[Use of the partogram in Serbia and its characteristics]

Graphic presentation of parameters during labor is done in Serbia since seventies [1]. Today partogram use is obligatory [2]. Choice of parameters and way of their presentation depend on institution in which they are being used [1]. However, the rules of graphic presentation should be obeyed when constructing cervigrams (graphs representing dilatation vs time). Furthermore, Cartmill and associates [3] found that the slope of the line which represents dilatation directly influences decisions of obstetricians towards interventions during labor. Steeper line reduces the number of decisions for intervention. Importance of these findings is even greater when one has in mind the known inconsistencies in obstetric decision-making [4].

From larger maternity hospitals (more than 1,000 labors per year) [5] information concerning use of partograms and partograms themselves were requested. Cervigrams were analyzed in order to evaluate labeling of axes, unambiguity in labeling divisions on scales and the slope of the dilatation line for dilatation of 1 cm/h. Evaluation of parameters which influence the precision of entering data into graphs such as the smallest units on scales and dimensions of 1 cm x 1 h fields in mm, was done.

The number of labors in central Serbia and Vojvodina is approximately 85,000 per year [6]. Of 26 maternity hospitals with more than 1,000 labors per year 13 use partograms during labor. Partogram forms were received from 11 maternity hospitals. At least 48% of all births in central Serbia and Vojvodina take place in maternity hospitals which use partograms. Larger maternity hospitals tend to use partograms in greater proportion than smaller ones, as shown in Table 1. How cervigrams comply with general rules of graphic presentation is shown in Table 2. Labeling of axes is done on 4 of 22 axes and unambiguous labeling of divisions on scales on 9 of 22 scales. Slope of the line of dilatation for dilatation rate of 1 cm/h in one cervigram is approximately 45 degrees (optimal slope). In the remaining 10 cervigrams the slope is significantly smaller being in the range from 25 to 30 degrees. Possibility of precise entering of data can be seen in Table 3. Dimensions of 1 cm x 1 h fields in all cervigrams except one are not integers. Smallest units on time scales are between 0.25 and 2 h.

Unlabeled coordinate axes, which are almost the rule for cervigrams in Serbia can be seen on other cervigrams [7]. However, it may not be of importance since cervigrams are mostly used by those who draw them. Accuracy and precision of entering data into cervigrams depends on: unambiguous labeling of scale divisions, dimensions of 1 cm x 1 h fields and smallest units on scales. Smallest units on time scales of cervigrams presented by other authors [8-10] are at most 1 h, while cervigrams in Serbia in 7 of 11 have smallest units of 2 h. Unambiguous labeling of scale divisions on cervigrams of the same authors is not noticed. Cervigrams in Serbian maternity hospitals exhibit unambiguous labeling in 13 of 22 observed scales. Since space for cervigram is often determined by the number of other parameters and space they occupy [8], dimensions of 1 cm x 1 h fields in mm are frequently not integers. This is the reason why values smaller than the smallest units on scales can be entered with great difficulty, if at all. Ten of eleven cervigrams from maternity hospitals in Serbia show such characteristics.

Cervigrams which are being used in maternity hospitals in Serbia show significantly lesser slope for 1 cm/h dilatation than 45 degrees and dimensions of 1 cm x 1 h fields in mm which are not being integers in all except in one cervigram for each characteristic. Unambiguous labeling of divisions is present in less than half (9 of 22) of scales and smallest units on time scales in most (7 of 11) of them are 2 h. Construction of cervigrams in such a manner does not provide accurate and precise graphic presentation of dilatation during labor and can be the source of error in obstetric decision-making. Lesser than optimal slope for 1 cm/h dilatation may influence obstetricians decisions towards more interventions during labor when such interventions are not necessary.