BOX 2-1
Monitoring Labor with the Partograph

The partograph is intended for use by health workers trained in childbirth who can observe and conduct normal labor and delivery, perform vaginal examinations, and assess and accurately plot cervical dilation on a graph against time. (WHO Partograph: Figures 2-7a and 2-7b; see following pages).

During first-stage labor, before the cervix has dilated to 3 centimeters, progress may be slow and irregular. This latent phase normally lasts 8 hours or fewer. In active, second-stage labor, cervical dilatation normally progresses at the rate of at least 1 centimeter per hour, indicated as the alert line. Slower rates would be recorded to the right of the alert line, signaling that the woman should be referred to a central facility. There, medical personnel must decide, based on their determination of maternal and fetal condition and the effectiveness of contractions, whether labor should be augmented with oxytocin or delivery should proceed by cesarean section.

The WHO multicenter trial found that using the partograph along with an agreed labor-management protocol produced several significant benefits. Labors lasting more than 18 hours were reduced from 8.3 percent to 4.5 percent in nulliparous women, and from 6.4 percent to 3.4 percent in all women. The proportion of labors requiring augmentation with oxytocin declined from 20.7 percent to 9.1 percent, and the rates of forceps deliveries and postpartum sepsis in both nulliparous and multiparous women reduced to a significant extent. Intrapartum late fetal deaths declined as well from 0.5 percent to 0.3 percent (World Health Organization, 1994b).

graphically tracking cervical dilation over time. A refined version of the initial device, known as the partograph, is now widely used to reduce maternal and fetal morbidity due to prolonged or obstructed labor. The central feature of the partograph is a graphical representation of the progress of labor—cervical dilatation, descent of presenting part, and duration and frequency of contractions—and its relationship to maternal and fetal condition (see Box 2-1). The pattern of cervical dilatation in normal labor among different ethnic groups is so similar that a partograph is useful throughout the world (Lennox and Kwast, 1995).

In the early 1990s, a partograph produced and promoted by WHO was tested in a multicenter trial in Southeast Asia involving 35,484 women (World Health Organization, 1994b). Based on the encouraging results of this trial, WHO recommends widespread use of the partograph. The partograph was revised in 2002 (Figures 2-7a and 2-7b). When used at a health center or maternity center, the device provides an early warning that labor is likely to be prolonged, and the woman should be transferred to a hospital. In the hospital, it can provide a warning that extra vigilance or an

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