions.

These results vary considerably with the Ethiopian study


and could be explained by the high oxytocin use in India
where time of oxytocin augmentation related to position on
the partograph was not shown.
The midwives and nurses in St. Luke hospital felt that
the modified partograph was helpful and enabled them
to interpret progress of labour for management decisions.
They carry great responsibility and rely on surgeons for
permission to perform artificial rupture of membranes and
oxytocin augmentation when the labour crosses the alert and
action line respectively. Odberg Pettersson and colleagues
(2000) and Fatusi and colleagues (2008) have evaluated
training and use of the composite partograph in Angola and
Nigeria respectively and have shown good results with the
use by health workers in peripheral maternities. In Nigeria
the health workers were one year trained community health
extension workers (CHEWS). A study in Tanzania showed
low compliance with partograph application, mainly due to
pressure from high workload (Nyamtema et al, 2008). These
three studies used the composite WHO partograph. Fhadi
and Chongsuvivatwong (2005) recommend promotion of
the modified partograph by midwives in maternity homes
in Indonesia. Correct partograph completion was 92.4%,
women moving beyond the alert line were 65% and referral
significantly increased with the use of the partograph.
There is only 6% coverage of delivery in Ethiopia and
the high percentage of women coming in the second
stage of labour is testimony to the difficulty of access to
health facilities. Ethiopia could endeavour to introduce the
modified partograph into the one year training of the health
extension workers (HEWS) who are similar to the CHEWS
in Nigeria. In Ethiopia 30 000 HEWS will be deployed by
2010 (Federal Democratic Republic of Ethiopia Ministry
of Health, 2008) in order to increase coverage of births at
primary level with ensuing increase in referral and reduction
in the high toll of maternal and perinatal mortality and morbidity. In hospital, regular supervision and criterion-based
audits of partographs against the management protocol may
increase labour augmentation, increase spontaneous and
operative vaginal deliveries and possibly decrease caesarean
sections. The midwives and nurses are to be commended
for their skills in vacuum extractions, a procedure that has
fallen into disrepute in many countries where considerable
morbidity and financial costs from unnecessary caesarean
sections could be prevented (Bailey, 2005). Furthermore,

AFRICAN JOURNAL OF MIDWIFERY AND WOMENS HEALTH, JULYSEPTEMBER 2008, VOL 2, NO 3

147

RESEARCH & EDUCATION

implementation of routine active management of the third


stage of labour is an indicator of good quality of care by
midwifery staff.

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

Abramson JH, Gahlinger MP (2001) Computer Programs for Epidemiologists:


PEPI Version 4.0 Salt Lake City: Sagebrush Press, USA
Bailey P (2005) The disappearing art of instrumental delivery: Time to
reverse the trend. Int J Gynecol Obstet 91: 8996
Central Statistical Agency (CSA) [Ethiopia] and ORC Macro (2006)
Ethiopia Demographic and Health Survey 2005. CSA Addis Ababa, Ethiopia
and ORC Macro, Calverton, Maryland, USA
Countdown Coverage Writing Group and on behalf of the Countdown
2015 Core Group (2008) Countdown to 2015 for maternal, newborn and
child survival: the 2008 report on tracking coverage of interventions. Lancet
371:124758
Dujardin B, De Schampheleire I, Sene H, Ndiaye F (1992) Value of the
alert and action lines on the partogram. Lancet 339: 133638
Fahdi M, Chongsuvivatwong V (2005) Evaluation of the World Health
Organization partograph implementation by midwives for maternity home
birth in Medan, Indonesia. Midwifery 21: 301310
Fatusi AO, Makinde ON, Adeyemi AB, Orji EO (2008) Evaluation of
health workers training in use of the partogram. Int J Gynecol Obstet
100(1): 4144
Federal Democratic Republic of Ethiopia (FDRE) Ministry of Health
(2008) The Current Status of Health Plans and Strategies in Ethiopia: A StockTaking Report. FDRE MOH Addis Ababa
Kohls E (2008) St. Luke Catholic Hospital and College of Nursing Annual
Report 2007. Wolisso, Southwest Shoa, Ethiopia
Lennox CE, Kwast BE (1995) The partograph in community obstetrics.
Trop Doc 25: 56-63
Mathews JE, Rajaratnam A, George A, Mathai M (2007) Comparison of
two World Health Organization partographs. Int J Gynecol Obstet 96:147
150
Ministry of Health, Federal Democratic Republic of Ethiopia (2006)
National Reproductive Health Strategy 2006-2015. MOH 2006
National Institute of Health and Clinical Excellence (NICE) (2007) NICE
clinical guidelines 55: Intrapartum care: care of healthy women and their
babies during childbirth. NICE, London, UK, www.nice.org.uk
Nyamtema AS, Urassa DP, Massawe S, Massawe A, Lindmark G, Van
Roosmalen J (2008) Partogram use in Dar es Salaam perinatal care study.
Int J Gynecol Obstet 100(1): 37-40
Odberg Pettersson K, Svensson ML and Christensson K (2000) Evaluation
of an adapted model of the World Health organization partograph used by
Angolan midwives in a peripheral delivery unit. Midwifery 16: 82-88
Philpott RH and Castle WM (1972) Cervicographs in the management of
labour in primigravidae. II. The action line and the treatment of abnormal
labour. J Obstet Gynaecol Br Commonw 79: 599602
Seffah JD, Amaniampong K, Wilson JB (1994) The use of the partograph
in monitoring labor in a prior cesarean section. Int J Gynecol Obstet 45: 281
UN Millennium Project (2005) Whos got the power? Transforming health
systems for Women and Children. Task Force on Child Health and Maternal
Health. Earth Scan, USA
UNICEF, WHO, UNFPA (1997) Guidelines for monitoring the availability
and use of obstetric services. UNICEF New York
World Health Organization (2000) Managing complications in pregnancy
and childbirth: a guide for midwives and doctors. IMPAC. WHO/RHR.007.
World Health Organization, Geneva
World Health Organization (1993a) Preventing prolonged labour: A Practical
Guide. The Partograph Part I. Principle and Strategy. WHO, Geneva WHO/
FHE/MSM 93.8
World Health Organization (1993b) Preventing prolonged labour: A Practical
Guide. The Partograph Part II. Users Manual WHO, Geneva WHO/FHE/
MSM 93.9
World Health Organization (1994a) World Health organization partograph
in management of labour. Lancet 343: 13991404
World Health Organization (1994b) The Partograph: The application of the
WHO partograph in the management of labour. Report of a WHO multicentre study 1990-1991. WHO Geneva WHO/FHE/MSM 94.4
World Health Organization (2006) Integrated management of pregnancy and
childbirth. Pregnancy, childbirth, postpartum and newborn care: a guide to
essential practice, 2nd edition. WHO Geneva

AFRICAN JOURNAL OF MIDWIFERY AND WOMENS HEALTH, JULYSEPTEMBER 2008, VOL 2, NO 3

You might also like