Partograms

I recently visited 21 hospitals during interview season for residency. I had a long list of criteria that I made sure to evaluate each hospital and each residency program with so that I would be able to fairly come to terms with my rank list and the couples match process. One of the things that I looked at each hospital was their central monitoring system for labor & delivery. What computer system did they use to watch live tracing for contractions and fetal heart tones? Are the computers and the systems used the most up to date possible? Oh look! Leather chairs in one of the central continuous monitoring rooms! How comfy!

I can tease myself a bit at how I evaluated central monitoring rooms in the US because for the past month I have been using partograms. In medical school, I never learned what a partogram was because we never used it in the US. Instead, I spent countless hours learning about how to read tocometer and fetal heart tone patterns. This month, I learned that pretty much every country except the US uses a partogram. A partogram is a graphical representation of labor. The one used by the hospital I worked at in the DR and recommended the World Health Organization includes information about cervical dilation measurement, fetal station, counting the number of uterine contractions, and listening fetal heart tones. After obtaining this data, the physician plots the points in order to graph the progress in labor. Any deviation from a normal slope of labor was cause for concern. My first day in labor and delivery I was in disbelief- THIS is how you monitor patients here?? How can I possibly know whether there is fetal distress without looking at continuous live tracings?? Where is the fancy flat screen TV?! Where is my portable bedside ultrasound?

After a month of working abroad, I’m a believer. You CAN monitor a patient’s labor without a computer in sight. During my month here, I learned how to be a better clinician. I learned how to listen to fetal heart tones with my stethoscope and plot this value on a partogram. I stopped relying on bedside ultrasounds and used my hands to determine the position of the fetus each and every time. I didn’t have an attending to double check my steps, so I had to grow up and confidently assert my cervical checks on my own. I learned how to read a partogram and how to know when trouble was occurring.

How accurate are partograms, really? Can you really know enough about how the fetus is doing by just listening and plotting on a chart? I looked into this today. I hope to do a more comprehensive search on this topic once I return home and have access to my school’s internet connection and all the free journals we get access to! In the meantime, here is my best attempt at answering a question with evidence-based medicine here in the DR on my own.

Partograms were first introduced by Friedman (1) in the 1950s, which was later improved by Philpott and Castle (172) by the addition of “action” and “alert” lines to the graph (2) which alert the clinician to fetal well-being and labor progress. An alert line represents the slowest 10% of a primigravida’s labor progress. An action line is placed 2-4 hours after the alert line to prompt management of slow labor progress. Current partograms recommended by the World Health Organization (WHO) are available on pre-printed paper that the clinician can fill in with the appropriate data points (3) like the one seen below. They are inexpensive and relatively easy ways to monitor care in obstetrics.

Although world organizations such as the WHO have recognized the partogram as an incredible advance in obstetrical care, many practioners in high-income countries question its effectiveness. I looked into a Cochrane Review article on partograms (4) to help answer my question. This review compiled data from five randomized controlled trials involving >6000 women in spontaneous labor at term. They found that there was no evidence that using a partogram had any effect on aspects of labor care or maternal or fetal primary or secondary outcomes. They looked at clinical outcomes such as section rate, duration of labor, artificial rupture of membranes, APGAR scores and found no significant difference in any of these clinical outcomes with and without the use of partograms. They suggested that partograms may be more effective in countries with limited healthcare resources which, importantly, were not well-represented in this review.

In under-resourced settings, such as where I worked for the past month, partograms help keep vigilance for adverse obstetric outcomes. One case–control study from Pakistan found the partogram reduced the frequency of need to augmentlabor, postpartum hemorrhage, ruptured uterus, sepsis, and perinatal and maternal morbidity and mortality (5). This study does not provide conclusive evidence to change established practice but is a nice look into the use of partograms in under-sourced settings. An article from Lancet in 1992 (6) found the following data: neonatal resuscitation rates and stillbirths were 9.8% higher in women who crossed the alert line and crossing the alert line had a sensitivity of 27%, a specificity of 93%, and a positive predictive value of 17% for neonatal resuscitation. The results show the usefulness and efficacy of the partogram as a method for medical intervention.

My conclusions: partograms can and do work anywhere in the world so it's good to know how to use them, but should not in my opinion be used to replace continuous monitoring if available. Also, I will be happy wherever I match, regardless of what the central monitoring room looks like. :)
1. Friedman E. Graphic analysis of labour. American Journal of Obstetrics and Gynecology 1954;68:1568-75.
2. Philpott RH, Castle WM. Cervicographs in the management of labour in primigravidae. Journal of Obstetrics and Gynaecology of the British Commonwealth 1972;79:592-598
3. WHO. World Health Organization partograph in management of labour. The Lancet 1994; 343:1399-1404.
4. Lavender T, Hart A, Symth RMD. Effect of partogram use on outcomes for women in spontaneous labour at term. Cochrane Database of systemic Review 2008, issue 4. Art No.:CD005461. DOI 10.1002/14651858. CD 005461.pub
5. Javed I, Bhutta S, Shoaib T. Role of partogram in preventing prolonged labour. Journal of the Pakistan Medical Association 2007;57(8): 408-411.
6.Dujardin B, De Schampheleire I, Sene H, and F Ndiaye. Value of the aleart and action lines on the partogram. Lancet. 1992, 30; 339 (8805): 1336-8.
7. Soni BL. Effect of partogram use on outcomes for women in spontaneous labour at term: RHL commentary (last revised: 1 June 2009). The WHO Reproductive Health Library; Geneva: World Health Organization.