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Improving Care For Mothers And Babies

In The Russian Federation


Collaborative on optimizing labor management through use of the
partograph
Report on the demonstration and spread collaboratives.

a. The evidence base


The partograph is a graphical tool for charting and visualizing the progress of labor, developed
by Friedman in the 1950s and enhanced in the 1970s by Philpott by the addition of an action
line to a chart of cervical dilation against time; crossing of this line indicates that labor is not
progressing normally and the caregiver should intervene. [2,3,4] It is used to monitor labor and
facilitate the detection of abnormal progress, and appropriate intervention, and has come into
wide use around the world.

The effectiveness of the partograph in reducing labor problems and their consequences in
maternal and infant morbidity and mortality. In the early 1990s, WHO conducted a cluster
randomized trial in eight southeast Asian hospitals, involving 35,484 women, which tested the
partograph in combination with a brief protocol on labor management [1]. The protocol called
for non-intervention during the first eight hours of the latent phase of labor and intervention
only after the action line was crossed, either by use of oxytocin to augment labor or by
caesarian section. (This protocol was not described in detail in the Lancet report). Birth
processes and outcomes were compared before and after introduction of the partograph. The
researchers found statistically significant reductions in the proportions of prolonged labors
longer than 18 hours in duration (6.4% of births before vs. 3.4% after, p=0.002) and in the
rate of use of labor augmentation with oxytocin (20.7% before vs. 9.1% after, p=0.028).
Sepsis declined from 0.70% to 0.21% (p=0.028)

There was no significant change in the use of caesarian section or in the incidence of maternal
mortality, uterine rupture or overall stillbirth, although the number of intranatal stillbirths
declined from 6 before introduction of the partograph to 3 afterwards. Early neonatal mortality
decreased from 89 cases or, 0.5% of live births to 50 cases, or 0.3% of live births, but this
decrease was non-significant.

Although the partograph was highly promoted by WHO after these results were published, and
it was adopted by many national health systems, its use remained controversial in Russia and
elsewhere. The criticisms are that it is difficult to disentangle the use of the tool from the

May 2012. This report was prepared by University Research Co., LLC for review by the United States
Agency for international Development (USAID). The USAID Health Care Improvement Project is made
possible by the American people through USAIDs Bureau for Global Health, Office of Health, Infectious
Diseases and Nutrition.
clinical protocol, that southeast Asian conditions are not applicable worldwide, and that the trial
was not rigorous because it was not individually randomized [5]. (From a quality improvement
(QI) perspective, the partograph and protocol are organizational interventions that are not
possible to randomize on a patient-by-patient basis.)

In Russia, use of the partograph has been permitted but not required, and no one standard
partograph form exists. Medicolegal requirements call for documenting labor progress and vital
signs line-by-line in the medical chart. While the WHOs 2003 manual, Managing complications
in pregnancy and childbirth, gives detailed instructions on decision-making using the
partograph and is available in Russian [6], its 404 pages do not lend themselves to easy
reference during labor and delivery.

b. The change package


We developed a change package containing the partograph, instructions for completion, a brief
evidence-based protocol on managing labor complications, and appropriate indicators, and flow-
chart algorithms as reminders for obstetricians, and tested the ability to improve the processes
and outcomes of labor. The protocol was drafted initially by Yuri Raskuratov DMS of Tver State
Medical Academy in Sept. 2009 and substantially revised under the guidance of Zulfiya
Khodzhaeva of the Kulakov Center.

The partograph used was a two-sided form, with the front side being a Russian translation of
the WHO partograph prepared by USAID partner Institute for Family Health (IFH), and the back
side providing standardized spaces for recording information about the overall length of labor,
the newborn and management of the third stage of labor. An example of a completed
partograph is shown below. The package included detailed discussion of diagnosis using the
partograph and management of three major types of labor abnormalities, classified as
traditional for Russian obstetricians as (a) weak labor (b) hypertonic or uncoordinated uterine
contractions and (c) excessively strong, rapid contractions. Diagnosis and management of
shoulder dystocia and breech presentation are also discussed. Flow chart algorithms for
management of the three main abnormalities are provided in the change package and in poster
form (for a translated example see figure 1).

Elements of the change package, all of which needed to be introduced together, were:

1. Adoption of a hospital-wide policy requiring real-time completion of the partograph for


all births begun vaginally at later than 33 weeks gestation
2. Introduction of the partograph documentation system
a. Assuring a supply of partograph forms
b. Creating a system for completion and filing of the partograph
c. Training staff
3. Introduction of the algorithms for management of complicated labor
a. Supplying instructional materials and reminders
b. Ensuring all delivery rooms have the necessary equipment and medications
c. Training staff

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4. Regular audit
a. Daily audit and review of all births at maternity department meetings
b. Monthly audit, indicator collection and review of trends.

c. Participants
13 facilities officially took part in this collaborative during the first phase as shown in Table
1,and 19 during the second phase, as shown in Table 2. Some in Tambov Region dropped their
participation and most Tver Region facilities unofficially adopted the partograph midstream. A
Kostroma Region regulation adopted at the beginning of phase 2 required use of the
partograph region-wide.

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Figure 1. Change Package Algorithm for Managing Weak Labor

Diagnostic
CriteriaA

Womanin
weaklabor

CriteriaB

Yes
Indications
C
for
section
Csection?

No

Laboraugmentation

Unsatisfactory
Evaluation
C
offetal
section
condition
Yes
Satisfactory

Has Vaginalbirthwith
<34cm 78cm
augmen Evaluation continued
tation
ofcervical augmentationand
continued>2
dilation evaluationoffetal
hrs?
condition
<7 cm,witha
No positivetrend

Has Yes
augmentation C
continued>34 section
hours?

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Table 1. Facilities pursuing the improvement goal of prevention and management of birth
complications with use of the WHO partograph during phase 1 of the project.

Region Number of List of Facilities Improvement Team Leadership


facilities
Kostroma 5 Sharya Central District Hospital P.A.Sharanov
Region Nerekhta Central District Hospital I.K. Petrova
Galich City Hospital RB Sharifkulov
Kostroma City Maternity Hospital No. 1 EA Novozhilova, TA Solovyova
Kostroma Region Hospital O.N.Dubrovina
Tambov 5 Uvarovo Central District Hospital, S.I.Korotkova
Region Tambov City Hospital No. 3 S.I.Vedishev
Michurinsk City Hospital No. 2, A.A.Popov, L.V.Kapralova
Rasskazovo Central District Hospital O.I.Popov
Morshansk Central District Hospital E.V.Zhukova
Yaroslavl 3 Yaroslavl City Clinical Hospital No. 2 AN Surovtsev, NN Galaganova
Region Tutaev Central District Hospital, Y.N.Zholobov, T.P. Repina
Rybinsk Perinatal Center V.Y.Krasilinikov,A.A.Prostyankina
Total 13

Table 2. Participants in the collaborative on optimizing labor management through use of


the partograph during phase 2 of the project.

Region Number of List of facilities Improvement Team


facilities Leadership
Kostroma 6 Galich City Hospital R.Sharifkulov
Region Sharya Central District Hospital PA.Sharanov
(Region-wide Nerekhta Central District Hospital IK Petrova
participation) Kostroma City Maternity Hosp. No. 1 EA Novozhilova, TA Solovyova
Kostroma Region Hospital O.N.Dubrovina, R.Sharifkulov
Manturovo City Hospital B.N. Speransky
Yaroslavl 2 Tutaev Central District Hospital Y.N.Zholobov, t.P.Repeina
Region Yaroslavl City Clinical Hospital No. 2 AN Surovtsev, NN Galaganova
Tambov 3 Michurinsk City Hospital No. 2, A.A.Popov, L.V.Kapralova
Region Uvarovo Central District Hospital, S.I.Korotkova
Rasskazovo Central District Hospital, O.I.Popov
Ivanovo 2 Ivanovo City Maternity Hosp. No. 1 O.V. Lobanova, L.G. Zykova
Region Kineshma Central Regional Hospital, S.V.Komarov, R.N.Kalinina
Tula Region 6 Kireevskaya Central District Hospital, I.V.Sadovnikova
Efremovskaya Central District Hosp N.A.Zheltov, A.A.Filshina
Tula Region Perinatal Center I.Y.Kopyrin
Novomoskovsk Maternity Hospital, I.A. Merkulova
Tula City Maternity Hospital No. 1 E.S.Makarova, E.M.Gusova
Aleksiniy Maternity Hospital A.M.Kravchenko
Total 19

d. Project inputs
In order to facilitate piloting of the partograph, the project printed about 9,000 partograph
forms during phase 1 and 4,500 partograph forms for Tambov Region facilities, during phase 2.
Facilities were supplied with printed copies of the latest version of the change package, CDs

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with digital copies of background documents such as the WHO handbook [6] as well as small
posters with the relevant clinical algorithms and large wall-sized partographs for training
purposes. Initial trainings on the partograph and labor management using it were provided
during learning sessions 1-3, using training materials developed by IFH. [7] Later, an animated
video showing how to complete the partograph was also provided . Staff from Kostroma Region
and Yaroslavl City Clinical Hospital No. 2 were developed as trainers. On-site audits of
partograph completion and compliance with the labor management algorithms by clinical
experts, usually conducted at 3 months after a facility started testing the partograph, were
critical components of the intervention. Clinical experts participating in this collaborative are
shown in Table 3 and training sessions listed in Table 4, below.

Table 3. Clinical experts for the collaborative on improving labor management using the
partograph.

Expert Qualifications/background Role in project and related policy


development activities
Zulfiya Head of the first obstetric unit on pregnancy Designated by Russian chief obstetrician-
Khodzhaeva, pathology, Kulakov Center, author of 153 gynecologist Leila Adamyan to oversee
DMS scholarly works and physician handbooks, obstetric aspects of the project.
participant in international research projects. Coordination and primary lecturer in video
Recipient of awards for excellence in health conferences on obstetrics. Lecturer at
care. learning sessions. Reviewed and edited
written change package on labor
management using the partograph.
Assessed quality care in Kostroma Region for
MOHSD coordinating committee. Co-author
of MOHSD methodological letter of July 2011
which included the partograph.
Yuri Chair, Obstetrics Department, Tver State Phase 1 clinical expert on obstetrics for
Raskuratov, Medical Academy. Participated in QAP. An Yaroslavl Region. Conducted site visits,
DMS, Professor honored doctor of the Russian Federation. participated in LS, conducted audits. Author
of written change package on the
partograph. Conducted clinical training on
labor management using the partograph.
Successfully disseminated the partograph in
Tver Region following publication of first
draft of written change package.
Larisa Obstetrician-gynecologist, head of the intake Phase 1 clinical expert on obstetrics and
Bykovskaya, unit at the Ivanovo Institute perinatal center, Phase 2 QI expert for Tambov Region.
CMS consultant for Tambov Region for the Ivanovo Conducted site visits, participated in LS,
Institute conducted audits. Co-author of written
change package on the partograph.
Conducted clinical training on labor
management using the partograph.
Valeria Obstetrician-Gynecologist, head of the Phase 1 clinical expert on obstetrics and
Gerasimova, maternity department of Torzhok central Phase 2 QI expert for Kostroma Region.
MD district hospital, Tver Region, participated in Conducted site visits, participated in LS,
QAP. conducted audits. Co-author of written
change package on the partograph.
Conducted clinical training on labor
management using the partograph at LS.
Irina Panova, Director of the Obstetrics Department and of Co-author of written change package on the
DMS the new simulation training center, Ivanovo partograph. Participated in LS.
Institute.

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Expert Qualifications/background Role in project and related policy
development activities
Oleg Baev, Head of the Maternity Department, Kulakov Reviewed written change package on the
DMS, Professor Center. Co-author of Kulakov Center internal partograph.
guideline on use of the partograph.

Table 4. Clinical trainings on labor management using the partograph.

Date Location Length Trainers Regions/facilities Partici-


pants

Mar 31 Manturovo 2 hrs O.N.Dubrovina Manturovo City Hospital 23


2010 Kostroma Kostroma Region Hosp Neiskaya Hospital
Region Mezhevskaya Hospital
Kologrivskaya Hospital
Apr 16 Buy 2 hrs O.N. Dubrovina, Buy Hospital 30
2010 Kostroma Kostroma Region Hosp. Gavrilovskaya Hospital
Region
Apr 20, Rybinsk, 3.5 hrs Y. Raskuratov, TSMA Rybinsk Perinatal Center 12
2010 Yaroslavl L.Karneeva, Ivanovo Obl Tutaev Hospital
Region T. Dmitrieva, Tver Obl. Yaroslavl City Clinical Hosp #2
A.Gazheva, IHCOI
Apr 30, Sharya 2 hrs O.N. Dubrovina, Sharya Hospital 55
2010 Kostroma Kostroma Region Hosp Rozhdenstvenskaya Hospital No.
2*
Region
Ponazyrevskaya Hosp*
Pavinskaya Hospital *
Sharya Med.College*
Pyschugskaya Hosp*
Vokhmanskaya Hospl*
Bogovarovskaya Hosp*
Village feldsher- midwife clinics*
Jun 18 Kostroma 2 hrs Dubrovina, Sokolova City Maternity Hosp. No. 1 14
2010 Michurina Volgorechenskaya Hospital
Kostroma Region Hosp Nerekhta Hospital
Kostroma Region Hospital
Jan. 19, Ivanovo 6 hrs L.Bykovskaya, Iv. Inst. Ivanovo City Hospital No. 1 19
2011 Ivanovo State Med Acad*

e. Testing of changes.
After a lively discussion of the advantages and disadvantages of the partograph during project
learning session 1, Yaroslavl City Clinical Hospital No. 2 agreed to serve as the pilot facility for
this collaborative. This hospital had been using a different variant of the partograph form for
over two years, but the partograph had not been in use by all physicians and, crucially, had not
been used to track the most complicated cases. There had been no standard algorithm for
labor management implemented.

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LarisaBykovskaya trains
providersinIvanovo

Dailypartograph
reviewbythe
maternity
departmenthead
Acompletedpartograph from Kireevskaya Hosp.
Galich Hospital,KostromaOblast. TulaOblast

Hospital No. 2 began implementing the partograph and a labor management algorithm based
on training provided at the learning session in June 2009. Within three months they had
demonstrated that it was feasible to complete the form in approximately 90% of births begun
vaginally. Immediately following presentation of these results at learning session 2 the
remaining facilities in the collaborative began to implement the partograph, along with the
algorithm on labor management. Hospital No. 2 continued to lead in establishing innovations;
finding that a key practice that continually stressed the importance of completing the
partograph, and which enhanced uniformity in its use, was review by the maternity department
head of the previous days charts at the morning 5-minute meetings of all maternity
department obstetricians and midwives. Since Hospital No. 2 delivered an average of seven
babies a day, fitting this review into a five-minute timeframe was entirely feasible. At the end of
phase 1, the Kostroma Region health department issued an executive order requiring use of the
partograph in births begun vaginally in all hospitals, Region-wide. They also introduced the
partograph into the preservice nursing curriculum at Kostroma Medical College.

Some obstetricians complained that completion of the partograph represented duplication of


effort (given the requirement to document labor longhand in the chart) and required too much
time. In response, Sharya Hospital, Kostroma Region, tested training of midwives to complete

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the majority of information on the form, such as header information, heartbeat, blood pressure,
pulse, and urine measurements, leaving it up to the obstetrician to chart only the progress of
labor and delivery. This innovation was shared and incorporated in the change package.
Midwives tended to have a very positive attitude to the partograph, saying it simplified their
work.

Hospital No. 2 piloted assessment of the effect of the change package on use of labor
augmentation and asphyxia. During phase 2, Tula City Maternity Hospital No. 1 and other large
urban hospitals tested whether the change package would result in reducing their high rates of
caesarian sections. Tula Region Perinatal Center, which had been using a different partograph
form without the action line for several years, compared labor outcomes using their traditional
form with those after adoption of the WHO partograph.

f. Work products
The written project change package was finalized and received the formal approval of the
Kulakov Center in May 2011. Final publication of the change package Optimization of labor
management using the partograph occurred in November 2011.

g. Evaluation methods
To assess compliance with the change package and processes of labor management, we
collected indicators, self-reported from facilities, on a monthly basis. The primary process
indicator was the percent of all births begun vaginally, in which the partograph was completed.
During Phase 1 we also validated this indicator using expert audit. Phase 1 expert chart audits
were also conducted on the percent of labors that included diagnoses of the three primary
complications addressed in the change package, whether these were managed appropriately,
and whether labor augmentation was used.

We tracked the percent of births, begun vaginally, with use of labor augmentation as a self-
reported indicator in phase 2. Based on the Safe Motherhood Initiative study, in phase 1 we
also assessed the percent of labors that were prolonged over 18 hours. Since this percent
proved to be near zero in our target regions, we dropped this indicator in phase 2. We also
tracked the rate of emergency caesarian sections as a percent of all births begun vaginally.

On a quarterly basis, we tracked two self-reported outcome indicators that we hypothesized


might be improved by improved labor management. These were percent of newborns with
intrauterine hypoxia or asphyxia and percent of newborns with birth trauma. We included both
mild and severe cases of these conditions in our indicator; asphyxia was defined as an Apgar
score of 7 or below at one minute after birth. Asphyxia was hypothesized to be a potential
complication of excessive use of labor augmentation, resulting in excessively strong
contractions and fetal distress. Birth trauma was hypothesized to be a potential complication of
obstructed labor and improper use of forceps or vacuum extraction.

To assess the overall impact of the change package, we collected regional level statistical data
on the number and percent of newborns with intrauterine hypoxia and asphyxia (ICD-10 codes

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P-20, P-21) and the number of deaths from intrauterine hypoxia and asphyxia, and the number
of cases and number of deaths from birth trauma (ICD codes P10-P15). We also assessed
overall early neonatal mortality.

h. Results
In phase 1, through audit and analysis of self-reported indicators, we found that of the 13
participating hospitals, 8 had fully implemented the package, as indicated by consistent
partograph completion rate in at least 90% of vaginal births, during the period from April-June,
2010. For those 8 hospitals, we compared rates of diagnosis of hypoxia and asphyxia and birth
trauma, collected from the audit, between the period April-June 2010, after full implementation,
and April-June 2009. During the earlier period, the partograph was in use at only one of the
eight hospitals, Yaroslavl City Clinical Hospital No. 2, where it was completed in about 60% of
births.

We found a highly statistically significant reduction in the combined relative risk of hypoxia and
asphyxia; the risk in the 2010 period was only 57% of that in 2009 (95% CI: [0.42, 0.78] by
the Mantel-Haenszel method, p=0.0003), with no significant differences among hospitals.
Analysis of the effect on birth trauma found a non-significant reduction of 27% in risk in 2010
compared to 2009. (RR=0.73, 95% CI[0.50, 1.08], p=0.11.).

The audit results suggested that prior to the project, physicians did not properly define the time
of start of active labor; leading to over-diagnosis of abnormally weak labor and overly
aggressive labor management , with excessive use of induction and vacuum-extraction,
occasionally leading to injury to the baby. Use of the partograph better enabled physicians to
assess labor timing and progress, improving management and outcomes.

However, the August 2010 audit indicated a need for improvement in training on labor
management and potentially in the flowchart algorithms, which were subsequently clarified. Our
experts diagnosed weak labor in 48, or 19% of 253 partographs audited, and found that it was
correctly diagnosed 88% of the time and correctly managed 85% of the time. At that time,
excessively strong contractions were underdiagnosed: experts recognized them in 25 cases but
local obstetricians only diagnosed them in 8 (32%) of these and properly managed them in 5
(20%) of the cases.

Full results of the project are shown in figures 2-6. Figure 2 shows the range of hospital
compliance on completion of the partograph. The highest performing 25 percent of reporting
hospitals have been completing the partograph in over 90% of births begun vaginally since Jan.
2010. Performance of the rest of participating hospitals has varied, but consistent completion is
reported in more than half of participating hospitals by the end of the project. Figure 3 tracks
the relationship between partograph completion (shown on the left axis) and the rate of use of
labor augmentation (on the right axis) at Yaroslavl City Clinical Hospital No. 2, our partograph
pioneer and the hospital that most carefully documented its processes and outcomes. Prior to
beginning the project, augmentation was used in 8-10% of births. Since January 2010, with
use of the partograph stable at over 90% of births begun vaginally use of labor augmentation

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has been consistent at between 3-6% of those births. Figure 4 presents another example of a
early and consistent adopter, Sharya Hospital. Following its initial expert audit in February
2010, diagnoses of labor abnormalities have dramatically declined, and incidence of
uncoordinated labor has disappeared completely.

Figure 5 shows the range of performance among participating hospitals in reported rates of
asphyxia and intrauterine hypoxia. Although the graph is not simple to interpret, and the
reporting hospitals are not the same throughout the time period, it is highly suggestive of a
trend toward reduction of incidence of asphyxia and hypoxia following introduction of the
partograph in the latter half of 2009. The median rates of less than 2% are very low and it is
possible that there is also an effect of improved diagnosis. The region-level data reinforce this
finding. In both Kostroma and Tambov Regions, rates of hypoxia and asphyxia dropped 30%
between 2008 and 2010. A similar analysis of data on birth trauma found no clear trend.

Median emergency caesarian section rates, assessed as a percent of births begun vaginally,
increased about 50% with adoption of the partograph, as shown in Figure 6. Among most
participating facilities these were initially extremely low6%-8%, -- likely due to limited access
to anesthesiologists, and they increased to 10%-12% by the end of the project period. Level 2
and 3 facilities, which initially had much higher rates of emergency C-sections, tended to see a
decrease. For instance, Tula Region Perinatal Center observed a 16% overall C-section rate
during the first nine months of 2011, compared to a 21% rate during the first nine months of
2010.

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Figure 2. Labor management collaborative. Partograph completion rate.

Partographcompletionrateamongmaternityhospitals
Asapercentofbirthsbegunvaginally
Median,25thand75thpercentiles
100
90
80
70
60
50 Phase 2
Hospitals
40 Project added
Start
30
20
10
0 J F M A M J J A S O N D J F M A
J J M A S O N D J F M A M J J A S
2009 2010 2011
Median 0 0 0 0 0 0 0 0 0 21 41 39 0 0 52 62 49 38 95 93 72 73 88 84 58 28 63 97 95 86 100 100 100
25th percentile 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 11 0 11 15 11 0 5 0 19 69 57 45 87 66 57
75th percentile 0 0 0 0 0 0 0 0 5 74 87 91 49 95 96 95 96 98 100 99 99 97 99 95 99 98 98 100 97 99 100 100 100
Reporting hospitals 7 7 7 7 7 7 8 9 9 8 8 8 16 16 16 16 16 16 13 13 10 10 10 9 10 11 12 12 11 11 7 7 3

Figure 3. Labor management collaborative. Partograph completion and labor


augmentation at Yaroslavl City Clinical Hospital No. 2.

Relationshipbetweenpartographcompletionanduseoflabor
augmentation,YaroslavlCityClinicalHospitalNo.2
100 20

90 18

80 16
%oflaborswithaugmentation
%partographcompletion

70 14

60 12

50 10

40 8

30 6

20 4

10 2
``````````````````````````````
0 12 0
J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J
2009 2010 2011
Figure 4. Labor management collaborative. Incidence of selected abnormalities of labor as a
percent of births begun vaginally, Sharya Hospital, Kostroma Region.
16

Excessive
strong contractions
14

Uncoordinated labor
12 Protracted
(weak)
labor

10

0
Jun/09

Jun/10
Jul/09
Aug/09

Jul/10
Aug/10

Jan/11
Feb/09

Feb/10

Apr/11
Jan/09

Jan/10
May/09

May/10
Sep/09

Nov/09
Dec/09

Sep/10

Nov/10
Dec/10

Feb/11
Mar/11
Apr/09

Oct/09

Apr/10

Oct/10
Mar/09

Mar/10

Introduction of
the partograph

Figure 5. Labor management collaborative. Asphyxia and hypoxia


Percentofnewbornswithasphyxiaandintrauterinehypoxia
amonghospitalsimplementingthepartograph
Median,25thand75thpercentiles
8

0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
2009 2010 2011
Median 5.1 4.5 4.0 3.0 3.3 1.8 3.5 1.6 1.7 1.7 1.4
25thpercentile 3.9 3.2 3.4 2.7 1.1 0.7 1.0 0.2 0.3 0.1 0.7
75thpercentile 5.7 5.1 4.1 3.5 13 6.3 7.2 6.3 4.9 2.7 4.6 4.5
Reportinghospitals 4 4 4 5 9 9 10 9 10 6 3
Figure 6. Labor management collaborative. Emergency c-sections.

EmergencyCaesarianSections
inHospitalsIntroducingthePartograph
22 Percentofbirths begunvaginally, median, 25thand 75thpercentiles

20
18
%ofbirthsbegunvaginally

16
14
12
10
8
6
4
2
0 J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S
2009 2010 2011
Median 5.6 4.2 8.0 8.6 7.0 6.0 10. 9.7 6.1 8.3 11. 7.3 8.1 11. 10. 9.5 10. 5.4 6.1 10. 8.0 14. 9.1 7.1 15. 9.1 10. 10. 12. 10. 12. 9.2 12.
25th percentile 5.0 3.0 4.8 6.6 2.5 4.2 6.1 5.0 4.2 3.0 4.3 4.3 4.9 5.3 5.9 7.7 4.5 4.1 4.0 7.0 5.9 3.8 7.1 5.5 10. 5.0 8.7 5.4 5.2 5.6 7.5 5.0 11.
75th percentile 6.8 11. 12. 14. 11. 15. 10. 11. 9.6 9.1 16. 11. 13. 17. 17. 15. 14. 12. 14. 14. 14. 16. 20. 17. 19. 16. 20. 13. 17. 16. 14. 15. 13.
# of hospitals 9 9 9 8 9 9 10 10 10 9 9 9 16 16 15 15 16 16 13 13 9 9 9 9 10 11 12 12 11 11 8 8 5

i. Discussion
The results demonstrate how careful application of a clear labor management protocol, with
standard tools and regular monitoring and control, can decrease the variation in performance
both within and across hospitals, and improve neonatal outcomes. The partograph is a low-cost
intervention with a potentially large return, but its success requires organizational discipline
within a hospital, to ensure its obstetricians adhere to a common standard.

The finding of an effect of implementation of the partograph on hypoxia and asphyxia, though
not unexpected, has not been reported in the peer-reviewed literature. A similar finding has
been reported, however, in our Health Care Improvement Project (HCI) Maternal and Child
Health (MCH) collaborative in Nicaragua.

In September 2010, the Kulakov Center obstetrical department approved its own internal
protocol on use of the partograph in normal births, and presented this protocol before a plenary
session of the major annual national MCH forum, Mother and Child. Obstetrical Department
head Oleg Baev, DMS, debated the value of using the partograph against the head of the
obstetric department at Russian State Medical University, who held the opposing view.

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In July 2011, the Ministry of Health and Social Development (MOHSD) issued a methodological
letter, reviewed by our partner Elena Bailbarina, MD, that explicitly endorsed use of the
partograph and algorithms for labor management [8]. Calling the partograph the simplest, but
effective method of graphical management of labor it states in bold letters that partograph
use in vaginal birth should be mandatory. The methodological letter also calls for

maternity hospital directors to arrange training on the partograph for all obstetricians
and midwives on the partograph
medical colleges and academies to provide training on the partograph
Hospitals to provide quarterly monitoring of partograph completion and use
Monitoring of the effect of partograph use using four indicators:
o Percent of labors over 18 hours
o Percent of labors with augmentation
o Emergency C-section rate
o Rates of intranatal stillbirth

During the project final conference, Oleg Filippov DMS, deputy director of the MOHSD MCH
department, proposed adapting the project change package on labor management using the
partograph, into a more detailed MOHSD methodologic letter.

Although these formal endorsements by the MOHSD should remove some barriers to use of the
partograph, there are others that remain. There is still no Russian standard partograph form,
and the partograph is not an approved part of the medical record. Therefore, physicians and
hospital administrators worry, it cannot form part of the official medicolegal record in a lawsuit
or be used to defend a physician from prosecution if accused of poor quality medical care. As a
result, data about the vital status of the fetus and the progress of labor needs to be entered
into the medical record twice in any facility using the partograph, discouraging physicians from
using it. Some regional and hospital officials are concerned about the legitimacy of using
budgetary funds to print the partograph, in the absence of a standard approved form. These
uncertainties could be resolved with formal regulatory action at the federal level.

j. References
1) World Health Organization Maternal Health and Safe Motherhood Programme, World Health
Organization partograph in management of labour..Lancet 1994; 343; 1399-404
2) Friedman EA. Primigravid labour. A graphicostatistical analysis. Obstet Gynecol 1955; 6: 567-89.
3) Philpott RH, Castle WM. Cervicographs in the management of labour in primigravidae. I: the alert line
for detecting abnormal labour, J Obstet Gynaecol Br 1972; 79: 592-98.
4) Philpott RH, Castle WM. Cervicographs in the management of labour in primigravidae. II: the action
line and treatment of abnormal labour, J Obstet Gynaecol Br 1972; 79: 599-602
5) JP Neilson, T Lavender, S Quenby S Wray, Obstructed labour: Reducing maternal death and disability
during pregnancy, Br Med Bull (2003) 67 (1): 191-204. doi: 10.1093/bmb/ldg018
6) World Health Organization, Managing complications in pregnancy and childbirth:
A guide for midwives and doctors, 2003
7) Institute for Family Health, Course handbook on family-oriented maternity care. Chapter 6: The
Partograph, 2006

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8) Methodological Letter: On organization of the work of maternity services under the conditions of
introduction of modern perinatal technologies, MOHSD letter 15-4/10/2-6796, June 13, 2011.

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