Arch Gynecol Obstet (2009) 279:643–647

DOI 10.1007/s00404-008-0788-z

ORIGINAL ARTICLE

Revising the primigravid partogram: does it make any diVerence?

L.-J. van Bogaert

Received: 30 June 2008 / Accepted: 25 August 2008 / Published online: 6 September 2008© Springer-Verlag 2008

AbstractObjective To investigate the distribution of the rate ofcervical dilatation of primigravid labour and its deviationfrom the standard partogram.Design Retrospective observational study.Setting South African district hospital serving an indigentrural population.Population Expectant management of labour of healthynulliparous women in active labour, at term, with a single-ton pregnancy and cephalic presentation.Methods Audit of 1,595 partograms of spontaneous prim-igravid labour. The standard partogram’s alert line wasreplaced by a customised alert line based on the lowest 10thcentile of the rate of cervical dilatation of the study popula-tion and an alert line representing the 10% slowest labours.The action line was placed parallel and 4 h to the right ofthe alert lines.Main outcome measure The distribution of labours left toand on the respective alert lines, and right to the actionlines.Results The lowest 90th centile of the customised alertline yielded a rate of cervical dilatation of 0.860 cm/h.Three quarters of labours evolved left to the revised alertline as opposed to 56.1% left of the standard alert line[Odds ratio (OR) 0.49, 95% conWdence interval (CI)0.42–0.56]. The mean rate of cervical dilatation of the 10%

slowest labours was 0.535 § 0.076 cm/h (P < 0.0001), and95.7% of labours evolved left to the corresponding alertline (OR 8.40, 95% CI 6.44–11.0).Conclusion The alert line representing the mean of the10% slowest labours leads to an unrealistic distribution oflabour on the partogram. A revised alert line based on thelowest 10th centile of the local population is more represen-tative and should perhaps be used in the management oflabour.

Keywords Partogram · Primigravidae · Customisation

Introduction

The time-honoured partogram based on the original workby Friedman [1] and by Philpott and Castle [2] has gainedthe status of usual care of labour. It is the tool for the man-agement of labour and is recommended as such by theWorld Health Organization [3]. A number of observationalstudies, however, have reported wide variations in mean,median, and centile values of the rate of cervical dilatation[4, 5]. This may explain the lack of uniformity in size andshape of the partogram and the timing of the alert andaction lines on a number of partograms that deviate fromPhilpott’s original version [6].

The aim of the partogram is to reduce the incidence ofprolonged labour, the proportion of labours requiring aug-mentation, the proportion of emergency caesarean sections,and the intra-partum stillbirth rate [7]. To achieve this goal,the alert line is supposed to diVerentiate normal (left to oron the alert line) from prolonged labour (right to the alertline). For those implementing the active management oflabour, it results that action is to be taken as soon as thealert line is crossed [8]. With expectant management, on the

L.-J. van BogaertDepartment of Obstetrics and Gynaecology, MEDUNSA Satellite Campus, Philadelphia Hospital, Dennilton, South Africa

L.-J. van Bogaert (&)Post Net Suite 7, Private Bag x8689, Groblersdal 0470, South Africae-mail: ljfvanbo@lantic.net

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other hand, intervention is recommended only when theaction line is reached and/or crossed [2, 3].

The timing of the action line behind the alert line varies.Philpott and Castle [2] set the action line pragmatically 4 hto the right of the action line, the time needed in their spe-ciWc setting to refer a woman with abnormal labour to afacility where appropriate action could be taken. The stan-dard partogram uses the same action line. Others [10, 11]have recommended an action line set respectively 2 and 3 hbehind the alert line.

The standard partogram’s alert line, deWned as a rate ofcervical dilatation of 1 cm/h, represents the mean rate of cer-vical dilatation of the slowest 10% of primigravid spontane-ous labours [2, 4, 12]. As a matter of fact, this wasestablished from the study of one hundred labours prior tothe implementation of the partogram. It is thus based on thelabour characteristics of only 20 women; the authors did notprovide any explanation or justiWcation for their choice.Using these norms, Philpott and Castle [2] found that 78.2%of women delivered without crossing the alert line, and that21.8% crossed the alert line. Of the latter, half deliveredwithin 4 h after the alert line was crossed, and half crossedthe action line. There was no mention of labours on the alertline. A recent study, assuming that patients’ characteristicswould be similar to those described by Philpott and Castle,expressed concern about the fact that half of their primigr-avid labours evolved right to the alert line [13].

In view of a number of disparities and uncertaintiesabout the norms applied to the standard partogram, an auditwas carried out to compare the distribution of primigravidspontaneous labour charted on a retrospectively constructedrevised partogram with the standard partogram.

Methods

The present study was conducted in a District Hospital thatserves both as a primary and secondary care institution. Itserves a rural population. The monthly average number ofdeliveries is 400. Over the last years, the caesarean sectionrate has been stable around 15.0% and the instrumentaldelivery rate (ventouse) between 3.5 and 4.0%. The perina-tal mortality rate was 24/1,000; the South African nationalaverage is 30/1,000 [14]. Augmentation of labour with oxy-tocin was not standard practice in the department becauseof staV and supervision shortages. Amniotomy was discour-aged in order to reduce the risk of vertical mother to childtransmission of HIV. Epidural facilities were not available.Hence, the management of labour was expectant anddiVered from the management of labour practiced by Phil-pott and Castle [2] (i.e. amniotomy, oxytocin, and epiduralanaesthesia once the action lined is reached, and caesareandelivery 2 h later if no further progress was obtained).

A total of 1,595 completed partograms was audited onthe day following delivery. To be eligible, women had toreach term without medical complication and have a spon-taneous onset of labour with a singleton foetus in vertexpresentation. They needed to have a completed partogram.The active phase of labour was identiWed when contractionswere regular and painful, and the cervix was three or morecentimetres dilated. The duration of the Wrst stage of labourwas deWned as the time spent in labour ward from admis-sion to the moment of pushing at full dilatation. The secondstage was deWned as the time elapsed between the Wrstactive expulsion eVorts and delivery. Only primiparae hav-ing a completed partogram entered the study. All had aspontaneous vaginal delivery. The recruits entered thestudy prospectively but the audit was carried out retrospec-tively. The data were handled anonymously. A similarstudy was run with multiparas [15].

First, the standard partogram’s alert line of 1 cm/h andaction line (4 h) were used to plot the rates of cervical dila-tation and their relative distribution left to the alert line, onthe alert line, and right to the alert line. Secondly, the samewas done using the lowest 10th centile of the study popula-tion’s rate of cervical dilatation. Thirdly, an alert line wasconstructed using the mean rate of cervical dilatation of the10% slowest labours with an action line parallel and 4 hright to the alert line.

Statistical analysis was done using the statistical softwareGraphPad Prism. Descriptive statistics, unpaired t tests, andcontingency table analysis were carried out. Odds ratios (OR)were calculated with their 95% conWdence intervals (CI).Statistical signiWcance was set at a P value <0.05.

Results

The mean duration of the active phase of labour was288 § 148 min; the second stage lasted for an average of47.4 § 34.2 min. The overall distribution by speed of cervi-cal dilatation is illustrated in Fig. 1. The rate of cervical

Fig. 1 Relative distribution of primigravid labours

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dilatation is shown in Table 1. There was a highly signiW-cant diVerence between the slowest 10% and the entiregroup in terms of mean, median, 90 and 95% CIs. It mainlyshows that the mean rate of cervical dilatation of the 10%slowest labours was twice slower than the lowest 10th cen-tile of the entire study population.

The landmarks of the partogram using respectively thestandard and the revised values are illustrated in Table 2. Itshows that the normal duration of the active phase of labour(3–10 cm dilatation) ranged from 7 h on the standard parto-gram to 8 (lowest 10th centile) and 11 h (10% slowestlabours) on the revised partograms. The maximum durationof labour from the alert line to the action line set 4 h laterranged from 11 to 12 and 15 h, respectively.

The distribution of labours evolving on the alert line andleft or right to the alert line of the standard partogram andof the revised partogram is shown in Table 3. With a con-ventional alert line representing a rate of cervical dilatationof 1 cm/h, only 1.5% of labours evolved on the alert line.With the revised alert line representing the lowest 10th cen-tile, 9.5% of labours followed the alert line [�2 = 97.0;

P < 0.0001; OR = 6.90 (4.46–10.67)]. Only 26.0% crossedthe revised alert line of which 14.5% reached and/orcrossed the revised action line, versus 34.4 and 29.4%,respectively, on the standard partogram [�2 = 29.7;P < 0.0001; OR = 2.46 (1.77–3.42)]. Only 3.8% of alllabours reached and/or crossed the action line set 4 hbehind the revised alert line.

The distribution of labours comparing the revised valuesusing the mean of the 10% slowest labours is shown inTable 4. Only 1.2% of labours evolved on the alert line and90.0% evolved left to the alert line. Out of the 8.8% thatevolved right to the alert line, 22.9% reached and/orcrossed the action line.

Discussion

Since the aim of the alert line is to distinguish normal fromabnormal (i.e. prolonged) labour, it follows that correctiveintervention such as active management of labour willdepend on the norms used to deWne the alert line, whereas

Table 1 Rate of cervical dilatation of spontaneous primigravid labour

Rate of cervical dilatation (cm/h)

Entire group (n = 1,595)

Slowest 10% (n = 320)

P value

Mean 1.32 § 0.72 0.63 § 0.11 <0.0001

Median (interquartile range) 1.13 (0.83–1.58) 0.65 (0.56–0.73)

90% CI 0.86–0.90 0.62–0.64

95% CI 1.28–1.35 0.62–0.64

CoeYcient of variation (%) 55.0 18.1

Table 2 The partogram’s landmarks: standard versus revised

Variable Standard Revised

Lowest 10th %

Slowest 10%

Speed of cervical dilatation on the alert line (cm/h) 1.0 0.860 0.631

Duration of the active phase of labour on the alert line (h) 7.0 8.0 11.0

Speed of cervical dilatation on the 4-h action line (cm/h) 0.636 0.583 0.467

Duration of the active phase till the action line (h) 11.0 12.0 15.0

Alert line/action line speed ratio 1.57 1.50 1.35

Table 3 Comparative distribution of spontaneous primigravid labours: standard versus lowest 10th centile of the revised alert line

Labour Alert line P value OR (95% CI)

Revised (0.86 cm/h)

Standard (1.0 cm/h)

Left to the alert line 1,156 (72.5%) 895 (56.1%) <0.0001 0.49 (0.42, 0.56)

On the alert line 24 (1.5%) 152 (9.5%) <0.0001 6.90 (4.46, 10.67)

Right to the alert line 415 (26.0%) 548 (34.4%) <0.0001 1.49 (1.29, 1.73)

Reached and/or crossed 4-h action line

60/415 (14.5%) 161/548 (29.4%) <0.0001 2.46 (1.77, 3.42)

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expectant management will intervene when the action lineis reached and/or crossed. Although a number of descrip-tive studies have reported signiWcant variations in rates ofcervical dilatation [6], the standard partogram based on thenorms established by Philpott and Castle [2] remains thestandard management tool [3]. If the standard partogramdoes not reXect the average labour pattern of a speciWc pop-ulation, untimely intervention is likely to take place.

The standard partogram’s alert line represents the aver-age rate of cervical dilatation of the slowest 10% of 100spontaneous primigravid labours [2]. The use of the samecriterion on a larger sample of a similar population, how-ever, yielded a signiWcantly lower value of 0.63 cm/h. Theuse of this cut-oV value resulted in a distribution of laboursexcessively skewed to the left of the partogram and a theo-retically acceptable maximum duration of labour of 15 hbefore intervention (viz. with expectant management oflabour). Since this would lead to a management deviatingtoo much from accepted practice (viz., a maximum durationof labour of 12 h) this alert line was not deemed realisticand clinically applicable. Therefore, a clinically moreacceptable 10th centile cut-oV value was tested as a normfor customisation (Fig. 2).

The concept of customisation refers to the establishmentof nomograms based on locally derived rather than on pop-ulation data; population deWned centile charts relate poorly

to outcomes. In obstetrics, it has been applied to foetalgrowth, foetal biometry, and birthweight centiles [16–19].Because maternal and foetal anthropometry vary amongpopulation groups nomograms reXecting the characteristicsof a speciWc population are likely to be more representativeand clinically more relevant. There is, a priori, no reason torule out that the same principle could apply to labour char-acteristics. The use of the discriminatory value of the low-est 10th centile derived from the local population’s rate ofcervical dilatation to build the alert line yielded a value of0.86 cm/h, or 1.2 times slower than the standard alert line.This resulted in a normal duration of the active phase of 8 h(instead of 7) and a maximum acceptable duration of 12 h(instead of 11).

The distribution of labours on the revised partogramincreased the proportion of labours left to the alert line from56.1% (on the standard-care partogram) to 72.5. Among thelabours right to the alert line that reached and/or crossed theaction line, the proportion decreased from 29.4 to 14.5%,respectively. Only 3.8% of all labours managed expectantlyand plotted on the customised partogram reached and/orcrossed the action line. This compares favourably with the1.7 and 4.0% of prolonged labours (>12 h) reported withactive management of labour [8, 9].

The comparison of the present data with those reportedby Philpott and Castle [2] is hampered by the fact that theauthors reported no labour evolving on the alert line,whereas 9.5% of our observed labours did follow the usual-care alert line. None the less, the revised alert line showed atrend in the distribution of normal and abnormal labour rel-atively close to expectation (WHO [20]): about three quar-ters left and one quarter right to the alert line, and 14.5% ofthe labours right to the alert line reaching and/or crossingthe action line. The neonatal outcome was not part of thisstudy and has been reported elsewhere [14].

Conclusion

The debate about the pros and cons of the active manage-ment of labour is far from over [7]. Although the study wasnot intended to compare expectant with active manage-ment, it supports the suggestion that the diVerence in

Table 4 Comparative distribution of spontaneous primigravid labour: lowest 10th centile versus slowest 10% alert line

Labour Customised alert line P value OR (95% CI)

Lowest 10th % (0.86 cm/h) Slowest 10% (0.63 cm/h)

Left to the alert line 1,156 (72.5%) 1,455 (91.2%) <0.0001 3.95 (3.21, 4.85)

On the alert line 24 (1.5%) 19 (1.2%) <0.0001 1.27 (0.69, 2.32)

Right to the alert line 415 (26.0%) 140 (8.8%) <0.0001 3.66 (2.97, 4.49)

Reached and/or crossed 4-h action line 60/415 (14.5%) 32/140 (22.9%) <0.02 0.57 (0.35, 0.92)

Fig. 2 Revised versus standard partogram

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duration of labour is not absolutely convincing. The imple-mentation of active management of labour in developingworld settings is mostly not feasible; therefore, expectantmanagement of labour remains an acceptable standardpractice. However, the use of the standard partogram islikely to motivate more interventions than absolutelyrequired if the alert line is not representative of the locallabour patterns. Further validation studies are necessary toevaluate the clinical usefulness of revising the partogram.The potential beneWts would be a better distinction betweennormal and abnormal labour and timelier interventionswhen needed.

References

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