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International Journal of Gynecology and Obstetrics (2007) 96, 147–150

SPECIAL ARTICLE

Comparison of two World Health OrganizationpartographsJ.E. Mathews, A. Rajaratnam, A. George, M. Mathai ⁎

Department of Obstetrics and Gynecology, Christian Medical College, Vellore, India

Received 23 June 2006; received in revised form 7 August 2006; accepted 22 August 2006

⁎ Corresponding author. DepartmentWorld Health Organization, CH 121Tel.: +41 22 791 3210; fax: +41 22

E-mail address: mathaim@who.int

0020-7292/$ - see front matter © 200All rights reserved.doi:10.1016/j.ijgo.2006.08.016

Abstract

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

KEYWORDSPartograph;Latent phase;User friendliness;World HealthOrganization

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

of Making Pregnancy Safer,1 Geneva 27, Switzerland.791 5853.(M. Mathai).

6 International Federation of G

enables staff attending women in labor to record thechanges in maternal and perinatal variables, and the alertand action lines are meant to help the staff recognizealerts or initiate action (Fig. 1).

However, since the composite partograph covers thelatent as well as the active phase, when a womanadmitted during the latent phase enters the activephase, an attendant must btransferQ her cervical dilatationvalue to the appropriate place by means of a broken line.This btransferQ has been difficult for some staff tounderstand, leading to mistakes when filling out parto-graphs [2]. And since a prolonged latent phase is relatively

ynecology and Obstetrics. Published by Elsevier Ireland Ltd.

Figure 1 The bcompositeQ WHO partograph.

148 J.E. Mathews et al.

Figure 2 The bsimplifiedQ WHO partograph.

149Comparison of two World Health Organization partographs

infrequent and not usually associated with poor perinataloutcome, the usefulness of recording the latent phase inthe partograph has been questioned [2]. Moreover,differentiating the latent phase from false labor beingdifficult, diagnosis is often made in retrospect [3];meanwhile, the staff is likely to intervene more activelythan necessary [2].

The simplified partograph in the current WHO guideline[4] excludes the latent phase (Fig. 2) and recording beginswith the active phase (with cervical dilatation now≥4 cm). Alert and action lines are similar to those in thecomposite WHO partograph, but unlike in the compositeversion, descent of the fetal head is not recorded in thesimplified one.

The 2 WHO partographs were compared in a cross-overstudy of 3 months' duration. Physicians working in 12-hourshifts at this teaching hospital were instructed on the use ofone of the partographs, which they then used for the next10 days. After a week, the intervention was repeated withthe other partograph. The order of use was randomized.Care was provided using WHO guidelines for the hospitalsetting [3].

Participants scored the 2 partographs for each of thefollowing categories: user-friendliness (scores of 0–10),teachability (scores of 0–5) and overall usefulness (scoresof 0–5). All partographs were checked for completeness,and the difficulties the physicians experienced whilerecording were documented.

In all, 658 women in labor were provided care by 18physicians who used these partographs. While mostmaternal and perinatal outcomes were similar when laborwas monitored using either partograph (Table 1), laborvalues crossed the action line significantly more oftenwhen the composite partograph was used, and the womenwere more likely to undergo cesarean deliveries.

The composite partograph scored lower on user-friendliness (mean±SD, 6.2±0.9 vs. 8.6±1.0; χ2>10.1;P=0.002). Most participants (83.4%) reported difficulty inusing the composite partograph bsometimesQ but noparticipant reported difficulty using the simplified parto-graph (χ2=10.1; P=0.001). Most participants (84%) gavethe maximum score of 5 for the bteachabilityQ of thesimplified partograph, but no participant gave the compo-site partograph the maximum score in that category.However, since the simplified partograph did not includethe descent of the fetal head, it was considered less usefulthan the composite partograph (median scores of 3 and 4,respectively). Cervical dilatation was carefully recorded inboth partographs, but recording was more thorough forother variables with the simplified partograph (contrac-tions, 92% vs. 74%; fetal heart rate, 90% vs. 83%; pulse rate,86% vs. 65%; and blood pressure, 92% vs. 49%).

Overall, the simplified WHO partograph was more user-friendly, was more likely to be completed than the compositeWHO partograph, and was associated with better laboroutcomes.

Table 1 Comparison of labor outcomes and user satisfaction using the composite partograph and the simplified partograph⁎

Variable Composite partograph Simplified partograph P value or RR (95% CI)†

Labor crossing the alert lineNulliparas 34 (19.4) 28 (17.9) 0.7Multiparas 30 (16.1) 17 (12.1) 0.3

Labor crossing action lineNulliparas 19 (10.9) 2 (1.3) 1.7 (1.43–2.02)Multiparas 6 (3.2) 1 (0.07) 0.1

≥2 vaginal examinationsNulliparas 24 (13.7) 14 (9.0) 0.2Multiparas 7 (3.8) 3 (2.1) 0.4

Oxytocin useNulliparas 53 (30.3) 43 (27.6) 0.6Multiparas 33 (17.7) 22 (15.6) 0.6

Instrumental deliveryNulliparas 15 (8.6) 16 (10.3) 0.6Multiparas 11 (5.9) 10 (7.1) 0.7

Cesarean deliveryNulliparas 22 (12.6) 5 (3.2) 1.62 (1.31–2.0)Multiparas 10 (5.4) 2 (1.4) 1.49 (1.14–1.96)

Apgar score<7 at 5 minNulliparas 4 (2.3) 5 (3.2) 0.6Multiparas 3 (1.6) 1 (0.07) 0.5

Mean birth weight, mean±SD, gNulliparas 2933±504 3025±949 0.3Multiparas 3048±430 2964±561 0.1

Admission to NICUNulliparas 38 (21.7) 23 (14.7) 0.1Multiparas 36 (19.3) 24 (17) 0.6

User friendliness score, mean±SD 6.2±0.9 8.6±1.0 0.002Difficulty reported in using the partograph, % 83.4 0 0.001

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

150 J.E. Mathews et al.

References

[1] World Health Organization Maternal Health and Safe MotherhoodProgramme. World Health Organization partograph in manage-ment of labour. Lancet 1994;343:1399–404.

[2] Dujardin B, De Schampheliere I, Kulker R, Bailey J. Thepartograph: is it worth including the latent phase? Trop Doct1995;25:43–4.

[3] World Health Organization. Managing complications in pregnancyand childbirth. Geneva, Switzerland: World Health Organization;

2000. Available at: http://www.who.int/making_pregnancy_safer/publications/archived_publications/mcpc.pdf.

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