Approximately half a million women lose their lives every year because of
complications of pregnancy and about 99% of these occur in developing
countries. The risk of a woman dying as a result of a complication related
to pregnancy in developing countries can be as much as a hundred times that
of women in Western Europe or North America. An average of 450 women die
for every 100 000 live births in the developing world.
Recognizing the unacceptably high maternal mortality ratio, the preventable
nature in the majority of cases, and the social consequences of a mothers
death to her family and children, the Safe Motherhood Conference organized
jointly by The World Bank, WHO and the United Nations Population Fund held
in Nairobi in February 1987 concluded with a “Call to Action.” This call
demands that health workers involved in the care of mothers and children
take positive action now to reduce maternal mortality and morbidity. Among
the actions called for are: to ensure that all pregnant women are screened
by supervised and appropriately trained non-physician health workers where
appropriate, with relevant technology (including partographs as needed), to
identify those at risk; and to provide prenatal care and care during
labour, as expeditiously as possible.
Postpartum haemorrhage and sepsis are the most common causes of maternal
death in developing countries, but obstructed labour and ruptured uterus
may cause as many as 70% of all maternal deaths in some situations.
Prolonged labour in the developing world is commonly due to cephalopelvic
disproportion (CPD), which may result in obstructed labour, maternal
dehydration, exhaustion, uterine rupture and vesico-vaginal fistula.
Protracted labour is more common in primigravid women than in multipara and
the complications and effects of CPD differ between them. In countries
where CPD is not prevalent, abnormal progress of labour is often due to
inefficient uterine action. Universally, less direct consequences of
prolonged labour include maternal sepsis, postpartum haemorrhage and
Early detection of abnormal progress of labour and the prevention of
prolonged labour would significantly reduce the risk of postpartum
haemorrhage and sepsis, and eliminate obstructed labour, uterine rupture
and its sequelae.
The partograph, a graphic recording of progress of labour and salient
conditions of the mother and fetus, has been used since 1970 to detect
labour that is not progressing normally, to indicate when augmentation of
labour is appropriate and to recognize cephalopelvic disproportion long
before labour becomes obstructed.
The partograph serves as an “early warning system” and assists in early
decision on transfer, augmentation and termination of labour. It also
increases the quality and regularity of all observations on the fetus and
the mother in labour, and aids early recognition of problems with either.
The partograph has been in use in a number of countries, and used
extensively in a few. It has been found to be inexpensive, effective and
pragmatic in a variety of different settings including developed and
developing countries. It has shown to be effective in preventing prolonged
labour, in reducing operative intervention and in improving the neonatal
outcome. The partograph developed by WHO and described here has been
extensively tested in a multicentre trial in Indonesia, Malaysia and
Thailand. The results have emphatically confirmed the results of earlier
Table 1 illustrates the results than can be achieved using a partograph.
Labours lasting more than 24 hours, perinatal mortality and caesarean
section rates all dropped considerably in these two African studies after
the partograph was introduced. Table 2 summarises the improvements in
labour outcome that were achieved in the multicentre trial of the WHO
partograph. Prolonged labour, augmented labour, caesarean sections and
intrapartum fetal deaths all fel.
Rates of prolonged labour, caesarean section and perinatal mortality
before and after the introduction
of the partograph in labour management
Expressed as % of total deliveries.
Rates of prolonged labour, augmented labour, caesarean section and
intrapartum fetal deaths in a multicentre trial of WHO partograph
The objectives in producing this information and manual on the partograph
To encourage implementation of the partograph throughout the world
with a view to reducing prolonged labour and its sequelae.
To promote further research into its use and benefits, particularly as
a referral tool.
HISTORY OF THE PARTOGRAPH
E.A. Friedman in 1954, following a study on a large number of women in the
USA, described a normal cervical dilatation pattern (see Fig. I.1).
Fig. 1.1. Friedman’s curve showing phase of maximum slope
Friedman divided labour functionally into two parts. The (early) latent
phase extends over 8-10 hours and up to about 3 cm dilation. This was
followed by an active phase, characterized by acceleration from about 3-10
cm at the end of which deceleration occurred. This work has been the
foundation on which others have built.
In 1969 Hendricks et al. demonstrated that, in the active phase of normal
labour, the rate of dilatation of the cervix in primigravidae and
multiparae varies little and that there is no deceleration phase at the end
of the first stage of labour.
Philpott, in extensive studies of primigravidae in Central and Southern
Africa, constructed a nomogram for cervical dilatation in his population
and was able to identify deviations from the normal and provide a sound
scientific basis for early intervention leading to the prevention of
prolonged labour. Since then, various authors have developed similar
nomograms in other geographical areas. None of these have shown significant
differences between ethnic groups
THE PARTOGRAPH: THE WHO MODEL
The WHO model of the partograph was devised by an informal working group,
who examined most of the available published work on partographs and their
design. It represents in some ways a synthesised and simplified compromise,
which includes the best features of several partographs. It is based on the
The active phase of labour commences at 3 cm cervical dilatation.
The latent phase of labour should last not longer than 8 hours.
During active labour, the rate of cervical dilatation should be not
slower than 1 cm/hour.
A lag time of 4 hours between a slowing of labour and the need for
intervention is unlikely to compromise the fetus or the mother and
avoids unnecessary intervention.
Vaginal examinations should be performed as infrequently as is
compatible with safe practice (once every 4 hours is recommended).
Midwives and other personnel managing labour may have difficulty in
constructing alert and action lines and it is better to use a
partograph with preset lines, although too many lines may add further
The average time in labour after admission to a health institution in the
developing world is 5-6 hours. In most cases, therefore, not more than 2
vaginal examinations should be necessary.
The multicentre trial of the WHO partograph has confirmed the
appropriateness of this design and no modifications have been recommended
as a result of this trial, except for deletion of the heavy vertical line
extending upward from 3 cm.
Table 3 demonstrates how effectively an appropriately placed action line
identifies labour where intervention is likely. In those studies listed in
Table 3, between 3% and 30% of cases studied crossed the action line, a
probable reflection of the variety of different partographs in use. In the
WHO multicentre trial, 10% of women crossed the action line; 22% of these
were delivered by caesarean section, compared to 1% when the action line
was not crossed.
Mode of delivery among labours not crossing and crossing action line in
* Figures are % of total labours not reaching action line.
+ Figures are % of total labours reaching or crossing action line.
Figure I.2 shows the partograph advocated and extensively tested by WHO.
This partograph, like others, is basically a graphic representation of the
events of labour plotted against time in hours. It consists of three
The fetal condition
The progress of labour
The maternal condition.
It can be used for all labours in hospital. In the periphery, it would only
be used for low risk labours where spontaneous vaginal delivery is
anticipated. High risk patients should be transferred to hospital
The partograph does not replace adequate screening of women on arrival in
labour to exclude conditions that require urgent attention or immediate
transfer. It is designed to detect deviations from normal delivery that
develop as labour progresses.
The progress of labour
This part of the graph has as its central feature a graph of cervical
dilatation against time. It is divided into a latent phase and an active
The latent phase
The latent phase of labour is from the onset of labour until the cervix
reaches 3 cm dilatation. If this phase is delayed for longer than 8 hours
in the presence of at least 2 contractions in 10 minutes, the labour is
more likely to be problematical and therefore, if the woman is in a health
centre, she should be transferred to hospital. If she is in hospital, she
needs critical assessment and a decision about subsequent management.
The active phase
Once 3 cm dilatation is reached, labour enters the active phase.
In about 90% of primigravidae, the cervix dilates at a rate of 1 cm/hour or
faster in the active phase.
The alert line drawn from 3 cm to 10 cm represents this rate of dilatation.
Therefore, if cervical dilatation moves to the right of the alert line, it
is slow and an indication of delay in labour. If the woman is in a health
centre, she should be transferred to hospital; if in hospital, she should
be observed more frequently.
The action line is drawn 4 hours to the right of the alert line. It is
suggested that if cervical dilatation reaches this line, there should be a
critical assessment of the cause of delay and a decision about the
appropriate management to overcome this delay.
This partograph is designed for use in all maternity settings, but has a
different level of function at different levels of health care. In a health
centre, the critical function is to give early warning that labour is
likely to be prolonged and that the woman should be transferred to hospital
(alert line function). In the hospital setting, moving to the right of the
alert line serves as a warning for extra vigilance; but the action line is
the critical point at which specific management decisions must be made.
Other observations on the progress of labour are also recorded on the
partograph and are essential features in the management of labour. In
particular, it is important to note the descent of the fetal head through
the pelvis and the quality of uterine activity.
The fetal condition
The fetus is monitored closely on the partograph by regular observation of
the fetal heart rate, the liquor, and the moulding of the fetal skull
The maternal condition
Regular assessment of the maternal condition is achieved by charting
maternal temperature, pulse and blood pressure, and by regular urinalysis.
The partograph also contains a space to chart administration of drugs, IV
fluids, and oxytocin if labour is augmented.
The implementation of the partograph implies a functioning referral system
with essential obstetric functions in place. Its use should also improve
the efficiency and effectiveness of maternity services.
The proposed partograph and its accompanying management guidelines can only
be used where the woman presents herself to the formal health care system
in labour and where staff who fulfil certain minimum training criteria
work. These staff must:
Have adequate training in midwifery to observe and conduct normal
labour and delivery.
Be able to perform vaginal examinations in labour and accurately
assess cervical dilatation.
Be able to plot cervical dilatation accurately on a graph against
There is evidence that midwife-auxiliaries with quite basic training are
able to fulfil these functions and it should therefore be possible to
introduce the partograph into a peripheral level of formal health care. In
these circumstances, the critical function of the partograph is to indicate
when referral is appropriate.
It is, however, essential that the introduction of the partograph be
combined with a programme of training in its use and of close supervision,
encouragement and follow-up of those using it.
Despite the fact that the partograph has been described and used since the
early 1970s, it is still not used worldwide. One primary reason for this is
the lack of conviction felt about its usefulness by decision-makers and
some leaders of the profession. Another main obstacle to widespread use is
the existence of so many varieties of the partograph; the potential new
user is at a loss as to which set of conflicting guidelines to follow.
To overcome these two primary hindrances, the following strategy is
Use the simplified partograph developed by WHO. It includes the
essential features of most of the partographs currently in use.
Introduce this partograph to decision-makers at Ministries of Health,
as well as to leaders of the profession in each country, especially to
those in teaching hospitals.
Implement this partograph initially in teaching hospitals and referral
centres. Its application can then be extended to health centres.
Encourage medical and midwifery schools to teach the principles and
use of the partograph, and to include it in the curriculum.
Encourage research into all aspects of the application of the
partograph. This research should include evaluation of training
programmes, as well as investigation of the impact of the partograph
on labour management and on adverse outcomes of labour. Particularly
needed is research into the use of the partograph as a referral tool
in labour. The WHO multicentre trial has emphatically confirmed the
value of the partograph in hospital practice.
It is realized that in many developing countries the formal health care
system does not look after all pregnant women. If efforts do not go beyond
the formal sector, it is unlikely that the existing appalling maternal
mortality and morbidity will be influenced very much. Therefore efforts
should be made to reach pregnant women outside the formal health care
system. This can be done in a variety of ways:
Traditional birth attendants (TBAs) should be involved as much as
possible as agents of change. They should participate in conveying
messages to pregnant women and village elders about the need to seek
assistance early during pregnancy and labour.
In those countries where mutual respect exists between trained
midwives and TBAs, the latter have been persuaded to refer women in
labour not later than 12 hours after they receive them. This
experience should be emulated in other countries.
Other methods of communication should be used as much as possible
(e.g. village health committees, the radio, church groups, newspapers)
to convey to rural communities the message that delayed labour can
lead to problems for the mother and her baby and that help should be
sought early (within 12 hours of the onset of labour).
It is also hoped that the improved results in labour management that
should result from the use of the partograph will increase the
credibility of the formal health care system and encourage more women
to seek assistance early in labour.