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Original Research
Introduction: Neal and Lowe developed a physiologic partograph to give clinicians an evidence-based, uniform approach to assessing active labor
progress and diagnosing dystocia in high-resource settings. The aim of this pilot study was to examine the feasibility of implementing the Neal
and Lowe partograph for in-hospital labor assessment.
Methods: A descriptive study of low-risk, nulliparous women with spontaneous labor onset was performed at an academic medical center. Eight
certified nurse-midwives from a single practice used the Neal and Lowe partograph for the assessment of labor progress. Descriptive statistics were
used to summarize characteristics, interventions, and outcomes for women with partograph-assessed labors. Labors assessed by nurse-midwives
(n = 83) or obstetricians (n = 75) using their usual assessment strategies were also described for the year prior to partograph introduction to
contextualize partograph-assessed labor findings. Inferential statistical tests were not performed.
Results: Thirty-one of 34 (91.2%) partographs were used correctly. Seventy-one percent (n = 22) of these women progressed to complete dilatation
within expected physiologic time frames while the remaining women (n = 9) experienced labor dystocia. Similar proportions of women in the
partograph and usual labor assessment groups received oxytocin during labor. The cesarean rate was lower in the partograph group than in the
usual care groups. No cesareans were performed for dystocia in active labor for women whose labors were assessed via partograph.
Discussion: Implementation of the Neal and Lowe partograph for in-hospital labor assessment is feasible. Incorrect plotting and/or interpretation of the partograph may be further minimized by providing clinicians opportunities for ongoing partograph training after implementation or
through partograph software development. The Neal and Lowe partograph may assist clinicians in safely and significantly decreasing primary cesarean births performed for active labor dystocia in high-resource settings. Larger scale, hypothesis-testing studies of partograph implementation
are now warranted.
c 2016 by the American College of Nurse-Midwives.
J Midwifery Womens Health 2016;61:235241
Keywords: cesarean birth, labor onset, nulliparity, oxytocin, partograph, parturition
INTRODUCTION
Address correspondence to Jeremy L. Neal, CNM, PhD, 461 21st Avenue South, Nashville, TN 37240; (615) 875-9998. E-mail: jeremy.neal@
vanderbilt.edu
1526-9523/09/$36.00 doi:10.1111/jmwh.12442
c 2016 by the American College of Nurse-Midwives
235
Partographs are tools that clinicians can use to graphically record and visually assess cervical dilation and fetal descent
during labor.
Commonly used partographs were designed for the early detection of slow cervical dilation so laboring women could be
transferred from a low- to higher-resource setting.
The Neal and Lowe partograph was specifically designed for use in higher-resource settings where most births in the United
States occur.
Pilot data support the feasibility of implementing the Neal and Lowe partograph for the in-hospital assessment of nulliparous women at term gestation with a single, vertex fetus.
Neal and Lowe partograph use may help to safely decrease the incidence of cesarean birth for the diagnosis of labor dystocia
in nulliparous women.
METHODS
236
The Neal and Lowe partograph5 is composed of a dystocia line and displays time (hours) on the x-axis and cervical
dilatation (cm) and fetal station on the y-axis (Figure 2). The
spontaneous onset of labor is prerequisite to partograph use.
Labor is defined as regular contractions (2 or more in 10 minutes, each lasting 40 seconds or more) and effacement more
than 75%. Membranes may be intact or ruptured, and bloody
show may be absent or present. The partograph for this study
was initiated in the presence of labor and a qualifying cervical examination, that is, at 4 cm (earliest start) if this dilatation was immediately preceded by adequate cervical change
over time (ie, 1 cm or more in 2 hours or less) or at 5 cm or
more (direct start) regardless of the rate of previous cervical
change. An updated version of the Neal and Lowe partograph
has a direct start point of 6 cm or more rather than 5 cm or
more, aligning with new guidelines regarding the threshold
for active labor onset put forth jointly by the American College of Obstetricians and Gynecologists and the Society for
Maternal-Fetal Medicine.11 Because clinicians correctly determine true dilatation in only half of all cases1619 but are accurate within 1 cm from true dilatation in 90% of cases,16,18,19
examinations reported as a range are rounded down to the
nearest integer dilatation (eg, 6-7 cm is rounded to 6 cm).
The Neal and Lowe partograph is initiated and continued only
when there are no complications requiring urgent attention
through intervention.5
Time of cervical examination, cervical dilatation, and fetal station are the only data documented on the partograph
following each cervical examination. The first qualifying cervical dilatation is plotted on the left-most point of the dystocia line at the corresponding dilatation point with an X, fetal
station is plotted with an O, and time of examination is entered on the time line. The initial examination time is considered to be hour zero (0) and the time line and hour boxes are
completed in one-hour increments from this point forward.
Subsequent examinations are also plotted on the partograph,
and active labor progress is assessed on the partograph based
on cervical change over time. To minimize error and facilitate
ease of partograph use, the time of examination is rounded to
the most recent 15-minute increment and entered on the appropriate time line; for example, an examination performed
and maternal condition during labor are assessed per the usual
care patterns dictated by department policy.
The aim of this pilot study was to evaluate the feasibility of implementing the Neal and Lowe partograph for the
in-hospital labor assessment of NTSV women with spontaneous labor onset. As pilot studies are not hypothesis testing
endeavors,20 inferential statistical tests were not performed.
SPSS Statistics 23 (IBM Corporation, Armonk, NY) was used
to calculate descriptive statistics. The characteristics and birth
outcomes of the study sample were described as n (%) for categorical variables and median (10th, 90th percentile) for continuous variables.
RESULTS
left-most point of the dystocia line at the corresponding dilatation point) thereby invalidating interpretation and categorization of labor progress; the other partograph was excluded
because it was initiated on a woman admitted for induction of
labor.
The characteristics and birth outcomes of the CNM partograph assessment group (n = 31), the usual CNM labor assessment group (n = 83), and the usual general obstetrician group
(n = 75) are shown in Table 1. Maternal age was similar among
the groups. The obstetrician group had a lower percentage
of women who were overweight or obese before becoming
pregnant (26.7% vs 38.7% and 35.0% in the CNM partograph
and usual CNM labor assessment groups, respectively). Similar proportions of women in each group received oxytocin
during labor. The cesarean rate was lowest in the CNM partograph group (9.7%), as compared to the CNM and general
obstetrician usual labor assessment groups (13.3% and 16.0%,
respectively). There were no cesareans performed for dystocia in active labor for women whose labors were assessed via
partograph whereas this indication accounted for half of the
cesareans in the usual labor assessment groups. There were
proportionately fewer Apgar scores of 7 or lower in the CNM
partograph assessment group, as compared to the usual care
groups, but rates of neonatal intensive care unit admissions
were similar.
The partograph-assessed labors are shown in Table 2.
Twenty-two of 31 (71.0%) women whose labors were assessed
via partograph had cervical dilation that remained left of or on
the dystocia line without delay. Three women in this group
(13.6%) received oxytocin during active labor; of these, 2
women (Participants 11 and 12) were given oxytocin for prolonged rupture of membranes. The other woman (Participant
13) received oxytocin augmentation without rationale despite
dilation remaining left of the dystocia line without delay. All
238
There were no logistical feasibility limitations with implementing the Neal and Lowe partograph for the in-hospital labor assessment of NTSV women with spontaneous labor onset. Cervical dilatation and fetal station were correctly plotted on the partograph for all but 2 women with spontaneous
labor onset; in these 2 women, the same CNM incorrectly
plotted initial cervical examination findings at the right-most
rather than left-most point of the dystocia line, thereby invalidating interpretation of the partograph from that point
forward. One woman who had dilation remaining left of or
on the dystocia line without delay received oxytocin augmentation without documented rationale (eg, prolonged rupture
of membranes), a deviation from the partograph protocol
Volume 61, No. 2, March/April 2016
Table 1. Characteristics and Birth Outcomes of Nulliparous Women by Provider Type and Labor Assessment Approach (N = 189)
Certified Nurse-Midwife
Certified Nurse-Midwife
a
Assessment Groupa
Characteristic
(n = )
(n = )
(n = )
Maternal age, y
2 (6.5)
5 (6.0)
2 (2.7)
17 (54.8)
49 (59.0)
53 (70.6)
8 (25.8)
16 (19.3)
12 (16.0)
4 (12.9)
13 (15.7)
8 (10.7)
18 (58.1)
33 (39.8)
37 (49.3)
24 (32.0)
10 (32.3)
32 (38.6)
2 (6.5)
9 (10.8)
4 (5.3)
28 (90.3)
59 (71.2)
66 (88.0)
Vaginalspontaneous
25 (80.6)
69 (83.1)
57 (76.0)
Vaginalinstrumental
3 (9.7)
3 (3.6)
6 (8.0)
Cesarean
3 (9.7)
11 (13.3)
12 (16.0)
Mode of birth
0 (0)
6 (54.5)
6 (50.0)
2 (66.7)
3 (27.3)
5 (41.7)
1 (33.3)
2 (18.2)
1 (8.3)
19 (61.3)
41 (49.4)
37 (49.3)
Infant sex
Female
Male
Weight (newborn), lb
12 (38.7)
6.74 (5.57, 8.13)
42 (50.6)
7.14 (5.88, 7.92)
38 (50.7)
6.92 (5.59, 8.21)
Apgar scores
7 at 1 min
3 (9.7)
23 (27.7)
20 (26.7)
7 at 5 min
0 (0.0)
3 (3.6)
3 (4.0)
1 (3.2)
2 (2.4)
5 (6.7)
Abbreviation: BMI, body mass index; NICU, neonatal intensive care unit.
a
Data are n (%) and median (10th, 90th percentile).
239
Reached
Partograph
Participanta
Interpretation
1
2
Dilatation at
Partograph
Oxytocin Use
Complete
During
Dilatation
Active Laborb
Start (cm)
Yes
5
6
No
Yes
Mode of Birth
No
Vaginal
10
11
Xc
12
Xc
13
Xd
14
15
Xe
Xe
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
X
X
Cesarean
X
Xf
X
X
a
Participants are ordered based on cervical dilatation at partograph initiation followed by partograph interpretation category (ie, left of dystocia line without delay, left of
dystocia line with 4-hour delay, or right of dystocia line), rather than on chronological partograph use.
b
Partograph is designed for assessment of active labor progress only.
c
Oxytocin augmentation used for prolonged rupture of membranes despite dilation remaining left of dystocia without delay.
d
Oxytocin augmentation used despite dilation remaining left of dystocia without delay, indicating deviation from protocol.
e
Cesarean performed in second-stage labor for arrested fetal descent.
f
Cesarean performed in active labor for nonreassuring fetal heart pattern.
Jessica Anderson, CNM, MSN, WHNP-BC, is Director of Center for Midwifery and a Senior Instructor at
the University of Colorado College of Nursing, Aurora,
Colorado.
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