International Journal of Scientific Research in Knowledge, 2(9), pp.

433-443, 2014
Available online at http://www.ijsrpub.com/ijsrk
ISSN: 2322-4541; 2014 IJSRPUB
http://dx.doi.org/10.12983/ijsrk-2014-p0433-0443


433
Full Length Research Paper

Implication of the Two WHO Partographs, (Composite and Simplified) Regarding
Maternal and Neonatal Outcome

Samar Dawood Sarsam
1
*, Rabab Muter Flayeh
2
, Ulfat Mohammad Alnakkash
3

1
Assistant professor, Dept. of Obs. & Gyn. Alkindy College of Medicine, University of Baghdad, Iraq

2
Senior house officer, Elwiya Teaching Hospital, Iraq
3
Specialist in Obs & Gyn,

Elwiya Teaching Hospital, Iraq

*Corresponding Author: Email: samarsarsam4@yahoo.com

Received 18 July 2014; Accepted 26 August 2014

Abstract. Partograph is an inexpensive tool that serves as an "early warning system" and can assist in early decision making
on transfer, augmentation, and termination of labor. This is a randomized prospective comparative study conducted at Al-
Elwiya Maternity teaching Hospital in Baghdad-Iraq. The objective of this work is to compare two World Health Organization
(WHO) Partographs, the composite Partograph including the latent phase with the simplified one without latent phase
regarding maternal and fetal outcomes. Study sample consisted of 670 women with term, singleton, vertex presentation, in
spontaneous labor. Either Partograph was used on laboring women. The following outcomes: labor crossing the alert and
action line, augmentation of labor, rate of cesarean section, maternal complications, user friendliness and perinatal outcome
were compared. Labor values crossed the alert and action line was significantly more often with composite Partograph (P<
0.001). Augmentation of labor have been significantly required more in cases of composite group (p- value <0.001). Vaginal
deliveries were higher in cases monitored with the simplified group (p<0.005). Cesarean section was more in cases monitored
with composite Partograph (p-value <0.001). Admission to the neonatal care unit was more in cases of composite Partograph
group, weather the patients were nulliparous or multiparous, the difference was statically significant (p<0.005). Most users
(91%) had trouble with composite Partograph, but no resident doctor reported difficulty with simplified Partograph. It was
concluded that the World Health Organization simplified Partograph is easier to use and is a better option for both the laboring
women and the user, when compared to the composite Partograph.

Keywords: Composite Partograph, fetal outcome, maternal outcome, simplified Partograph.

1. INTRODUCTION

Labor has been considered as bodily process in the
ancient Greek legacy and its surveillance has therefore
been subjected to planning, monitoring and regulation
(Navneet, 2011).
Every day, approximately 800 women die from
preventable causes related to pregnancy and childbirth
(WHO, 2012). Several interventions have been
designed to curb this alarming high rate of maternal
mortality. Recognizing the unacceptably high
maternal mortality ratio, the preventable nature in the
majority of cases, and the social consequence of
mother's death to her family and children (WHO,
2012).
The World Health Organization recommends using
the partograph to follow labor and delivery, with the
objectives to improve health care and reduce maternal
and fetal morbidity and death (WHO, 1993)
The Partograph is usually a pre-printed paper form
on which labor observations are recorded. The aim of
the Partograph is to provide a pictorial overview of
labor, to alert midwives and obstetricians to deviations
in maternal or fetal wellbeing and labor progress
(Lavender et al., 2013).
It is a simple, inexpensive graphic presentation of
labor and is an excellent visual resource to analyze
cervical dilatation and fetal presentation in relation to
time. Since 1990 WHO has published 3 different
types of the partograph. The first of these partographs
also called as the composite partograph includes a
latent phase of 8 hours and an active phase starting at
3 cm cervical dilatation. It has an alert line with a
slope of 1 cm per hour which commences at 3 cm
dilatation and an action line is 4 hours to the right of
and parallel to the alert line. It also provides space for
recording descent of the fetal head, indicators of
maternal and fetal well-being and medication
Sarsam et al.
Implication of the Two WHO Partographs, (Composite and Simplified) Regarding Maternal and Neonatal Outcome
434
administered (WHO, 1994). WHO modified the
partograph for use in hospitals in 2000 (WHO, 2000).
The latent phase was excluded in this partograph,
the active phase commences at 4 cm dilatation. The
reason for excluding the latent phase was that
interventions are more likely if latent phase is
included and because staff reported difficulties in
transferring from latent to active phase (Kwast et al.,
2008).
WHO further modified the partograph for the third
time, this time for use by skilled attendants in health
centers. This simplified partograph is color coded.
The area in between the alert and action line is colored
amber, indicating the need for greater vigilance.
Cervical dilatation not descent of the head is recorded
on the partograph which is a part of labor record.
Other indications of maternal and fetal wellbeing are
recorded elsewhere in the labor record (WHO, 2006).


Fig. 1: composite Partograph (WHO, 1994)

2. MATERIALS AND METHODS

This randomized prospective comparative study was
conducted at Elwiya maternity teaching hospital
Baghdad Iraq, from the first of July, 2012 to the end
of July 2013, during this period 10745 women
delivered in this hospital. Our sample size was 670
laboring mother, 325 of them were primigravid and
345 were multiparous. All laboring women on Sunday
and Tuesday during this period were included in this
study after taking their consent.
The Authority of Hospital Administration
approved the study protocol. Laboring mothers were
admitted to the hospital after taking full history and
examination and all were sent for hemoglobin level,
blood group and RH random blood sugar, general
urine examination and ultra sound examination.
Inclusion criteria: women with singleton term, vertex
presentation, uncomplicated pregnancy in
International Journal of Scientific Research in Knowledge, 2(9), pp. 433-443, 2014
435
spontaneous labor. Exclusion criteria: previous scar,
short stature <140 cm, multiple pregnancy, anemia,
antepartum hemorrhage, preeclampsia, intrauterine
death, preterm and any medical or obstetrical
problem. Patients fulfilled the inclusion criteria were
followed by using either composite (group 1) or
simplified Partograph (group 2). The plotting of the
composite Partograph was started as soon as the
women was in labor while in simplified Partograph,
the application started with equal or more than four
centimeters cervical dilatation, for the composite
Partograph there were 165 primipara and 175
multipara and for the simplified one 160 primipara
and 170 multipara . For each case fulfilling the
inclusion criteria the following information should be
plotted on the graph: laboring mother's name, age,
gravida " and "para" status, registration number in the
hospital , the date and the time when first attended for
delivery , the laboring women were followed in the
following sequences:

2.1. Fetal Condition

Fetal heart recorded every half hour or more
frequently normal fetal heart was between 110 -
160;<110 or >160 beat per minute indicated fetal
bradycardia or fetal heart tachycardia respectively
which requires immediate action . we monitored the
fetal heart for at least one minute with the women in
left lateral position if possible, the best time for to the
fetal heart was immediately after peak of the uterine
contraction, using soniciad or CTG. fetal heart rate
plotted with a dot, subsequent dots are connected by
solid line. The state of amniotic membranes was
evaluated which can assist in assessing fetal condition.
On the other hand, Molding is an important indicator
of how well the pelvis can accommodate fetal head.

2.2. Progress of Labor

Cervical dilatation: the central part of the of the
Partograph is the area of cervical dilatation, on the left
side of the Partograph is the number from zero to ten,
vertical site of each square represent one centimeter
per hour, in the horizontal line each square represent
half hour, dilatation of the cervix was measured in
centimeters. for the composite Partograph covers the
latent phase which was from o,1,2 up to 3 centimeters
cervical dilatation last 8 hour or less, and an active
phase beginning when cervical dilatation reach 3 cm
as seen in in, fig.1 (composite (WHO) Partograph
(WHO, 1994).
In the "Simplified Partograph" excluding the latent
phase of labor, and considering the beginning of
active phase of labor at 4cm cervical dilatation instead
of 3 cm, there were some other changes in the
simplified Partograph, which includes excluding the
descent of the fetal head; recording will be plotted
immediately on the alert line as in fig. 2. (Simplified
(WHO) Partograph (Kwast et al., 2008) There is two
diagonal line in the section of the Partograph, the alert
line and action line, the alert line represent the rate of
cervical dilatation one cm per hour which considered
the lowest level of cervical dilatation per hour in
normal labor for both nulliparous and multiparous.
When labor progressing well the rate of cervical
dilatation should remain on the left of the alert line,
when the rate of cervical dilatation to the right of the
alert line, it indicates slow progress of labor and we
do appropriate action like as aminiotomy or
augmentation of labor. The action line is parallel to
the alert line four hours to the right, when cervical
dilatation reaches or crosses the action line, it
indicates dangerously slow progress of labor, in this
situation decision must be taken .For continuous
monitoring of labor, regarding cervical dilatation we
did vaginal examination every four hours or more
frequently if indicated. After full dilatation of the
cervix we continued to record, uterine contractions,
blood pressure, pulse rate, and fetal heart.
Descent of the fetal head: descend of the head was
performed by abdominal examination immediately
before vaginal examination. We recorded the head
position on the composite Partograph with "O". In the
simplified Partograph, descent of the fetal head was
excluded.
Uterine contractions: in normal labor the
contractions become more frequent and last longer as
labor progress. Numbers of contractions in ten-minute
period describe the frequency of contractions. The
duration of contraction is from the first time felt
abdominally to the time when the contraction passed
off and was measured in seconds. Observations of the
contractions are made every 30 minutes on the
Partograph. The duration and intensity of uterine
contractions recorded on their own section on the
scale is numbered from 1-5 squares each square
represent one contraction and are shaded with
appropriate shading, seen in fig. 3 (WHO, 1999).
If unsatisfactory progress of labor due to
inadequate uterine contractions was detected, we
considered using aminiotomy if no progress we used
oxytocin infusion to augment labor. There is separate
area for recording oxytocin titration and drugs used.

2.3. Maternal Condition

Blood pressure, temperature, volume and content of
urine are recorded on the bottom of Partograph, below
the recording of drug and intravenous fluid given. The
assessment through the Partograph helps to clinical
decision making regarding mode of delivery, either by
Sarsam et al.
Implication of the Two WHO Partographs, (Composite and Simplified) Regarding Maternal and Neonatal Outcome
436
caesarean section if there is clinical indication as fetal
distress or obstructed labor or others or by vaginal
delivery, immediate care to the mother and newborn,
the newborn baby was handled by pediatrician on
duty.

2.4. Neonatal Outcome

Neonatal outcome, Apgar score at one and five
minutes, weight and any abnormality was recorded on
the Partograph.


Fig. 2: Simplified (WHO) Partograph (Kwast et al., 2008)

Fig. 3: uterine contractions intensity as recorded on the partographs (WHO, 1999)

2.5. Statistical Analysis

Data of this study were transferred into computerized
databases software with statistical analysis facilities;
statistical package for social sciences (SPSS) software
version 18, 2008 for windows was used in all
statistical analysis and procedures. Level of
significance (P-Value) 0.05 considered as
significant and 0.001 considered as highly
significant.

International Journal of Scientific Research in Knowledge, 2(9), pp. 433-443, 2014
437

Fig. 4: comparison of Labor outcomes and user satisfaction

3. RESULTS

Six hundred seventy women were included in this
randomized prospective comparative study, 340 were
monitored with composite partograph (1
st
group) and
330 were monitored with simplified partograph (2
nd

group). Out of the 340 patients in the 1st group, 165
were nulliparous and 175 were multiparous compared
to 160 nulliparous and 170 multiparous in the 2nd
group. Table (1) shows the comparison of labor
outcomes and user satisfaction in between the two
groups, labor values that crossed the alert line and the
action line were significantly more frequent when
composite partograph was used than simplified
partograph.
Labor crossed the alert line in 85 case (25%) of
those monitored by the composite partograph and 51
case (15.5%) of those monitored with the simplified
partograph, (P=0.0014). Labor crossed the action line
in 36 (10.6%) laboring woman in 1st group vs.
8(2.4%) labors in 2nd group (p<0.001).
Augmentation of labor had been significantly
required more in cases of composite group than those
of simplified group, 118 (34.7%) vs. 57 (17.3%)
respectively, P<0.001, in both Nulliparous and
Multiparous women, P<0.001 and 0.0011,
respectively. The number of vaginal delivery is higher
in cases monitored by simplified partograph than
those with composite group, 305(92.4%) vs.
265(77.9%) respectively, p<0.05.
Patients in 1
st
group, 75(22.1%) of them underwent
cesarean section, while 25(7.6%) case underwent
cesarean section in the 2
nd
group (p<0.001).
Postpartum hemorrhage was occurred in 18 case
(5.3%) of those monitored with composite partograph
as compared to 20 case (6.1%) of those with
simplified partograph, however, the difference was
statistically not significant, P>0.05. Apgar score < 7 in
5 minutes was not significantly different in between
both groups, P>0.05.
Admission to NCU (Neonatal care unit) was more
in cases of composite partograph group rather than
those with simplified one, whether the cases were
Sarsam et al.
Implication of the Two WHO Partographs, (Composite and Simplified) Regarding Maternal and Neonatal Outcome
438
nulliparous or Multiparous, the difference was
statistically significant, P<0.05. The mean user
friendliness score was lower for the composite
partograph (2.66 1.19) vs. (9.78 2.3) for simplified
partograph, p<0.001). Most of the users (91%)
experienced difficulty with the composite partograph,
but none reported difficulty with the simplified
partograph. All these finding were shown in table (1)
and figure (4).
cases for whom cesarean section was performed,
the indications for cesarean sections were presented in
table (2), as shown in this table, fetal distress was the
dominant indication in both composite partograph and
simplified partograph groups as in figure (5), with a
highly significant difference in between both groups,
fetal distress was more frequent in composite group
than simplified partograph group, 57 (16.8%) vs. 13
(3.9%), respectively, P<0.001.
The second indication was no progress of labor
which was present in 12 (3.5%) case among
composite group vs. 6 (1.8%) in the second group,
nonetheless, the difference was statistically not
significant, P>0.05, other indications were shown in
table (2), with no statistical significant difference in
between both groups, P>0.05.
admission to the NCU was indicated in 76(22.4%)
case of composite group and 33(10.0%) case of
simplified group, the indications of admission were
summarized in table(3).
It had been significantly found that hyper
bilirubinaemia was the frequent indication in both
groups and it was significantly more frequent in
composite group than simplified group, 35 (10.3%)
vs. 12 (3.6%), respectively, P<0.001, figure (6).
Meconium aspiration, Sepsis and Asphyxia
showed no significant differences in between both
groups, P>0.05.
Low birth weight was significantly more frequent
in composite group; 14 (4.1%) as compared to
simplified group; 5 (1.5%), P=0.036, figure (6).
Other indications (like transient tachypnea of
newborn and respiratory distress syndrome) were
3.5% in composite group and 1.2% in simplified
group, P<0.001.



Table 1: Comparison of labor outcomes and user satisfaction
Variable Composite (n=340) Simplified (n=330) P*
No. % No. %
Labour crossing the alert line 85 25.0 51 15.5 0.0014
Nulliparous 55 16.2 31 9.4 0.0002
Multiparous 30 8.8 20 6.1 0.035
Labour crossing the action line 36 10.6 8 2.4 < 0.001
Nulliparous 20 5.9 6 1.8 <0.001
Multiparous 16 4.7 2 0.6 0.0011
Augmentation of labor 118 34.7 57 17.3 <0.001
Nulliparous 73 21.5 33 10.0 <0.001
Multiparous 45 13.2 24 7.3 0.007
Vaginal delivery 265 77.9 305 92.4 < 0.001
Nulliparous 125 36.8 143 43.3 0.042
Multiparous 140 41.2 162 49.1 0.023
Caesarean Section 75 22.1 25 7.6 <0.001
Nulliparous 54 15.9 22 6.7 0.001
Multiparous 21 6.2 3 0.9 <0.001
Postpartum hemorrhage 18 5.3 20 6.1 0.39
Nulliparous 7 2,1 8 2.4 0.47
Multiparous 11 3.2 12 3.6 0.47
Apgar score <7 at 5 minutes 13 3.8 10 3.0 0.36
Nulliparous 8 2.3 7 2.1 0.47
Multiparous 5 1.5 3 0.9 0.37
Admission to the NCU 76 22.4 33 10.0 0.0011
Nulliparous 42 12.4 18 5.5 0.0013
Multiparous 34 10.0 15 4.5 0.023
User friendliness score 2.66 1.19 - 9.78 2.3 - <0.001
Difficulty in using the partograph 91% 0% <0.001

International Journal of Scientific Research in Knowledge, 2(9), pp. 433-443, 2014
439
Table 2: Indications for Caesarean Section
Variable Composite (n=340) Simplified (n=330) P*
No. % No. %
Fetal distress 57 16.8% 13 3.9% <0.001
Non progress of labor 12 3.5% 6 1.8% 0.13
CPD 2 0.6% 4 1.2% 0.32
Deep transverse arrest 2 0.6% 2 0.6% 0.32
Obstructed labor 2 0.6% 0 0.0% 0.24
Total 75 22.1% 25 7.6%

Table 3: Indication for admission to Neonatal Care Unit
Indication for admission Composite (n=340) simplified(n=330) P*
No. % No. %
Hyper bilirubinaemia 35 10.3%
3.5%
0.3%
0.6%
4.1%
3.5%
12 3.6% 0.0006
0.087
0.595
0.65
0.036
0.043
Meconium aspiration 12 5 1.5%
Sepsis 1 3 0.9%
Asphyxia 2 4 1.2%
Low birth weight 14 5 1.5%
Others 12 4 1.2%
Total 76 22.3% 33 9.9% <0.001


Fig. 5: Distribution of significant indication for cesarean sections according to partograph groups

4. DISCUSSION

Many WHO partograms has been implemented all
over the world, in our department we were
accustomed to use the composite partograph. After
WHO modification of partograph to the simplified
one with no latent phase and no records of descent of
presenting part and being colored we decided to use
this type of partograph in our department and compare
it with the composite one regarding maternal and fetal
outcome. The present study was started to highlight
which WHO Partograph is associated with better labor
outcomes and is more user friendly so that the use of
Partograph becomes a routine practice in all health
setup in Iraq.
Our results showed that labor crossing the alert and
action line were more in the first group This result is
in concordance with study done at Belgaum, India
(Kenchaveeriah et al., 2011), Pakistan (Mathews et
al., 2007) and study conducted in Median- Indonesia
(Fahdy and Chongsuvivatwong, 2005).
While study done at Vellore - India reports 17.7%
and 15.1% in the two groups respectively (Javed et al.,
2007) and same results from study done in Liverpool
(Lavender

et al., 1998).
Augmentations of labor have been significantly
required more in cases of composite group in both
Sarsam et al.
Implication of the Two WHO Partographs, (Composite and Simplified) Regarding Maternal and Neonatal Outcome
440
nulliparous and multiparous women. This is in
concordance with study at Belgaum- India,
(Kenchaveeriah et al., 2011), and Vellore (Javed et al,
2007). While lower rates of augmentation observed in
study done at Calcutta (Alauddin et al., 2008). The
large WHO multicenter trial in south East Asia had
augmentation in 10.6% of cases where composite
Partograph was used (WHO, 1994). One important
association, which we found in the current study, was
that augmentation was more in laboring women in
whom labor crossed the alert and action lines. Similar
results noticed in study at Belgium (Dujardin et al.,
1992).
The present study was again in accordance to
study done at Leeds- UK where they had intervened
actively when latent phase of the Partograph was used
(Cartmill and Thornton, 1992). These results were
because the simplified partograph has no latent phase
and it is applied when the cervix is 4 cm dilated.


Fig. 6: Distribution of significant indication for admission to NCU according to partograph groups

4.1. Mode of Delivery

Vaginal deliveries in cases monitored by simplified
Partograph were more than in composite group. P-
value <0.05, it agrees with study at Belgaum- India
(Kenchaveeriah et al., 2011), and study done at
Calcutta (Alauddin et al, 2008). Of the laboring
women randomized to the composite Partograph,
22.1% underwent cesarean section, in those with
simplified group cesarean section was performed in
7.6% , p value <0.001 which was statically significant.
Similar to study at Belgaum- India (Kenchaveeriah et
al., 2011) and study from Calcutta had similar results
(Alauddin et al., 2008). Published literature from
Dublin- Ireland highlights 5.4 % of laboring women
undergoing cesarean section in composite Partograph
group (Impey and Lawrence, 2000). While study from
Vellore showed only 8.8% and 2.35% of laboring
women in composite and simplified group
respectively undergone cesarean section (Javed et al,
2007). Fetal distress was the dominant indication for
cesarean section in both composite and simplified
groups, which was highly significant. Fetal distress
was more frequent in composite group than the
simplified group. Similar results reported at Belgaum-
India (Kenchaveeriah et al., 2011). The second
indication was no progress of labor which was present
in 3.5% of cases among composite group vs 1.8%
among the simplified group, nonetheless, the
difference was statically not significant, this is in
concordance with study done at Belgaum, India
(Kenchaveeriah et al., 2011).
A large multicenter trial done at South East Asia
including 35,484 women, 3.4 % had prolonged labor
while using composite Partograph (WHO, 1994).
Study done at Medan- Indonesia had similar findings
where 3% had prolonged labor when composite
Partograph was used (Fahdy and Chongsuvivatwong,
2005). Study from Liverpool showed 6.1% failure of
progress of labor (Lavender et al., 1998). We also
International Journal of Scientific Research in Knowledge, 2(9), pp. 433-443, 2014
441
observed that number of cesarean section was more in
nulliparous, irrespective of the Partograph used. There
were two cases 0.6% of cesarean section due to
obstructed labor in the composite Partograph while no
case due to obstructed labor in the simplified group,
this is attributed to the simplified partograph being
started at 4 am dilated cervix. Study at Belgaum-India
(Javed et al., 2007) showed no case of obstructed
labor in both groups, similar to study at Calcutta
(Lavender et al, 1998). While study at Medan-
Indonesia showed that obstructed labor occurred in 11
case when simplified Partograph was used (Fahdy and
Chongsuvivatwong, 2005). Postpartum hemorrhage
defined as blood loss of more than 500 ml after
vaginal delivery and more than 1000 after cesarean
section, there was no significant difference this is
similar to study from Belgaum-India (Kenchaveeriah
et al., 2011) and study at Calcutta (Alauddin et al,
2008). There was no similarity with result from study
at Liverpool, where they had observed blood loss >
500 ml in 93 laboring women (Lavender et al., 1998).

4.2. Neonatal Outcome

Another aspect of the study was to observe the
neonate of the laboring women. we detected no
statically significant differences in the number of
infant with Apagor score <7 at 5 minute in both
groups which was similar to study at Belgaum, India,
(Kenchaveeriah et al., 2011), Vellore (Javed et al,
2007) and Liverpool (Wacker et al, 1998). However,
the result varied from study at Indonesia (Fahdy and
Chongsuvivatwong, 2005). Admission to the neonatal
care unit was more required in cases of composite
Partograph group rather than those with the simplified
one, whether the cases were nulliparous or
multiparous. The difference was statically significant,
this was in concordance with study at Belgaum- India
(Kenchaveeriah et al., 2011).Vellore study had
similarity with our results, where the admission to the
neonatal care unit was 20% in the composite
Partograph and 16% in the simplified group (Javed et
al, 2007). The majority of admissions were due to
hyperbilirubinaemia and low birth weight. Though the
difference between two groups was statically
significant, it was not related directly to monitoring of
labor these results were similar to results obtained in
Belgaum- India (Kenchaveeriah et al., 2011). Low
birth weight was significantly more frequent in
composite this in agreement with study done at
Belgaum- India (Kenchaveeriah et al., 2011).
Meconium aspiration syndrome, sepsis and birth
asphyxia were other important causes, which were not
statically significant.


4.3. User Friendly

Simplified Partograph was much more user friendly
as compared to the composite Partograph in our study,
our results were similar to study at West Africa
(Cartmill and Thornton, 1992) and Belgaum- India
(Kenchaveeriah et al., 2011). Another study done at
Vellore showed a score of (8.6 1.0 vs 6.2 0.9) in the
simplified and composite Partograph respectively
(Javed et al., 2007). Most of the users 91%
experienced difficulty with the composite Partograph,
but non-reported difficulty with the simplified
Partograph as in study at Belgaum- India
(Kenchaveeriah et al., 2011), 86% of the maternity
staff at hospital in Germany preferred the simplified
Partograph because of its time saving, being colored
and user-friendly qualities (Wacker et al., 1998). Most
of the participants (83%) had difficulty with plotting
composite Partograph at Vellore (Javed et al., 2007).
The simplified WHO represent a synthesized and
modified form that includes the best feature of several
Partograph. It has been found to be inexpensive,
effective and pragmatic in different settings including
developed and developing countries and has been
effective in preventing prolonged labor, reducing
operative intervention and in improving the neonatal
outcomes. Therefore, the need to incorporate the
simplified Partograph in our practice and help Iraq
reach its Millennium Development Goal 5 (MDG5)
by 2015.

5. CONCLUSION

1. Vaginal deliveries were higher in cases monitored
with the simplified Partograph than those with the
composite one.
2. Cesarean section was more in cases monitored
with composite Partograph.
3. Admission to the NCU was more in the group
monitored with the composite Partograph than those
with the simplified one, weather the cases were
nulliparous or multiparous, the difference was
statically significant, (p<0.005).
4. Most users (91%) had trouble with the
composite Partograph, but no resident doctor reported
difficulty using the simplified Partograph. The mean
standard deviation (SD) user friendliness score was
lower for the composite Partograph (2.661.19).
5. The WHO Partographs are the best-known
Partographs in low resources settings, and WHO
simplified Partograph is associated with better
maternal and neonatal outcome and it is more users
friendly

Sarsam et al.
Implication of the Two WHO Partographs, (Composite and Simplified) Regarding Maternal and Neonatal Outcome
442
6. RECOMMENDATION

Maternal and Neonatal Health (MNH) Program
promotes the use of the Partograph to improve the
management of labor and to support decision
making regarding interventions. Our study
recommends the use of simplified Partograph, which
should be a routine practice in our primary and
secondary hospitals in monitoring progress of labor
for better maternal and perinatal outcomes.

REFERENCES

Alauddin M, Bal R, De A, Mandal P, Chakraborty M
(2008). Monitoring of labor with WHO
modified Partograph A study report. NJOG,
3(2): 8-11.
Cartmill RS, Thornton JG (1992). Effect of
presentation of Partograph on obstetric decision
making. Lacent, 339: 1520 -22.
Dujardin B, De Schampheleire I, Sene H., Ndiaye F.
(1992). Value of the alert and action on the
Partograph. Lancet, 339(8805): 1336-1338.
Fahdy M, Chongsuvivatwong V (2005). Evaluation of
world health organization Partograph
implementation by midwives for maternity
home birth in Medan, Indonesia. Midwifery,
21: 30 -10.
Impey L, Hobson J, Oherlihy C (2000). Graphic
analysis of actively managed labor. Prospective
study in 500 consecutive nulliparous women in
spontaneous labor. Am J Obstet Gynecol.,
183(2): 438-43.
Javed I, Bhutta S, Tabassum S (2007). Role of
Partograph in preventing prolonged labor.
Journal of Pakistan Medical Association, 57:
408.
Kenchaveeriah SM, Patil KP, Singh TG (2011).
Comparison of two WHO Partographs. J
Turkish- German Gynaecol Assoc., 12: 31-4.
Kwast BE, Poovan P, Vera E, kohls E (2008). The
modified WHO Partograph: do we need a latent
phase. African Journal of Midwifery and
women's Health, 2: 143 -8.
Lavender T, Alfirevic Z, Walkinshaw S (1998).
Partograph action line study: a randomized
trial British .J Obstet Gynaecol, 105: 976-80.
Lavender T, Hart A, Smyth RM (2013). Effect of
Partogram use on outcomes for women in
spontaneous labor at term Cochrane database
sys rev. Jul 10; 7:CD005461.
doi:10.1002/14651858.CD005461.pub4.
Mathews JE, Rajaratnam A, George A, Mathai M
(2007). Comparison of the two WHO
Partographs. International Journal of
Gynecology and Obstetrics, 96: 147-50.
Navneet M (2011). Partograph revisited. International
Journal of Clinical Cases and Investigations.
Volume 3 (issue 1), 1:6, 6
th
August, 2011.
Wacker J, Kyelem D, Bastert G, Utz B, Lankoande J
(1998). Introduction of a simplified round
Partograph in rural maternity units: Seno
Province, Burkina Faso, West-Africa. Trop
Doct., 28(3): 146-52.
World Health organization (1993). preventing
prolonged labor: a practical guide. The
Partograph part 1: principle and strategy.
WHO/FHE/MSM/ 93.8. Geneva: WHO.
World Health Organization (1994). Partograph in
management of labor World Health
Organization Maternal Health and Safe
Motherhood Program. Lancet, 343: 1399-404.
World Health Organization (1999). A practical Guide.
The Partograph part II. User's Manual.
WHO/FHE/MSM/ 93.9.
WHO (2000). preventing prolonged labor. A practical
Guide. The Partograph part III Facilitators
Guide: WHO/FHE/MSM/93.10.
World Health Organization (2000). Managing
complication in pregnancy and child birth.
World Health Organization.
World Health Organization (2006). Pregnancy,
childbirth, postpartum and newborn care: A
Guide for essential practice. Geneva: World
Health Organization.
WHO (2012). World Health Organization fact sheet,
maternal, Newborn, Child and Adolescent
health.
International Journal of Scientific Research in Knowledge, 2(9), pp. 433-443, 2014
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Assistant prof. Samar Dawood Yakoub Sarsam was born in Baghdad (1960), got her M.B.Ch.B
Degree (1984); Post graduate diploma in Obs. & Gye. (D.O.G) 1992; Board in Obs. & Gye.
(C.A.B.O.G) 1992; Worked as Specialist in Mosul (1992-2006); she joined the academic staff at
university of Mosul (2002- 2005); she joined the academic staff at University of Baghdad, Al
Kindey Medical College and got the assistant professor degree at 2008. Areas of specialization and
interest: infertility and laparoscopy.









Dr. Ulfat Mohammed Ali Jawad Al Nakkash was born in Baghdad (1968); got his M.B.Ch.B
Degree (1992), Post graduate Diploma in Obs. & Gye. (D.O.G) 2003; Board in Obs.& Gye.
(C.A.B.O.G) 2004; he is the Director of Elwyia Maternity Teaching Hospital. Director of Zenat al
hayat Fertility Centre.











Dr. Rabab Mutar Flayeh was born in Hella (1976) got her M.B.Ch. B Degree (2000); working as
senior house officer and post graduate student at Elwiya Maternity Teaching Hospital.