Journal of Midwifery & Womens Health

www.jmwh.org

Original Research

Pilot Study of Physiologic Partograph Use Among Low-Risk,

Nulliparous Women With Spontaneous Labor Onset
Jeremy L. Neal, CNM, PhD, Nancy K. Lowe, CNM, PhD, Amy S. Nacht, CNM, MSN, MPH, Kate Koschoreck, CNM,
MSN, Jessica Anderson, CNM, MSN, WHNP-BC

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

ans, accounting for almost half of cesareans in nulliparous

women.68 More accurate diagnosis of dystocia provides the
best opportunity to prevent primary cesarean births,9 an ongoing national priority in the United States.1013
The Neal and Lowe partograph incorporates several
evidence-based principles, including accurate diagnosis of active labor onset for each woman and cervical dilation rate expectations that are grounded in contemporary understanding of labor progression.5 The tool is designed for use in
hospital settings, where 98.6% of all US births occur.14 The
Neal and Lowe partograph is meant to allow ample time
for physiologic labor to progress while also objectively indicating when interventions aimed at speeding labor may be
justified; the tool also allows for ongoing evaluation of interventions, if used. It is posited that widespread use of this innovative partograph in high-resource settings may safely and
significantly decrease primary cesareans performed for active labor dystocia.5 Thus, the Neal and Lowe partograph differs considerably from the purpose of commonly used partographs that were designed for the early detection of slow
cervical dilation so the laboring woman could be transferred
from a low- to higher-resource setting.15
The aim of this pilot study was to examine the feasibility of implementing the Neal and Lowe partograph for the inhospital labor assessment of NTSV women with spontaneous
labor onset. Results will inform hypothesis testing in subsequent larger-scale studies.

1526-9523/09/$36.00 doi:10.1111/jmwh.12442


c 2016 by the American College of Nurse-Midwives

A partograph is a clinical tool that provides maternity care

providers with a pictorial overview of progress during labor.
Cervical dilation and fetal descent are graphically recorded on
the central section of most partographs, facilitating early detection of abnormal progress. The World Health Organization
credits partograph use with decreasing rates of prolonged labor, oxytocin use, cesarean birth, and certain birth morbidities
in developing world regions, when compared to usual care,1,2
and strongly recommends use of partographs for women in
both high- and low-income settings.3 While partograph use
is reflected in standard intrapartum care guidelines in some
world regionsfor example, National Institute for Health and
Care Excellence guidelines4 (United Kingdom)these labor
assessment tools are rarely used in the United States despite
their potential benefits.
Neal and Lowe developed a physiologic partograph to
provide clinicians a uniform approach to assessing active labor progress and diagnosing true dystocia during the first
stage of labor for nulliparous women with a term, single, vertex (head-down) fetus (NTSV) with spontaneous labor onset.5
Dystocia is the most common indication for primary cesare-

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

We performed a descriptive study at the University of

Colorado Hospital on the Anschutz Medical Campus, Aurora, Colorado. This is a large academic medical center in
the western region of the United States wherein more than
3000 women give birth each year. Institutional review board
approval was granted for all study-related activities. Eight
certified nurse-midwives (CNMs) from University NurseMidwives, a midwifery faculty practice that attends hospital births, were trained on the use of the Neal and Lowe
partograph for the assessment of labor progress. Training
involved a one-hour in-person and/or Web-based presentation about partograph principles, design, use, and interpretation, and plotting of various labor scenarios. The trained
CNMs were approved by the institutional review board as
key study personnel and they then recruited low-risk, nulliparous women during third-trimester prenatal appointments.
Written informed consents were obtained from women agreeable to the use of the Neal and Lowe partograph (paper-andpencil version) by a trained CNM for assessment of their
first-stage labor progress.
Only low-risk, healthy NTSV women admitted for spontaneous labor onset and an anticipated vaginal birth were
eligible for partograph assessment during labor. Additional eligibility criteria included maternal age of 18 to 39 years, no
significant medical history (eg, cardiac, pulmonary, kidney,
or autoimmune disease), absence of pregnancy complications
(eg, preeclampsia, diabetes, oligohydramnios), and absence of
identified fetal complications (eg, anomalies, nonreassuring
status, intrauterine growth restriction). Women undergoing
inductions of labor were not eligible.
For purposes of comparing women with partographassessed labors to usual care assessment strategies within this
medical center, birth data for women meeting the same inclusion criteria for the year immediately prior to partograph
introduction were extracted from an existing, deidentified
perinatal database. The usual care groups were differentiated
only by the attending provider type and group during labor
and birth, that is, the usual CNM care group (n = 83) or the
general obstetrician group (n = 75). Figure 1 depicts the sample selection process for the usual care groups.

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

Volume 61, No. 2, March/April 2016

Births in the University of Colorado Perinatal

Database for 2012 (N = 3,156)
Primiparous or multiparous births (n = 1,882)
Nulliparous births (n = 1,274)
Preterm or postterm births (n = 201)
Term births (n = 1,073)
Non-cephalic presentation / unknown (n = 337)
Cephalic presentation (n = 736)
Multiple gestation (n = 1)
Singleton gestation (n = 735)
Induction of labor, cesarean before trial of
labor, or unknown (n = 263)
Spontaneous contraction onset and trial of
labor (n = 472)
Maternal age < 18 years (n = 40)
Maternal age 18 years (n = 432)

Higher-risk exclusions (n = 126)

Diabetes (any type) (n = 10)
Hypertensive condition (n = 33)
History of other organ disease (n = 18)
Fetal/chromosomal anomaly (n = 28)
BMI status indeterminate (n = 37)

Lower-risk status (n = 306)

Final Usual Care Sample (n = 158)

Certified Nurse-Midwifery care (n = 83)
Obstetrician care (n = 75)

Birth attended neither by a general obstetrician

from the University of Colorado nor a
certified nurse-midwife from the University
Nurse-Midwives group; or attendant could not
be determined (n = 148)

Figure 1. Diagram of Patient Selection

at 8:52 am is rounded to 8:45 am when using the paper-andpencil partograph.

Partograph use categorizes labor progress into one of 3
categories. For cervical dilation remaining left of or on the
dystocia line without delay, no interventions are indicated
(Figure 2). For dilation moving right of the dystocia line, thorough assessment is indicated, with consideration of care options including supportive therapy only, oxytocin augmentation, or birth based on maternal-clinician decision making.
Additionally, at 5 cm or more, oxytocin augmentation may
be considered any time there is more than a 4-hour delay
in cervical change (ie, no change to the next integer dilatation) even if the dystocia line has not been crossed, based
on maternal-clinician decision making. The particular oxytocin regimen used and/or the decision to perform a cesarean
for dystocia is not directed by the partograph. Other labor
management decisions are per provider usual care patterns in
consultation with the laboring woman, for example, pain
management, timing of amniotomy, or cervical examination
frequency. Observations of fetal condition, uterine activity,
Journal of Midwifery & Womens Health r www.jmwh.org

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

Thirty-one of 34 (91.2%) partographs used to assess womens

progress during labor were used correctly and included in
analyses. Of the 3 excluded partographs, 2 were excluded because initial cervical examination dilatation points were not
correctly plotted on the partograph (ie, not plotted on the
237

Figure 2. Partograph with example data

Partograph data are from Participant 10 and represent an example of labor progress that remained left of the dystocia line without delay. Use of the
partograph for assessment of labor progress ended once complete cervical dilatation was reached and second-stage labor was managed in the usual
care pattern of the certified nurse-midwife. This woman achieved a spontaneous vaginal birth.

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

women whose cervical dilation remained left of the dystocia

line without delay achieved vaginal birth except one (Participant 14); the sole cesarean birth was performed in the second
stage of labor for arrested fetal descent.
Six of 31 (19.3%) women with partograph-assessed labors
moved right of the dystocia line. Three women in this group
(50.0%) received oxytocin during active labor, and 5 (83.3%)
reached complete dilatation. One woman who moved right of
the dystocia line had a cesarean birth during active labor for
nonreassuring fetal heart pattern (Participant 26). Three of 31
(9.7%) women whose labors were assessed via partograph had
dilation that remained left of or on the dystocia line but with a
4+ hour delay at the same dilatation point (Participants 15, 16,
and 25). Each of these women received oxytocin augmentation during active labor and reached complete cervical dilatation. Two achieved vaginal birth while the other underwent a
cesarean birth in second-stage labor for arrested fetal descent
(Participant 15).
DISCUSSION

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

Obstetrician Usual Labor

a

Assessment Groupa

Partograph Assessment Group

Usual Labor Assessment Group

Characteristic

(n = )

(n = )

(n = )

Maternal age, y

25.0 (20.0, 30.8)

23.0 (19.0, 30.0)

27.0 (21.0, 35.4)

Gestational age at birth, wk

40.0 (38.0, 41.0)

40.0 (38.3, 41.1)

39.6 (37.9, 40.7)

22.9 (18.6, 33.7)

23.2 (19.0, 32.5)

22.5 (18.9, 30.4)

BMI prepregnancy, kg/m

Underweight (BMI 18.5)

Normal weight (BMI 18.5-24.9)
Overweight (BMI 25-29.9)
Obese (BMI 30)

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)

Artificial rupture of membranes

18 (58.1)

33 (39.8)

37 (49.3)

Oxytocin augmentation used

24 (32.0)

10 (32.3)

32 (38.6)

Narcotic analgesia used

2 (6.5)

9 (10.8)

4 (5.3)

Epidural analgesia used

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

Indication for cesarean

Dystociafirst stage

0 (0)

6 (54.5)

6 (50.0)

Arrest of fetal descentsecond stage

2 (66.7)

3 (27.3)

5 (41.7)

Nonreassuring fetal status

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)

Newborn admission to NICU

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).

(Participant 13). No other deviations from the partograph

protocol occurred in this pilot study.
While the partograph was correctly used in more than
90% of participants, incorrect plotting and/or interpretation
of the paper-and-pencil version of the partograph may be
further minimized by providing clinicians opportunities for
ongoing partograph training or 24/7 access to a super user.
Alternatively, development of partograph software that allows
for autopopulation of cervical dilatation and fetal station
plot points on the partograph following traditional electronic
charting of these data would ensure correct plotting. Likewise, software interpretation prompts would ensure correct
clinician interpretation of the partograph but leave care
option decision making to the woman and provider should
labor progress move right of the dystocia line or remain left
of or on the dystocia line but with a 4+-hour delay.
Pilot studies are limited to evaluations of feasibility and
are not suited for hypothesis testing or even sample size de-

Journal of Midwifery & Womens Health r www.jmwh.org

terminations for subsequent studies.20 No conclusions can be

drawn from our pilot study on the influence of partograph use
for limiting oxytocin use or decreasing cesareans performed
for dystocia during active labor. However, it is noteworthy
that no cesareans were performed for dystocia during active
labor in the partograph-assessed labor group, whereas this
indication accounted for half of the cesareans performed in
the usual care groups. A diagnosis of dystocia accounts for
almost half of cesareans in nulliparous women,68 yet criteria
to diagnose dystocia vary widely among clinicians. At the very
least, the Neal and Lowe partograph gives clinicians a common, evidence-based approach to assessing labor progress
and diagnosing dystocia among nulliparous women with
spontaneous labor onset. There is a possibility that this
innovative partograph can also play a role in safely
and significantly decreasing primary cesarean births
performed for active labor dystocia in high-resource
settings.

239

Table 2. Partograph-Assessed Labors (n = 31)

Reached

Partograph
Participanta

Interpretation

1
2

Dilatation at
Partograph

Oxytocin Use

Complete

During

Dilatation

Active Laborb

Start (cm)

Yes

Left of dystocia line without delay

Left of dystocia line without delay

Left of dystocia line without delay

Left of dystocia line without delay

5
6

No

Yes

Mode of Birth

No

Vaginal

Left of dystocia line without delay

Left of dystocia line without delay

Left of dystocia line without delay

Left of dystocia line without delay

Left of dystocia line without delay

10

Left of dystocia line without delay

11

Left of dystocia line without delay

Xc

12

Left of dystocia line without delay

Xc

13

Left of dystocia line without delay

Xd

14

Left of dystocia line without delay

15

Left of dystocia line with 4-hour delay

Xe

Xe

16

Left of dystocia line with 4-hour delay

17

Right of dystocia line

18

Right of dystocia line

19

Left of dystocia line without delay

20

Left of dystocia line without delay

21

Left of dystocia line without delay

22

Left of dystocia line without delay

23

Left of dystocia line without delay

24

Left of dystocia line without delay

25

Left of dystocia line with 4-hour delay

26

Right of dystocia line

27

Right of dystocia line

28

Right of dystocia line

29

Right of dystocia line

30

Left of dystocia line without delay

31

Left of dystocia line without delay

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.

Implementation of the Neal and Lowe partograph for the

in-hospital labor assessment of NTSV women with spontaneous labor onset is feasible. Larger-scale, hypothesis-testing
studies of partograph implementation are now warranted.
AUTHORS

Jeremy L. Neal, CNM, PhD, is an Assistant Professor at

the Vanderbilt University School of Nursing, Nashville,
Tennessee.
240

Nancy K. Lowe, CNM, PhD, FACNM, FAAN, is a Professor

at the University of Colorado College of Nursing, Aurora,
Colorado.
Amy S. Nacht, CNM, MSN, MPH, is Director of University
Nurse-Midwives and a Senior Instructor at the University of
Colorado College of Nursing, Aurora, Colorado.
Kate Koschoreck, CNM, MSN, is a Senior Instructor at the
University of Colorado College of Nursing, Aurora, Colorado.
Volume 61, No. 2, March/April 2016

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.
CONFLICT OF INTEREST

The authors have no conflicts of interest to disclose.

ACKNOWLEDGMENTS

Funding for this study was received from the Research

Seed Grant Program, The Ohio State University College of
Nursing, Columbus, Ohio. The authors kindly acknowledge
the research support received from the nurse-midwives of
the University of Colorado College of Nursing, Anschutz
Medical Campus, Aurora, Colorado.
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