Physiologic partograph to improve birth safety and outcomes among low-risk, nulliparous women with spontaneous labor onset

Abstract

Oxytocin augmentation and cesarean rates among low-risk, term, nulliparous women with a spontaneous onset of labor in the United States approximate 50% and 26.5%, respectively. This indicates that the quality of obstetrical care is less than optimal in this nation. Exorbitant oxytocin use, the intervention most commonly associated with preventable adverse perinatal outcomes, jeopardizes birth safety while the high cesarean rate in this high-volume group compromises population health and increases health care costs. Dystocia, characterized by the slow, abnormal progression of labor, is the most commonly reported indication for primary cesareans, accounting directly for approximately 50% of all nulliparous cesareans and indirectly for most repeat cesareans. Diagnoses of dystocia are most often based on ambiguously defined delays in cervical dilation beyond which labor augmentation is deemed justified. Dystocia is known to be over-diagnosed which undoubtedly contributes to contemporary oxytocin augmentation and primary cesarean rates. Labor attendants would benefit from an evidence-based framework for homogenous labor assessment. To this end, we present a physiologically-based partograph for 'in-hospital' use in assessing the labors of low-risk, term, nulliparous women with spontaneous labor onset. This tool incorporates several evidence-based labor principles that combine to give needed clinical meaning to 'dystocia' as a diagnosis. It is hypothesized that our partograph will safely limit diagnoses of dystocia to only the slowest 10% of low-risk, nulliparous women. This should, in turn, safe-guard against unnecessary, injudicious, and potentially harmful use of oxytocin when labor is already adequately progressing while also indicating when its use may be justified. We further hypothesize that cesareans performed for dystocia in this population will decrease by ≥ 50%. No significant influence on other labor process or labor outcome variables is expected with partograph use. Widespread use of this physiologically-based partograph will be warranted if our hypotheses are supported.

Figure 1

Partograph for Low-Risk, Nulliparous Women with Spontaneous Labor Onset

Figure 2

Central Component of Common Partographs. Reprinted with permission of John Wiley and Sons from Philpott RH, Castle WM. Cervicographs in the management of labour in primigravidae. I. The alert line for detecting abnormal labour. J Obstet Gynaecol Br Commonw 1972;79(7):592-598.

Figure 3

Hyperbolic, Median Nulliparous Labor Curve with Linear Conceptualization. Reprinted with permission of John Wiley and Sons from Neal JL, Lowe NK, Patrick TE, Cabbage LA, Corwin EJ. What is the slowest-yet-normal cervical dilation rate among nulliparous women with spontaneous labor onset? J Obstet Gynecol Neonatal Nurs 2010;39(4):361-369.

Figure 4

Example 1: Labor remaining left of the dystocia line without delay. Scenario:

1. ■

   At 9:37 am, the cervix is dilated 5 cm and the fetal head is at −2 station. The partograph is initiated by plotting an `X' at 5 cm on the dystocia line and an `O' at −2 station. On the time line, 9:30 am is documented which becomes the start of hour zero (`0'). The time line is completed in 1-hour increments from that point forward.

2. ■

   At 12:03 pm, the cervix is dilated 6 cm and the fetal head is at −2 station. Labor progress is adequate, remaining left of the dystocia line and without delay.

3. ■

   At 2:25 pm, the cervix is dilated 8 cm and the fetal head is at 0 station. Labor progress is adequate, remaining left of the dystocia line and without delay.

4. ■

   At 4:40 pm, the cervix is completely dilated and the fetal head is at +1 station. Use of the partograph is complete. Second stage labor is managed in the `usual care' pattern of the labor care provider.

Figure 5

Example 2: Labor moving right of the dystocia line. Scenario:

1. ■

   At 4:07 pm, the cervix is dilated 5 cm and the fetal head is at −3 station. The partograph is initiated by plotting an `X' at 5 cm on the dystocia line and an `O' at −3 station. On the time line, 4:00 pm is documented which becomes the start of hour zero (`0'). The time line is completed in 1-hour increments from that point forward.

2. ■

   At 5:41 pm, the cervix is dilated 5 cm and the fetus head is at −3 station. Labor remains left of the dystocia line without partograph-defined delay.

3. ■

   At 7:15 pm, the cervix is dilated 6 cm and the fetal head is at −2 station. Labor progress is adequate, remaining left of the dystocia line and without delay.

4. ■

   At 9:20 pm, the cervix is dilated 6 cm and the fetal head is at −2 station. Labor dystocia is diagnosed as progress moves right of the dystocia line. Thorough assessment is indicated with management option choices including supportive therapy only, oxytocin augmentation, or delivery. Oxytocin augmentation is chosen.

5. ■

   At 11:39 pm, the cervix is dilated 7 cm and the fetal head is at −2 station. Labor remains right of the dystocia line.

6. ■

   At 12:52 am, the cervix is dilated 8 cm and the fetal head is at −1 station. Labor remains right of the dystocia line.

7. ■

   At 1:50 am, the cervix is completely dilated and the fetus is at 0 station. Use of the partograph is complete. Second stage labor is managed in the `usual care' pattern of the labor care provider.

Figure 6

Example 3: Labor remaining left of the dystocia line with delay. Scenario:

1. ■

   At 11:15 pm, the cervix is dilated 3 cm and the fetal head is at −2 station. The parturient does not yet meet criteria for partograph initiation.

2. ■

   At 12:54 am, the cervix is dilated 4 cm and fetal head remains at −2 station. The partograph is initiated due to ≥ 1 cm change in dilation in ≤ 2 hour window. An `X' is plotted at 4 cm on the dystocia line and an `O' is plotted at −2 station. On the time line, 12:45 am is documented which becomes the start of hour zero (`0'). The time line is completed in 1-hour increments from that point forward.

3. ■

   At 3:06 am, the cervix is dilated 5 cm and the fetal head is at −2 station. Labor progress is adequate, remaining left of the dystocia line and without delay.

4. ■

   At 5:19 am, the cervix is dilated 7 cm and the fetal head is at −2 station. Labor progress is adequate, remaining left of the dystocia line and without delay.

5. ■

   At 8:10 am, the cervix is dilated 7 cm and the fetal head is at −1 station. Labor remains left of the dystocia line without partograph-defined delay.

6. ■

   At 9:22 am, the cervix is dilated 7 cm and the fetal head is at −1 station. Labor progress is delayed due to the > 4 hour delay in cervical change. Thorough assessment is indicated with management option choices including supportive therapy only, oxytocin augmentation, or delivery. Oxytocin augmentation is chosen.

7. ■

   At 10:52 am, the cervix is dilated 8 cm and the fetal head is at 0 station. Labor progress is again adequate, remaining left of the dystocia line.

8. ■

   At 1:02 pm, the cervix is completely dilated and the fetal head is at +1 station. Use of the partograph is complete. Second stage labor is managed in the `usual care' pattern of the labor care provider.