Keywords

Partograph, Prolong Labour, Intervention

Introduction

Labour is a process of biochemical, physiological and physical changes that result in delivery of foetus. It is most important moment in obstetric life of a women & it is therefore important for it to be properly understood and management.1 Following hemorrhage, infection and pre-eclampsia/eclampsia; a significant cause of maternal mortality in our population is prolonged labour.Any labour which is unduly prolonged is likely to give rise to four types of distress namely, maternal, foetal, obstetricians’s and last but not least relative’s distress.

Partograph is a Greek word meaning “Labour Curve”. Maintenance of the partograph in labour enables the obstetricians to recognize dystocic labour for timely obstetric interference, to reduce the average duration of labour, lower the incidence of caesarian section and hence lower the maternal morbidity / mortality and incidence of infection [2,3,4].

The first graphic analysis of progress of labour was performed by friedman and much more improved by philpott and castle[5].

The world health organization partograph clearly differentiates normal from abnormal progress in labour and identifies those women likely to require intervention. This partograph has been modified in 1994 to make it simple and easier to use.

Along the X axis of partograph are numbers 0-10 against square, each square represents 1 cm dilatation. Along the bottom line is Y axis of partograph are number 0-24, each square represent 1 hour. Dilatation of cervix is measured in centimeters. The plotting of latent phase has been omitted in W.H.O. modified partograph and it begins at 4 cm when patient enters in active phase instead of 3 cm cervical dilatation.

Aims and Objective

The study was designed to comparing the maternal and fetal outcome along with normal progress of labour in W.H.O. modified partograph and latent phase partograph, to assess the incidence of prolonged labour and neonatal mortality, and determine the incidence of obstetrics intervention. i.e.– augmentation by oxytocin infusion, forceps delivery, lower segment caesarian section.

Materials and Method

This is a prospective study was conducted from March 2015 to November 2015 on patients in labour attending department of Obstetric and Gynaecology, Mahila Chikitsalaya, S.M.S. Medical College, Jaipur,. The study protocol was approved by Authority of Hospital Administration. Detailed history were taken from all patients including obstetric and menstrual history. General physical, obstetrics examination and all routine investigation including ultrasound examination were carried out.

Primi gravida presented in labour pain, live foetus with vertex presentation, having term or near term singletone pregnancy wth adequate and borderline pelvis were included in the study. Pregnancy with heart disease, anemia, elderly primi gravidae, infertility treated were also included in the study.

The patients who had a diagnosis of abnormal presentation, twin pregnancy, severe oligohydramnios, APH, cord prolapsed, previous caesarean section with breech presentation, eclampsia or IUFD were excluded from the study. All necessary information regarding patients was plotted on partograph sheet.

Cases were randomly divided into two groups. Labour of 200 cases were monitored in group-1 by W.H.O. modified partograph and intervened when labour reaches to action line whereas in group-2, labour of 100 cases monitored by latent phase partograph and augmented in latent phase after passing 8 hrs.

A checklist was made to obtain information regarding parameters of labour and components of the modified WHO partograph according to standard protocol. Standard protocols was follows as cervical dilatation, status of membranes and liquor, moulding, descent of the presenting part and blood pressure monitored every 4 hours; foetal heart rate, maternal pulse and uterine contractions monitored every 30 minutes; condition of the baby after birth including the Apgar score ( Apgar score ≥ 7 was considered satisfactory in our study).

Statistical Analysis

All data thus collected was entered in an excel sheet. The data was coded and analyzed using statistical package for social sciences (SPSS) software version 18. p values were computed and interpretation was done accordingly. The level of significance was taken as P value < 0.05. All results are statistically verified by chi-square test.

Results

Table- 1 Showing most of the cases were in 20-29 age group in both partograph

Table 1: Showing distribution of delivering cases according to age group

Module 19 yrs. 20-29 yrs. > 30 yrs. Total (n=300)
W.H.O. modified partograph 23 164 13 200
-11.50% -82% -6.50%
Latent phase partograph 10 84 6 100
-10% -84% -6%

Table-2 Showing zone wise distribution of delivered cases according to head level above the brim. Number of delivered cases were more in zone A (statistically significant), when labour monitored by W.H.O. modified partograph as compared to latent phase partograph and as the head becomes progressively deeply engaged, lesser the chances of dysfunction of labour.

Table 2: Showing zone wise distribution of delivered cases according to head level above the brim

Level of Head W.H.O. modified partograph Latent phase partograph
Zone-A Zone-B Zone-C Total (n=200) Zone-A Zone-B Zone-C Total (n=100)
(n=154) (n=32) (n=14) (n=66) (n=25) (n=9)
4/5 16 8 6 30 4 11 4 19
-53% -27% -21% -21.05% -57.89% -21.09%
3/5 110 20 8 138 57 13 5 75
-79.72% -14.49% -5.79% -76% -17.33% -6.66%
2/5 22 4 26 5 1 6
-84.47% -15.33% -83.66% -16.66%
1/5 4 4
-100%
0/5 2(100%) 2

Note: x2= 13.598 ; d.f. = 2 p < 0.01 Significant- W.H.O. modified partograph

x2 = 21.569 ; d.f. =1 p < 0.01 significant -latent phase partograph

In W.H.O. modified partograph, 75% cases with cervical dilatation with 4-5 cm delivered in zone A, 17.22% cases delivered in zone B, 7.77% cases delivered in zone C, Whereas in latent phase partograph, 57.62% cases with cervical dilation 0-2 cm delivered in zone A, 28.84% cases delivered in zone B, 7(13.46%) cases delivered in zone C. This implies that more the cervical dilatation, lesser the chances of dysfunction of labour (Table -3).

Table 3: Showing distribution of cases according to cervical dilatation

Zone W.H.O. modified partograph Latent phase partpgraph
Cervical dilatation Cervical dilatation
4-5 cm >5 cm 0-2 cm <4 cm
Zone A 135 19 30 36
(75%) (95%) (57.69%) (75%)
Zone B 31 1 15 10
(17.22%) (5%) (28.84%) (20.83%)
Zone C 14 7 2
(7.77%) (13.46%) (4.16%)
Total 180 20 52 48

P value = < 0.01 (significant)

Table 4: Showing distribution of cases according to outcome of labour in relation to zone

Outcome of labour W.H.O. modified partograph Latent phase partograph
Zone-A Zone-B Zone-C Total Zone-A Zone-B Zone-C Total
(n=154) (n=32) (n=14) (n=200) (n=66) (n=25) (n=9) (n=100)
Spontaneous Vaginal delivery 141 20 1-* 162 59 18 1 78
87.03% 12.34% 0.63% 81% 75.64% 23.07% 1.28% 78%
Forceps 11 10 1 22 3 6 1 10
50% 45.45% 4.54% 11% 30% 60% 10% 10%
Caesarian 2 2 12 16 4 1 7 12
12.50% 12.50% 75% 8% 33.33% 8.33% 58.33% 12%

Table- 4 showed that in W.H.O. modified partograph 141(87.03%) cases delivered vaginally, forceps applied in 11(50%) cases and caesarian section done in 2(12.50%) cases in Zone A whereas in latent phase partograph 59(75.64%) cases delivered normally, forceps applied in 3(30%) cases and caesarian performed in 4(33.33%) cases respectively.

In W.H.O. modified partograph 22(11%) cases delivered by forceps, among them 4.54% forceps applied for foetal distress and 4.54% for prolong labour while in latent phase partograph 10(10%) cases delivered by forceps, among them 20(20%) forceps applied for foetal distress and 10(10%) for prolong labour. Rest all of the forceps, applied for medical disorder and high risk pregnancies in both partographs.

It shows incidence of prolong labour and foetal distress are more, when labour monitored by latent phase partograph. In W.H.O. modified partograph 16(8%) cases delivered by caesarian section. Indication for caesarian section was foetal distress (6.25%), prolong labour (50%), incordinated uterine action (ICUA 12.50%), elderly primi (18.75%), infertility treated (12.50%). Whereas in latent phase partograph 12(12%) cases delivered by caesarian section. Among them indication for caesarian section was foetal distress (16.66%), prolong labour (58.33%), ICUA (8.33%), elderly primi (8.33%), infertility treated (8.33%).

Table 5: Showing distribution of cases according to mode of intervention

Mode of delivery W.H.O. modified partograph Latent phase partograph X2 d.f. P value Significance
Augmentation 20 22 797.30% 1 0.01 Sig.
10% 22%
Forceps 22 10% 0.116 1 >0.05 NS
11.00% 10.00%
Caesarian 16% 12% 1.263 1 0.01 Sig.
8% 12.00%

The table 5 shows that 10% cases required augmentation, 11% cases required forceps and 8% cases delivered by caesarian section, when labour monitored by W.H.O. modified partograph while 22% cases required augmentation, 10% cases required forceps, 12% cases delivered by caesarian section in latent phase partograph. The mode of intervention like augmentation and caesarian section value statistically differ significantly but in forceps delivery the value, do not differ significantly between both partograph.

Table 6: Showing distribution of prolonged labour

Group Prolonged Labour
Present Absent
W.H.O. modified partograph (n=200) 10% 190%
5% 95%
Latent phasepartograph 15% 85%
(n=100) 15% 85%
Total 25% 275%
(n=300) 8.33% 81.67%

X2 = 8.737 d.f. = 1 p < 0.01 Significant

Table 6 shows that prolong labour was found in 5% cases in W.H.O. modified partograph, which is lower than as compared to latent phase partograph (15%). The value of prolong labour statistically differ significantly between both partograph.

Table 7: Showing distribution of fetal outcome

Group Still Birth
Occurred Non occurred
W.H.O. modified partograph 1 199
(n=200) (0.50%) (99.50%)
Latent phase partograph 2 98
(n=100) (2%) (98%)
Total 3 297
(n=300) (1%) (99%)

X2 = 0.378 d.f. = 1 p < 0.05 Significant

Table 7 shows that occurrence of still birth was more in latent phase partograph as compared to W.H.O. modified partograph, 2% v/s 0.5% ( p < 0.05).

Discussion

Labour is a dynamic process leading to child birth. Improper management of labour may lead to fetal morbidity and mortality. Therefore, to keep the balance of expectancy and intervention, partographic labour management is the best way to monitor the progress of labour. It provides information about maternal and fetal wellbeing and alerts the clinician to the possibility of labour disorder. The present study was started to confirm which Partograph is associated with better labour outcomes, so that the use of partograph becomes a routine practice in all health centres in India.

Our study included 300 cases in labour. The cases were randomly divided in two groups. 200 cases were monitored by W.H.O. modified partograph and 100 cases were monitored by latent phase partograph. In our study the mean age of our cases were 23.8 yrs.

The present study shows that as the head become progressively deeply engaged, lesser the chances of dysfunction labour in both partograph and cases delivered in zone A, are more in W.H.O. Modified partograph.

Study conducted by R.H. Philpott and W.M. Castle[6,7] showed similar results in which 78.08% cases with fixed head delivered in zone A.

Influence of cervical dilatation on course of labour was also observed in our study. Lesser number of patients in latent phase partograph delivered in zone A, because those patients were either pre labour or in false labour. Our findings is consistent with the Philpott and W.M. Castle study[6,7] that showed maximum number of cases (78.08%) delivered in zone A with cervical dilatation >5 cm, whereas lesser number of cases were delivered in zone B & C having lesser cervical dilatation. So the observation suggested that more the cervical dilatation, more the chances of patient to deliver in zone A.

In labour monitored by W.H.O. modified partograph 1 (4.54%) out of 22 (11%) forceps applied for foetal distress, 1 (4.54%) for prolonged labour whereas in latent phase partograph 2 (20%) out of 10 (10%) applied for foetal distress, 1 (10%) applied for prolonged labour, suggest that incidence of prolong labour and foetal distress are more, when labour monitored by latent phase partograph.

The study conducted by W.H.O. (1994) shows 9.6% forceps application rate which is almost similar to our study.[8] Partograph constructed by Shirish and Praveen also shows higher incidence of forceps application due to foetal distress, when labour was monitored by latent phase partograph.[9]

Our study shows that 16 (8%) out of 200 cases were terminated by caesarean section, 1 out of 16 cases had foetal distress, labour was prolonged in 8 cases, 2 cases had incoordinate uterine action, 3 for elderly primigravida, pregnancy had occurred after a prolonged period of infertility in 2 cases, when labour monitored by W.H.O. modified partograph. On the other hand latent phase partograph 12 (12%) out of 100 cases were terminated by caesarian section. 3 of the 12 caesarian section done for foetal distress, 7 for prolong labour, 1 for elderly primi and 1 caesarian done for prolonged infertility.

This implies that caesarian section was done for prolong labour and foetal distress, which were more in latent phase partograph. Thus, concluded from above study that early A.R.M. and oxytocin is associated with more intervention, when monitoring done by latent phase partograph. Multicentric trial study of W.H.O. (1994) showed 8.3% caesarean section rate in modified partograph, which is similar to our result.

Goffinet F in 1999 also noted the association of increased caesarian section with early amniotomy.[10]

The present study shows that labour was augmented in 10% cases, forceps was applied in 11% cases and caesarian section done in 8% cases when labour was monitored by modified partograph. Whereas augmentation done in 22% cases, 10% required forceps and 12% was terminated by caesarian section in latent phase partograph. Thus, it is concluded that augmentation and intervention is more when labour monitored by latent phase partograph.

Study conducted by W.H.O. (1994) shows almost similar observation. In their series labour was augmented in 9.1% cases, forceps was applied in 9.6% cases and labour was terminated in 8.3% cases.[11]

In labour monitored by W.H.O. modified partograph incidence of prolong labour was found in 5% cases whereas in latent phase, it was 15% (p value <0.01). Increased incidence of prolong labour in latent phase partograph might be due to stimulation of labour and early A.R.M, which is consistent with the study of Friedman[12].

Study conducted by R.H. Philpott (1972) and W.M. Castle[6] shows nearly similar observation (4.6%) when assessing labour by active phase partograph. Similar study conducted by ledger and witting[13], observed that labour was prolonged in 22% cases which was higher than our study. He had assess the labour by latent phase partograph. Discrepancy in observation may be due to use of sedatives by them in their study.

Our study shows 0.5% still birth in W.H.O. modified partograph and 2% still birth in latent phase partograph (P value is >0.05). Timely intervention and discriminate use of oxytocin may be the reason of reduction of still birth in W.H.O. modified partograph.

The partographic analysis of labour gives an early warning for the diagnosis of abnormal progress, and assists, early decision for intervention and termination of labour. The use of components of partograph provides an accurate and reliable roadmap for the students, midwives, and obstetricians.

Conclusion

W.H.O. modified partograph has the efficacy to diagnose all labour abnormalities with agreed protocol. It allows timely intervention and be effective in preventing prolonged labour, and improving the neonatal and maternal outcome as compared to previously popular latent phase partograph. So all efforts should be made to provide this life saving WHO parto analysis to as many patients as possible.