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An important development in the management of labour was the
introduction of the
partogram. First developed by Hugh Philpott
in 1972 to identify abnormally slow labour, the
partogram is a graphical representation of
the changes that occur in labour, including cervical
dilatation, fetal heart rate, maternal pulse, blood pressure,
and temperature; it also shows a numerical record of features
such as urine output and the volume and type of intravenous
infusions (including oxytocin drips). It is therefore possible
at a glance to identify deviations from normal in any of these
variables.
Partogram: the broken lines show expected progress of cervical dilatation in multiparous (left) and primiparous (right) women. Labour progress is different in primiparous and multiparous women and is best displayed graphically on a partogram, which shows average dilatation rates by parity
The rate of cervical dilatation in the active phase at which augmentation of labour is indicated is controversial. In the 1960s through to the early 1980s O'Driscoll and colleagues suggested that any nulliparous woman with a rate of cervical dilatation below the average (1 cm/h) should be augmented. Thus active management would be used in half of women in their first pregnancies; few multiparous women progress this slowly. Most obstetricians in Britain are now more conservative, and 0.5 cm/h is commonly taken as the cut off. Usually the first step in augmentation is to rupture the amniotic membranes; if this is not followed by a speedy labour intravenous oxytocin is given to stimulate contractions. Careful clinical monitoring is needed to ensure that contractions do not exceed one every two minutes, or fetal hypoxia may result from restriction of the maternal afferent placental blood flow. When the progress of labour is so slow (despite oxytocic stimulation) that the woman is becoming exhausted and the fetus at risk of hypoxia, a caesarean section is the best solution. An individual decision is taken by each woman on the recommendation of her obstetrician. A caesarean section cannot be performed without the mother's specific consent, except when she is mentally incompetent and then the decision must be made by a court. A study in Canada found tha the use of a partogram without a mandatory management of labour protocol had no effect on rates of CS or other intrapartum interventions in healthy primiparous women at term.0701 The 2-hour partogram increases the need for intervention without improving maternal or neonatal outcomes, compared with the 4-hour partogram, advocated by the World Health Organization.0601
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