who partograph study lancet 1994

8/16/2019 WHO Partograph Study Lancet 1994

1/6

1399

Clinical practice

World Health Organization partograph in management of labour

World Health Organization maternal health and safe motherhood programme*

Summary As part of the Safe Motherhood Initiative, launched in 1987,

the World Health Organization have produced and promoted a

partograph with a view to improving labour management and

reducing maternal and fetal morbidity and mortality. This

partograph has been tested in a multicentre trial in south east

Asia involving 35 484 women.Introduction of the partograph with an agreed labour-

management protocol reduced both prolonged labour (from6·4% to 3·4% of labours) and the proportion of labours

requiring augmentation (from 20·7% to 9·1%) Emergencycaesarean sections fell from 9·9% to 8·3%, and intrapartumstillbirths from 0·5% to 0·3%. Among singleton pregnancieswith no complicating factors, the improved outcome was evenmore marked, with caesarean sections falling from 6·2% to

4 5%. The improvements took place among both nulliparousand multiparous women.

The World Health Organisation partograph clearlydifferentiates normal from abnormal progress in labour and

identifies those women likely to require intervention. Its use in

all labour wards is recommended.

Lancet 1994; 343: 1399-404

Introduction

Prolonged and obstructed labour are important causes ofmaternal morbidity and contribute significantly to the halfa million women worldwide who die annually as a result ofchildbirth.1.2 Active management has reduced prolongedlabour in western obstetric practice but many elements ofthis approach remain controversial. For example, risingcaesarean-section rates increase maternal morbidity while

showing little evidence of an improvement in fetal

outcome.4The

ideal patternof

labour management andintervention has yet to be determined.

Progress has been made in improving active managementof labour. The pattern of progressive cervical dilation innormal labour was identified by Friedman nearly 40 yearsago5 and its application with the aid of a partograph (agraphical record of the progress of labour) was developedby Philpott in Zimbabwe.6,7 Reports of the use of a

partograph in other countries have been published and ithas become clear that it can be used worldwide since the

pattern of cervical dilation in normal labour in different

racial groups is similar.8

Despite descriptive reports, there is little information on

changes in outcome of labour due to implementing a

Correspondence to: Dr B E Kwast, MotherCare Project, John Snow Inc,1616 N Fort Myer Drive, Suite 1100, Arlington, VA 22209, USA

*Participants listed at end of paper.

partograph. Philpott and Castle7 reduced prolonged

labour, caesarean sections, labour augmentation, and

perinatal deaths in Zimbabwe. Similar improvements havebeen reported from Malawi,9 but none from Papua NewGuinea.10 Beazley and Kurjakll reported an increase in

oxytocin augmentation and a shortening of labour. Noother such studies have been published. Interest in the

partograph to manage labour has, however, been rekindledby the World Health Organization’s (WHO’s) promotional

work and the publication ofa

partographbased on

theWHO design.12The Safe Motherhood Conference organised jointly by

the World Bank, WHO, and the United Nations PopulationFund held in Nairobi in 1987recommended that all

pregnant women in labour are managed by appropriatelytrained personnel using practical and relevant technology.Responding to this call, WHO developed a printedpartograph, the format of which was agreed by a WHOTechnical Working Group, and published manuals,teaching aids, and operations-research guidelines.13 Inorder objectively to evaluate the impact of the WHO

partograph on labour management and outcome, a multi-centre trial was done in Indonesia, Malaysia, and Thailand. A detailed analysis of the design and use of the WHO

partograph is reported elsewhere. 14

Patients and methods

The figure shows theWHO partograph which is similar to Philpottand Castle’s original description,6 retaining the action line in theactive phase drawn 4 hours to the right of, and parallel to, the alertline. The central feature is the cervicograph which plots cervicaldilation against time. Distinction is made between the latent phaseof labour (up to 3 cm cervical dilation) and the active phase whenlabour is expected to progress at a rate of at least 1 cm cervicaldilation

perhour

(thealert

line).Other maternal and fetal

observations are also recorded on the partograph. The WHO

strategy document13 recommends referral from health centre to

hospital when cervical dilation moves to the right of the alert line.In a central unit, conservative management is recommended untilcervical dilation reaches or crosses the action line. A protocol forlabour management with the partograph was devised and tested as

part of the study.4 pairs of hospitals in south east Asia were invited to participate

(2 pairs in Indonesia, 1 each in Thailand and Malaysia). All thecentres functioned as district general hospitals in urbanenvironments with adequate medical and midwifery staffing andsuitable facilities for operative obstetric care. All were alreadypractising active labour management including oxytocin

augmentation.The study ran for 15 months from 1 January, 1990. During thefirst 5 months, all centres collected data on their deliveries on a

standardised form for entry onto the database held on computer at

WHO headquarters in Geneva. After 5 months, the WHO

partograph was randomly introduced in one of each hospital pair.10 months into the study, the partograph was introduced into the

remaining hospitals and thus used in all 8 for the last 5 months. Nodiscussions were held concerning labour management or


2/6

1400

Figure 1: The WHO partograph

Progress of labour is recorded on the graph of cervical dilation againsttime (4 hourly observations), with space to record all fetal and maternalobservations. The illustration shows a woman admitted at 2 cm dilation

(latent phase), who progressed to 4 cm at the next vaginal examination.This observation in the active phase is transferred onto the Alert line (1cm per hour-the lower limit of normal progress) and the time scale for allsubsequent maternal and fetal observations is shifted to the rightaccordingly. Full dilation (10 cm) occurred at the next vaginalexamination, with delivery 10 minutes later.

partography until the partograph was introduced, at which point acommon protocol was agreed for commencing women on the

partographand for labour management. This protocol was adoptedin all 8 hospitals but did not introduce any new form of

management which was not already being carried out.The labour management protocol can be summarised as no

intervention in latent phase until after 8 hours; rupture membranesin active

phase;at active

phaseaction line consider

oxytocinaugmentation, caesarean section, or observation and supportivetreatment. Introduction of the partograph and the associatedlabour management protocol was achieved by several days’intensive teaching ofmidwifery and medical staffwith the help ofaWHO consultant in each centre. A partograph was commenced inall labours over 34 weeks’ gestation, including inductions,malpresentations, and multiple pregnancies, except when womenwere admitted at 9 cm or 10 cm cervical dilation or immediate

caesarean section was indicated.

Since subjects could not be individually randomised to receiveconventional or partograph obstetric care, the study unit was the

hospital rather than individual subjects. The WHO partographwith its protocol for the management of labour, was introduced intofour

hospitalsafter 5 months and in the remainder after 10 months.

The hospitals were grouped into pairs according to country and

geographical location and one of these pairs was selected at randomto use the partograph early. The pairing of hospitals ensuredbalance between the two sets.

An analysis of variance model for a nested design15 was used toassess the impact of introducing the partograph within each

hospital. Consequently, to assess the impact of the partograph oncontinuous endpoints, the partograph by hospital interaction term

Before After p

Implementation Implementation

Total deliveries 18254 17 230

Duratlon of labour (h)* 325 3 13 0 819

Median (5-95 percentiles) (017-20-4) (017-15 83)

Labour > 18 h* 1147(64) 589(34) 0002

Labour augmented 3785 (20 7) 1573 (9 1) 0023

Postpartum sepsis 127(0 70) 37 (0 21) 0028

Mode of deliveryt

Singleton pregnanciesSpontaneous cephalic 13 186 (72 4) 12 704 (73 9) 0201

Vaginal breech 618 (3 4) 591 (3 4) 0975

Vacuum or forceps 1793(98) 1649(96) 0 110

Caesarean section (total)t 2278(125) 1926(112) 0.841Elective 458(25) 418(24) 0576

Emergency 1802 (9 9) 1495 (8 7) 0678Other singleton vaginal§ 106 (0 6) 70 (0 4) 0 007

Multiple pregnancies All vaginal . 198(11) 210(12) 0339Caesarean section 41 (0 23) 37 (0 22) 0848

All women before and after implementation (number of women with percentages in

parentheses, except where stated).*Length of labour not recorded in 209 and 98 women before and after implementation,respectively. tMode of delivery not recorded for 11 (including 1 multiple pregnancy) and 15women before and after implementaton, respectively; 23 and 28 women delivered bylaparotomy before and after implementation, respectively. tClassification into elective or

emergency Caesarean section not clear in 18 and 13 women before and after

implementation, respectively. §Other singleton vaginal deliveries include 82 destructive and31 other deliveries.

Table 1: Duration of labour, augmentation, mode of delivery,and postpartum sepsis: all women

was used as the error term in the denominator of the F ratio with 1

and 7 degrees of freedom. The assessment of error was thus within

hospital between periods.Since the distribution of duration of labour was highly skewed,

values were log transformed before computation of summarystatistics and analysis of variance models. These have been backtransformed to the original scale (geometric means) for

presentation. For analysis of discrete endpoints, the empiricallogistic transform16 was used to estimate the impact of the

partograph within each hospital on a log-odds ratio scale. Thesewere averaged with weights inversely proportional to theirvariances to provide an overall estimate ofpartograph impact. Thestandard error of this estimate was based on the weightedwithin-hospital residual mean squareofthe logistic differences andthe t distribution with 7 degrees of freedom was used to assess the

significance of any changes and to construct confidence intervals.This analysis is analogous to that used for the the analysis of thecontinuous endpoints which considers the hospital by study-period interaction term as the correct estimate of error since this isthe

studyunit rather than the individual woman. The

summarylog-odds ratios are expressed as percentage reductions in eventrates (with 95 % confidence intervals) following the introduction ofthe partograph, except where stated otherwise. Additional analyseswere done to compare the impact of the partograph among those

hospitals that implemented early and those that implemented later.The impact on all women who were delivered during the 15

months of the study was assessed, whether or not the partographand its management protocol would be expected to result in

improvements. Results are also presented for the subgroup ofnormal women (54%) admitted in labour with cervical dilation no

greater than 8 cm on whom no immediate caesarean section was

indicated and who had none ofthe following features at the time ofadmission: hypertension, multiple pregnancy, malpresentation,

antepartum haemorrhage, previouscaesarean

section, gestationless than 37 or greater than 43 weeks. Results on all womendelivered during the study are presented, except for two womenwith abdominal pregnancies and 13 women (0-037%) on whominsufficient data were available for analysis (6 before and 7 after

implementation of the partograph). Additional missing data oncertain items, not sufficient to require exclusion, are indicatedwhere relevant in the tables. A detailed description of the trial

methodology and of the management protocol is available.’4


3/6

1401

Results

Data from 35 484 women were analysed. Indonesia’s four

centres contributed 13 803, with 12 054 from Malaysia’stwo centres, and 9627 from Thailand’s two. 18 254 women

were delivered before implementation of the partographand 17 230 after.

Mean age was 27-23 years (standard deviation 5-72) and

mean gestationon admission 39-0 weeks (21). 2970 women

(8.4%) were < 37 weeks. 39-1% were nulliparous, 51-9%parity 1-4, and 8-9% parity 5 or more. 2529 labours (7-1 %)were induced and a further 1397 women (39%) did nothave an observed labour but were delivered by elective orimmediate emergency caesarean section. The total

caesarean section rate was 12-1% (2-5% elective, 9-5%emergency, and 0-1% unclassifiable). There were 55 casesof ruptured uterus and 47 (0-13%) maternal deaths, almostall among women admitted from home with neglectedserious complications.There were 479 sets of twins and 8 sets of triplets

resulting in a total of 35 944 infants. 929 (2-6%) were

stillbirths and in the majority of cases (781) the fetus wasdead on admission. The mean birth weight was 3 065

(0-506) kg and 2-276 (0-558) kg for all singleton infants and

multiple births, respectively; with 9-2% and 61-4% lessthan 2-5 kg, respectively. There were 139 first-weekneonatal deaths recorded before discharge of the mother.

There were no differences in characteristics of women

who delivered before and after implementation of the

partograph (mean ages 27-29 [5’68] and 27-17 [5’75],p=055 and mean gestational age 39 01 [2’09] and 39-07

[2’01] weeks, p=0 26 before and after implementation,respectively; 39-0% and 39-2% were nulliparous, p=0-87,

and 55-1% and 53-0% were normalwomen, p=

0-68, beforeand after implementation, respectively; mean maternal

height 153-37 [5-55] cm before and 153 36 [5’45] cm after

implementation [p==0 73]). Most women had a minimumof two visits to an antenatal clinic; slightly fewer (91-7%)received this amount of antenatal care after implementationcompared to women before implementation (93-8%)(p=041).The impact of implementing the partograph on the

duration of labour, oxytocin usage, and mode of delivery isshown in table 1. Labours augmented with oxytocin werereduced by 54% (95% confidence interval, 13%-76%).

Despitethis, the mean duration of labour was

only slightlyreduced from 2-72 to 2-68 hours (adjusted geometricmeans)or from 5-72 (7-41) to 5-05 (5-89) hours (arithmetic means),with a drop of 41% (24%-54%) in labours lasting morethan 18 hours. Among singleton deliveries the rate of

spontaneous cephalic deliveries increased by 6% (- 4% to

17%), instrumental (vacuum extraction or forceps)deliveries were reduced by 9% (-3% to 20%) and

emergency caesarean sections by3% (-16% to 19%). Whenindications for emergency caesarean section were

examined, 62% of the overall reduction was accounted for

by cephalo-pelvic disproportion. Changes in otherindications for caesarean section were small; in particular

there was no change in the proportion of caesarian sectiondone for fetal distress. There were no significant changes inthe rates of other types of deliveries, including the rate ormode of delivery of multiple pregnancies. The meannumber of vaginal examinations during the first stage oflabour fell from 1.77 (135) before to 1 51 (1-24) after

implementation (adjusted within-centre difference 0 23[-001 to 047], p=0057).

Before After p

Implementation Implementation

Total deliveries 10049 9130

Duration of labour (h)* 3 83 4 15 0257

Median(5-95 percentiles) (058-189) (078-15-5)

Labour >18h* 551 (5 5) 249 (2 7) 0001

Labour augmented 2575 (25 6) 967(106) 0041

Postpartum sepsis 54 (0 54) 10 (0 11) 0 003

Mode of deliverytSpontaneous cephalic 8428(83-9) 7869(863) 18 h* 347(83) 176(45) 0017

Labour augmented 1353(321) 539 (13 7) 0049

Postpartum sepsls 34 (0 81) 3(008) 0001

Mode of deliverytSpontaneous cephalic 3129(743) 3069(783)


4/6

1402

Before After p

lmplementaflont lmplementationt

Total deliveries 5810 5192

Duration of labour (h)* 2 83 3 08 0 245

Median (5-95 percentiles) (042-152) (060-13 1)

Labour >18h’t’ 203(35) 72(14)


5/6

1403

partograph, and the similarity of the changes among those

hospitals that implemented the partograph early and those

that implemented it later suggest that the observed

differences were in fact due to the intervention studied.

Introduction of the partograph led to a reduction in

prolonged labour (> 18 hours), achieved despite halving the

proportion of labours receiving oxytocin augmentation.Caesarean section rates also fell and there was a

corresponding rise in spontaneous vaginal deliveries;operative vaginal deliveries by forceps were reduced withlittle change in vacuum extractions. The association of a

reduction in both augmentation and prolonged labouraccords with the findings of Philpott and Castlebut is inmarked contrast to the findings of most other authors.u,17That the labours were more efficient appears to be

confirmed by the reduced rate of caesarean sections. This

may be in part explained by the greater use of artificial

rupture of the membranes at earlier dilations after

implementation of the partograph, especially in Indonesia.The caesarean-section rates achieved were not as low as

some other studies. Although a single partographdesignmay be applicable to all populations, caesarean section rates

may vary with different populations.Thom et al18 found, ina single-centre study, that a similar proportion of womenfrom different ethnic origins reached an action line butcaesarean-section rates varied. A caesarean section rate of

0-5% was achieved by Bird19 in PapuaNew Guinea (0.7% if

symphysiotomies are included) among women of all

parities, probably broadly comparable to the normal groupin the WHO trial. Perhaps more remarkable was the 1.8%caesarean section rate reported among labouring nulliparaby O’Driscoll et al in Dublin.l’ O’Driscoll’s aggressivemanagement policy (55% augmentation rate) would not

necessarily be appropriate or desirable in other settings.Lowering augmentation rates from 32.1% to 13-7%reduced caesarean sections in this trial. Philpott and Castle7reduced caesarean sections from 9-9% to 2 6 °amongnullipara, who were the only women studied. The

corresponding drop for nullipara in this trial was from 9 -8 %to 6’9%. Although the reduction in prolonged labour hadno impact on postpartum haemorrhages, this, together withthe reduction in vaginal examination in labour and incaesarean sections, probably contributed to the significantfall in postpartum sepsis rates.There was no impact on the incidence of maternal deaths

or uterinerupture,

but these events occurred almost

entirely among women admitted with severe complications.They were rare in this group of women. Intrapartumstillbirths fell with the use of the partograph and othermeasures of neonatal outcome were not compromised byimprovements in maternal outcome. First-week neonatal

mortality prior to discharge also fell but the reportednumbers are small and such deaths underestimate the true

neonatal mortality rates since no systematic follow-up ofmothers or infants was undertaken. The improvementsdescribed were most marked in normal women who had no

other complications to influence the likelihood ofintervention and occurred among multiparous and

nulliparous women.The visual presentation of clinical information can affect

decision making and this may be particularly true of

partography.20 The results summarised here and reportedin detail elsewhere14 confirm that the WHO partographidentifies those labours likely to have an abnormal outcome.

A detailed analysis of the design did not suggest that anymodification is necessary. Caesarean section rates of 0.6%

when labour remained on or to the left of the alert line and

21-8% when the action line was reached, convincinglydemonstrates the capacity of the partograph to identifyproblem labours. A similar caesarean section rate (204%)occurred after a prolonged latent phase (8 hours on the

partograph) but the most important finding was the smallnumber of women who experienced a prolonged latent

phase. The existence of clear guidelines about when to start

the partograph was undoubtedly the main reason for this.O’Driscoll et al 17 similarly emphasised the critical

importance of the correct diagnosis of labour.The partograph itself is of little more than observational

value without a management protocol. The protocol used inthis trial merely indicated the timing of certaininterventions. No alterations to the nature of these

interventions was suggested, in particular each centrecontinued to use their pre-existing regime for oxytocinaugmentation. The main changes brought about by agreedmanagement protocol were that ARM in labour was

performed earlier in the active phase and that augmentationwas delayed, usually until the action line was reached (hencethe reduction in labours requiring augmentation). The

steady increase in augmentation rate as labour progressslowed across the partograph was therefore an inevitablebut appropriate result of the application of the protocolwith the partograph. Labour wards intending to use theWHO partograph may adapt local management protocols oftheir own but the improved labour outcomes reported inthis trial suggest that the WHO partograph works

successfully with the protocol described in the methods.It was not possible from this study to address the

partograph as an aid to referral decisions in labour.

Nonetheless, some conclusions can be drawn from the 27%

ofwomen in this study whose labours moved to the right ofthe alert line. If such a rate were typical among women

having an observed labour in a peripheral unit, the referral

of 20-30% of labouring women is likely to be unacceptableand impracticable in many settings. However, it must beconcluded that, where local circumstances permit (andevery effort should be made to ensure that they do

permit2l), women in labour should be transferred to a unitwith facilities for caesarean section when the progress of

labour moves to the right of the alert line, except whenlabour is advanced and delivery appears imminent.The impressions of the principal investigators and their

staff of the

partographas a

managementtool were

unanimously favourable. It was felt that observation of the

progress of labour was clearer and this helped in

interpreting findings and communication betweenmembers of the maternity-care team. The reduction ofintravenous infusions for augmentation of labour was

appreciated by the midwives as they could give more

supportive care to the women.

Appropriate technology is defined by the WHO as

"Methods, procedures, techniques and equipment that are

scientifically valid, adapted to local needs, acceptable tothose who use them and to those for whom they are used,and that can be maintained and utilized with resources

the community or country can afford".2O The WHOpartograph has been carefully evaluated in this study and itishoped that the results will encourage all maternity units touse a partograph with incorporated management guidelinesto the benefit ofmothers, babies, midwives, and doctors. Itsuniversal application has the potential not only to reducefetal and maternal mortality and morbidity but also toreduce the number of caesarean sections.


6/6

1404

A Multicentre Project coordinated by the Maternal and Child Health and

Family Planning Programme and the Special Programme of Research,Development and Research Training in Human Reproduction, WorldHealth Organization, Geneva, Switzerland.Manuscript prepared by: Dr B E Kwast, Dr C E Lennox,Dr T M M Farley.

Principal investigators and centres: Dr Hamonangan Hutapea,Dr Esanov Hasibudn, Dr Herman Garcia Tobing, University TeachingHospital, Medan, Indonesia; Dr Hakim Pohan, DrWim T Pangewanian,DrH Komar A Syamsudin, University Hospital Palembang, Indonesia;Dr lyan S Wiraatmadja, Dr Bambang Gunawan, Mrs Betty Yoelisman,Tangerang Hospital, Tangerang, Indonesia; Dr Sunarto Wiranogoro,DrM Barhuddin, Mrs Aryanti Wiyatno, Budi KumuliaanHospital, Jakarta, Indonesia; Dr C Ramakrishnan,Mrs Siti Azizah bte Abd Rahman, Kuala Pilah Hospital, Kuala Pilah,Malaysia; DrK Sachchithanatham, Mrs Mahani bte Atan,Muar Hospital,Muar, Malaysia; Dr Mayure Pattapong, Dr Wiroj Wannapatra,Dr Krit Charuchat, Phitsanulok Hospital, Phitsanulok, Thailand;Dr Sermsak Punnahitanont, Dr Chanan Sry-Jantongsiri,Miss Putchareewan Visitipanich, Nakhon Sawan Hospital, Nakhon

Sawan, Thailand.

Study and data co-ordination: Dr B E Kwast, Maternal Health and SafeMotherhood Programme, World Health Organization, Geneva,Switzerland; Dr TM M Farley, Miss M Vucurevic, Mr I Olayinka,Mr A Pinol, Special Programme of Research, Development and Research

Training in Human Reproduction, World Health Organization, Geneva,Switzerland.

Consultants: Prof S S Ratnam, Dr S Arulkumaran, National Universityof Singapore, Singapore; Dr C E Lennox, Law Hospital, Carluke, UK;DrK S Stewart, Stirling, UK.

Acknowledgments: Financial support for the multicentre trial on theWHO partograph was provided by contributors to theWHO SafeMotherhood Operations Research and the Special Programme of

Research, Development and Research Training in Human Reproduction.The collaboration and support of the Ministries of Health in Indonesia,

Malaysia, and Thailand are gratefully acknowledged. While the principalInvestigators are mentioned by name, the hard work of the nurses,nurse-midwives and doctors in all participating centres that made this

project possible is gratefully acknowledged.

References

1 Maternal mortality ratios and rates—a tabulation of availableinformation 3rd edition,WHO document WHO/MCH/MSM/91.6World Health Organisation, Geneva, 1991.

2 Mahler H. The safe motherhood initiative: a call to action. Lancet 1987;i: 668-70.

3 Crowther C, Enkin M, Keirse MJNC, Brown I. Monitoring the

progress of labour. In: Chalmers I, Enkin M, Keirse MJNC, eds.Effective care in pregnancy and childbirth. Oxford: University Press,1989.

4 Thiery M, Derom R. Review of evaluation studies on caesarean sectionPart I. Trends in caesarean section and perinatal mortality. In:

Kaminsky M, Bréart G, Buekens P, Huisjes HJM, McIlwaire G,Selbmann MK, eds. Perinatal care delivery systems: description andevaluation in European Community countries. Oxford: Oxford

University Press, 1986.5 Friedman EA. Primigravid labour. A graphicostatistical analysis.

Obstet Gynecol 1955; 6: 567-89.

6 Philpott RH, CastleWM. Cervicographs in the management of labourin primigravidae. I: the alert line for detecting abnormal labour.

JObstet

GynaecolBr Cwlth

1972;79: 592-98.

7 Philpott RH, CastleWM. Cervicographs in the management of labourin primigravidae. II: the action line and treatment of abnormal labour.

J Obstet GynaecolBr Cwlth 1972; 79: 599-602.8 Duignan NM, Studd JWW, Hughes AO. Characteristics ofnormal

labour in different racial groups. Br J Obstet Gynaecol 1975; 82:593-601.

9 Kwast BE, Rogerson G. An analysis of the duration of labour, themode of delivery and outcome in Queen Elizabeth Hospital before andafter the use of the partograph. Internal publication, Malawi, 1973.

10 Lennox CE. The cervicograph in labour management in the highlandsof Papua New Guinea. PapuaNew Guinea Med J 1973; 24: 286-93.

11 Beazley JM, Kurjak A. Influence of a partograph on the active

management of labour. Lancet 1972; i: 348-51.

12 Dujardin B, De Schampheliere I, Sere H, Ndiaye F. Value of the alertand action lines on the partogram. Lancet 1992; 339: 1336-38.

13 World Health Organization. The partograph. A managerial tool for theprevention ofprolonged labour. Section I: the principle and strategy.Section II: a user’s manual: WHO/FHE/MSM 93.8 and 9. WHO,Geneva, 1993.

14 World Health Organization. The application oftheWHO partographin the management of labour. WHO, Geneva: WHO/IHE/MSM 94.4.WHO, Geneva, 1994.

15 Cochran WG, Cox GM. Experimental designs. New York: Wiley,1957.

16 Cox DR. Analysis of binary data. London: Methuen, 1970.17 O’Driscoll K, Stronge JM, Minogue M. Active management of labour.

BMJ 1973; 3: 135-37.18 Thom MH, Chan KK, Studd JWW. Outcome of normal and

dysfunctional labor in different racial groups. Am J Obstet Gynecol1979; 135: 495-98.

19 Bird GC. Cervicographicmanagement of labour in primigravidae and

multigravidae with vertex presentation. Trop Doc 1978; 8: 78-84.

20 Cartmill RSV, Thornton JG. Effect of presentation of partograminformation on obstetric decision making. Lancet 1992; 339:1520-22.

21 World Health Organization. Essential elements of obstetric care at firstreferral level. WHO, Geneva, 1991.

22 World Health Organization and International Federation of

Gynaecology and Obstetrics. Appropriate technology in maternal andchild health. IntJ Gynecol Obstet 1992; 37: 229.

who partograph study lancet 1994

Documents