Preventing prolonged labor is a key strategy for reducing maternal and neonatal death. Once cervical dilation reaches 4 centimeters and contractions happen every ten minutes, a woman is considered to be in the active stage of labor. If this stage lasts too long, the woman faces higher risk of postpartum hemorrhage, sepsis, uterine rupture, and death. Likewise, prolonged labor places neonates at higher risk for anoxia, infection, and intrapartum death (1). This post covers the paperless partogram—a simple 2-step calculation that has the potential to simplify and improve the way clinicians prevent prolonged labor in low-resource areas.
For the past 30 years, the recommended clinical practice to prevent prolonged labor in low-resource areas has been the partograph, a graph that plots cervical dilation (and in some cases descent of fetal head/other indicators of labor progress) against duration of labor. The goal is to alert clinicians of slow progress in labor so that they can intervene to prevent prolonged labor.
The partograph is a low-cost tool for saving the lives of mothers and babies. But does that mean it is an appropriate tool? Dr. A. K. Debdas of India would say no. Even after the WHO simplified the partograph model to make it more user-friendly in 2000, the partograph is still rarely used in low-resource areas, and, when actually used, it is rarely interpreted correctly (2). Debdas argues that the WHO’s partograph fails to meet the organization’s own requirements for appropriate technology: the partograph has not been adapted to local needs, is not acceptable to those who use it, and cannot be used given the available resources. Debdas believes the partograph is simply too time-consuming for overburdened clinicians and too complicated for many skilled birth attendants—many of whom have not received higher education.
Dr. Debdas proposes a new, low-skill method for preventing prolonged labor—the paperless partogram. It takes 20 seconds, requires only basic addition and the reading of a clock or watch, and holds potential for more effectively mobilizing clinicians to prevent prolonged labor. Appropriate on all counts.
As Dr. Debdas says: in a split second, this method tells the provider:
* Where to go
* In how many hours
* When to terminate labor (instead of fruitlessly and dangerously let it go on) and
* When to transfer a woman to some higher centre with Caesarean capability
In the paperless partogram model, clinicians calculate two times, an ALERT ETD (estimated time of delivery) and an ACTION ETD. The ALERT calculation uses Friedman’s widely accepted rule that that cervix dilates 1cm per hour while a woman is in active labor (3). The clinician simply adds 6 hours to the time at which the woman becomes dilated to 4cm to find the ALERT ETD (when cervical dilation is at 10cm). The clinician adds 4 hours to the ALERT ETD to get the ACTION ETD. Both ETDs should be written in big letters on a woman’s case management sheet, the ACTION ETD circled in red.
At the time of the ALERT ETD, clinicians should be sensitized to the fact that the woman has not yet delivered and, if the current facility lacks C-section capabilities, make arrangements for transportation to a facility with available emergency obstetric care. At the time of the ACTION ETD, if the woman has not yet delivered, she is at risk for prolonged labor and the clinician must deliver her—now—by suitable medical treatment or surgical intervention. Throughout the process of active labor, the paperless partogram also helps prevent prolonged labor by prompting clinicians to work towards a roughly “on time” delivery. For example, if uterine contractions are poor close to the ALERT ETD, clinicians can give the woman oxytocin or an equivalent to strengthen contractions. Of course, if a woman faces obstetric complications before any ETD, clinicians should pursue medical interventions to keep her and her child healthy regardless of ETD.
This prolonged labor prevention strategy is cheap and easy to use, even for health workers without much formal education. The simplicity of this model also makes the paperless partogram an effective hand-over tool when clinicians change shifts, ensuring women continue to be monitored for prolonged labor if their care providers change. The paperless partogram illustrates the potential for about 20 seconds and two time stamps to help save the lives of mothers and babies.