Of the estimated annual toll of half a million maternal deaths, some 99 per cent occur in developing countries. An unknown proportion of these follow prolonged labour, due mainly to cephalopelvic disproportion which may result in obstructed labour, maternal dehydration, ruptured uterus and obstetric fistulae (and also, but less directly, in postpartum haemorrhage and neonatal infection). In the infant, prolonged obstructed labour may cause asphyxia, brain damage, infection and death. Obstructed labour, with or without ruptured uterus, features among the five major causes of maternal death in almost every developing country, although its relative importance varies from region to region. Nevertheless, it can be said with certainty that abnormally prolonged labour and its effects are important contributors to maternal and perinatal mortality and morbidity worldwide.
There are many constraints - geographical, economic, political and sociocultural - which lead to either the non-availability or non-utilisation of the basic obstetric care which is required to manage obstructed labour satisfactorily. The aim of safe motherhood interventions is to address, directly or indirectly, these constraints. Early detection of abnormal progress and prevention of prolonged labour would help reduce maternal and perinatal mortality. The partograph, which is a graphic recording of the progress of labour and the condition of the mother and fetus, has been in use for over 20 years, but not so widely as the reported results of its use would suggest is appropriate. In order to promote its wider and more rapid adoption, WHO held consultations which produced an agreed standard format. This has been the subject of a WHO multicentre trial conducted in Indonesia, Malaysia and Thailand (1). The report of the trial (2) confirms what had been found in earlier studies concerning its effectiveness, low cost and feasibility. In this trial, the proportion of labours which lasted over 18 hours was almost halved after introducing the partograph. The rate of caesarean section among “normal” women (i.e. without serious complications or high risk already on admission) was reduced from 5.2 to 3.7 per cent; and the percentage requiring augmentation of labour was more than halved. There were not the dramatic improvements in neonatal outcome which earlier trials, e.g. in Zimbabwe and Malawi, had shown. However, a study in Assiut in Egypt, at the same time as the multicentre trial but not part of it, did show a marked fall in the percentage of Apgar scores less than 7 at five minutes, and in perinatal mortality (3).
In 1988 the WHO Maternal Health and Safe Motherhood programme issued a series of four inter-related documents under the title The Partograph: A Managerial Tool for the Prevention of Prolonged Labour. These are now being re-issued in a slightly updated form to take into account the results of the multicentre trial under the general title Preventing Prolonged Labour: a practical guide - The Partograph. The first document Principles and Strategy (WHO/FHE/MSM/93.8), explains the history and the principles of the partograph, discusses various issues relating to its format, describes how the WHO partograph was devised and gives a brief account of its rationale and method of use.
It is essential to note that the partograph can only be used by health workers with adequate training in midwifery who are able to:
• observe and conduct normal labour and delivery;
• perform vaginal examinations in labour and assess cervical dilatation accurately;
• plot cervical dilatation accurately on a graph against time.
It has no place, therefore, in deliveries at home conducted by attendants other than those trained in midwifery. Whether used in health centres or “maternities” or in hospitals, the introduction of the partograph must be accompanied by a programme of training in its use and by appropriate supervision and follow-up. The first volume concludes by outlining a strategy to promote wider use.
The second of the four parts, WHO/FHE/MSM/93.9, is entitled User’s Manual. As implied, the correct use of every part of the partograph is explained in detail, with examples. It demonstrates how all the observations contribute to complement the central monitoring tool which is a graph of cervical dilatation, with its “alert” and “action” lines. Warning is given that the partograph is not to be started if there are already complications of the pregnancy/delivery (e.g. haemorrhage, eclampsia) which require immediate action. The document does provide the WHO protocol used in the multicentre study which produced excellent results and is recommended for use in conjunction with the partograph, though local adaptation is possible. For example, in a health centre or maternity without the facilities or skills to perform caesarean delivery, it is necessary to start making arrangements for transfer to a hospital when dilatation moves to the right of the alert line.
The third part (WHO/FHE/MSM/93.10) is a Facilitators Guide. It provides precise and comprehensive advice to those who are teaching midwives or medical students the use of the partograph. Teaching objectives, materials required, points of special emphasis, and exercises, all are specified.
The fourth and last part (WHO/FHE/MSM/93.11) is entitled Guidelines for Operations Research. The results of the multicentre trial have become available and, taken together with reports of hospital evaluations in other countries (3), demonstrate that the introduction and correct, well-supervised use of the partograph can significantly improve the outcome of pregnancy and delivery. Part IV specifies that operations research should not be concerned with the construction of nomograms for a particular population - that is unnecessary - but with a practical application of the knowledge of partographs gained worldwide to date. The gains registered from use of the partograph at hospital level are likely to be even greater at the level of health centres and maternities which rely on referral hospitals for emergency obstetric interventions. More objective criteria of delay in labour and a practical and methodical way of monitoring the progress of childbirth would be a significant contribution to greater safety and would be a welcome aid to reduce the uncertainties and anxieties of health professionals. WHO is supporting evaluations along the lines of the guidance given in Part IV in three centres. However, a number of problems remain. For example, health centres or health centre networks where this operational research should take place should have a minimum of 500 deliveries a year. This should not be an insupportable obstacle, and intensified efforts need to be made to provide the operational research basis for the wider promotion at this level.
In conclusion, a partograph correctly used certainly improves the management of labour and the outcome of pregnancy at the hospital level, and probably even more so at health centre level (4). Beyond the reach of aid through the partograph are the millions who are delivered with no attendant or with the assistance only of a relative or other untrained person. With the gradually increasing availability of appropriate technology, of which the partograph is a notable example, the safety of both supervised homebirths by a trained midwife and institutional (hospital or health centre) delivery should improve. With the trend towards births attended by a trained health worker in the community, hospital and health centre, more and more women and their babies can benefit from this greater safety. It remains for governments, peoples and all other partners in safe motherhood to do their utmost to accelerate this trend.