Open Journal of Obstetrics and Gynecology, 2013, 3, 1-8 OJOG
http://dx.doi.org/10.4236/ojog.2013.39A001 Published Online November 2013 (http://www.scirp.org/journal/ojog/)
Use of the partogram in labor: Analysis of its application in
different care models
Cláudia de Azevedo Aguiar1*, Roselane Gonçalves2, Ana Cristina d’Andretta Tanaka3
1Faculdade de Saúde Pública, Universidade de São Paulo, São Paulo, Brazil
2Escola de Artes, Ciências e Humanidades, Universidade de São Paulo, São Paulo, Brazil
3Department of Maternal and Child Health, Faculdade de Saúde Pública, Universidade de São Paulo, São Paulo, Brazil
Received 17 September 2013; revised 14 October 2013; accepted 20 October 2013
Copyright © 2013 Cláudia de Azevedo Aguiar et al. This is an open access article distributed under the Creative Commons Attribu-
tion License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
ABSTRACT
Objective: To compare and identify possible differ-
ences in the use of the partogram in different models
of delivery and birth care. Design/Setting: This was a
cross-sectional study performed in two Brazilian hos-
pitals with different models of care: Natural Birth
Center (NBC) and Traditional Obstetric Center (TOC).
Data were collected from the medical records of 112
mothers with low obstetric risk who underwent an
intrapartum cesarean section. Socioeconomic and de-
mographic variables, obstetric history, partogram
labor evolution, complications, and indication of ce-
sarean section were included. A significance level of
5% and a confidence interval of 95% were considered.
Data were analyzed in accordance with the Brazilian
Ministry of Health and World Health Organization
recommendations. Findings: In the NBC, the use of
the partogram follows the Ministry of Health recom-
mendations for filling-in variables with greater fre-
quency and significance (p < 0.001) beginning with
the active phase of labor in the correct column in re-
lation to the lines of alert and action (p = 0.00, OR =
42.2) and continuous records (p = 0.00, OR = 53.3).
However, obstetric interventions, such as use of oxy-
tocin, amniotomy and cesarean delivery were con-
centrated in area 1 of the partogram in both institu-
tions. Conclusions: In this study, the NBC used the
instrument most adequately; however there was no
difference from the other model (TOC) and regarding
the moment of interventions, many of them were
early. This finding implies that, regardless of the care
model, the partogram has been used bureaucratically
and not as a guiding instrument of assistance envi-
sioning safely and timely practices. In other words,
aside from a “humanized” physical structure, it is
necessary that obstetric practices should be focused
on best evidence, thus reducing maternal and perina-
tal risks.
Keywords: Partogram; Childbirth Care; Birth Center;
Obstetrical Surgical Center
1. INTRODUCTION
The partogram is a tool to register maternal and fetal
conditions; it also enables a quick visualization of labor
progress.
In 1965, Philpott developed this instrument, based on
Friedman improvements in cervicography [1]. In 1972,
Philpott and Castle tested the partogram in a study per-
formed in Rhodesia (Africa). For this study, they draw
lines of “action” and “alert” in the partogram to detect
potential risk labors of women who needed to be trans-
ferred from the countryside to a specialized medical cen-
ter [2,3].
During the 1970’s, research reaffirmed the effective-
ness of the partogram for reducing long labors, caesarian
sections and perinatal death during deliveries [1].
In the early 1990’s, the World Health Organization
(WHO) conducted a multicentric study about this instru-
ment with more than 35 thousand women, including both
nullipara and multipara, which showed a reduction of 3%
in prolonged deliveries, 11% in interventions to increase
delivery rhythm, 1.6% in caesarian sections, and 0.2% in
stillborn children. As a consequence of these results,
considering the use of the partogram as a safe and effec-
tive practice, the Organization began to recommend its
use as an essential instrument to promote and control
maternal and perinatal health [1,4].
The Partogram as recommended by WHO and adopted
*Corresponding author.

C. de Azevedo Aguiar et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 1-8 2
by the Brazilian Ministry of Health (BMH), contem-
plates three main labor components: fetal conditions, ma-
ternal conditions and the progress of labor. Fetal condi-
tions consider cardiac frequency of the fetus and amni-
otic liquid aspect. Maternal conditions refer to vital signs,
urine, bleeding, maternal position, and several intercur-
rence events. The progress of labor relates to the dilation
of cervix, fetal presentation, and conditions of uterine
contractions (frequency, intensity and duration) [1,5].
The partogram, since its idealization and prescription,
has been a target of discussion. An argument, sometimes
used against the partogram, is that it restricts clinical
practice, since the registration of its measures presup-
poses the evolution of labor, based on an ideal precon-
ceived time for the active phase of delivery care (1 cm
per hour).
Systematic reviews demonstrated that routine use of
the partogram, for obstetric care, has no effect on reduc-
ing intrapartum interventions (use of oxytocin, amniot-
omy, for example) [6,7]. Nevertheless, Brazilian studies
[8,9] point to positive effects of this instrument in ma-
ternal and perinatal results, ratifying WHO recommenda-
tions of the partogram use for almost two decades [4,10].
In accordance with the WHO [4] and the Brazilian
Ministry of Health [5], the proposed partogram model is
valid and recommended for any models of care during
childbirth.
In Brazil, the two main scenarios of delivery and birth
care are the traditional Obstetric Centers and the Natural
Birth Centers. An obstetrician, a midwife or an obstetric
nurse provide the obstetric assistance in these two mod-
els. In the case of the City of São Paulo, where the at-
tendance is provided by the Brazilian National Health-
care System (SUS), nurses or midwives give obstetric
assistance in labors considered of low or average risk.
Obstetric Centers are connected to surgery centers of
hospitals. Natural birth, instrumental vaginal deliveries,
caesarian sections, and curettages are performed there.
These centers are separated from antepartum and post-
partum rooms, which, in turn, are normally collective. As
for being traditional, the Obstetric Centers dispose of an
obstetric table for surgery and, in this context; interven-
tions and practices tend to be more invasive. On the other
hand, Natural Birth Centers were regulated in 1999, aim-
ing to provide humanized assistance with quality to natu-
ral births without dystocia. These centers dispose of a
unique layout with unified antepartum, labor and post-
partum rooms. Those using the NBC find practice based
on better evidences, promotion of privacy and freedom
for women and their companions.
Despite the Brazilian Health Ministry recommendation
for a humanized and safe assistance during labor and
birth, obstetric interventions are really high in the coun-
try and the caesarian section index during the last year
were higher than the natural delivery births (52.3% of
total caesarian sections, of which 90% were in private
hospitals and 35% in SUS).
Accordingly, the hereby study intended to compare the
use of the partogram before caesarian section in two dif-
ferent scenarios of care during labor and childbirth: tra-
ditional Obstetric Center and Natural Birth Center. There-
fore, the intention was to verify if the Natural Birth Cen-
ters, created in Brazil to oppose the traditional model of
the Obstetric Centers in order to humanize the assistance
through practices based on evidences, such as the use of
partogram, is safe for mother and child. The “Intrapartum
caesarian delivery” event is considered as a great indica-
tive of quality in care during childbirth, and the parto-
gram is a proper tool to register clinical care practices
and maternal-fetal findings.
2. METHODS
This was a cross-sectional study performed in two hos-
pitals located in the City of São Paulo, Brazil. Every
mother of low obstetric risk was included, they under-
went intrapartum caesarian sections in the year of 2010
and their deliveries were registered in the Partogram.
Women with gestational age ≥37 weeks, with only one
and an alive fetus in cephalic presentation, with normal
clinical and obstetric examination and who were admit-
ted in the hospital diagnosed as in labor were considered
low risk. All data were registered in these women’s hos-
pital records.
In one of the hospitals, low-risk pregnant women were
assisted in intra-hospital Natural Birth Center, whereas in
the other hospital, the assistance is performed in the tra-
ditional Obstetric Center. The herein referred hospitals
are denominated NBC (Hospital with Natural Birth Cen-
ter) and TOC (Hospital with Traditional Obstetric Center)
and their characteristics are described in Chart 1.
It is important to state that NBC is a maternal-hospital
of reference for high-risk pregnancy throughout the City
of São Paulo; accordingly, this is the reason why many
women are not admitted to NBC when presenting high-
risk conditions.
There were a total of 23 puerperal women in NBC and
89 in TOC.
Secondary data were collected in records of puerperal
women, including socioeconomic information, obstetric
information, hospitalization data, and labor progress reg-
istered in the partogram, as well as information about
caesarian indication.
Both institutions studied have adopted the partogram
recommended by the Brazilian Ministry of Health [5]
(Figure 1) for delivery care (model with lines of alert
and action already determined with intervals of 4 hours
beween the lines). t

C. de Azevedo Aguiar et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 1-8 3
Chart 1. Characterization of places of study.
NBC TOC
Characteristics of hospital Maternity Hospital where low-risk women
are assisted, regardless their delivery stage,
in intra-hospital Natural Birth Center.
General Hospital where low and high-risk
women are assisted, regardless their delivery
stage, at the Traditional Obstetric Center.
No. of natural birth in 2010 4462 1493
No. of caesarian section deliveries in
2010 (intrapartum and elective) 2165 702
No. of women who underwent
intrapartum caesarian deliveries and
had it registered in partogram 23 89
Professionals responsibl e for care
to low-risk parturient women Obstetric nurses, with doctors to
support in case of emergency. Obstetric nurses and doctors, simultaneously.
Antepartum environment Antepartum, labor and Postpartum rooms. Collective room, no curtains or panels separating beds.
Partum environmen t Antepartum, labor and Postpartum rooms. Surgery room
Puerperal environment Rooming Rooming
According to Brazilian Ministry of Health regulations
for a correct use of the partogram, it must be fulfilled as
follows:
1) The registration on the chart is started when the
parturient is really in the active phase of the labor (two to
three efficient contractions every 10 minutes and mini-
mal cervix dilation of 3 - 4 cm);
2) Line of alert must be traced in the following hour to
the first registration of cervix dilation. Line of action
must be traced in parallel after 4 hours.
3) Subsequent vaginal examinations should be taken
every two hours, however each column of the chart must
correspond to 1 hour.
For data analysis, the following variables were studied:
the partogram starting moment in relation to the phase of
labor, start of fulfilling the partogram in relation to line
of alert (correct column), continuous registration (1 hour
per column), registration of maternal and fetal findings
and registration of interventions.
Data were processed in Stata®, version 11.0, taking
into consideration the significance level of 5% (p < 0.05)
and Confidence interval (CI) of 95%. For statistical
analysis, test χ2 Mantel-Haenszel was used; and the
Fischer exact test was adopted for intervals lower than
five. Odds Ratio (OR) was calculated to estimate risk.
The results were described in the attached tables.
This study respected ethical aspects of the Brazilian
regulation regarding research involving human beings
(Regulation nr. 196/96), and the Research Ethical Com-
mittees approved the institutions involved (Protocols
2218; 0010.0.207.162-11; e 004/11).
3. RESULTS
Twenty-three (23) women of NBC and eighty-nine (89)
of TOC had, respectively, the following characteristics:
between 14 and 40 years of age; 61.4% and 63.6% were
housewives; 50% and 37.9% had white complexion. In
regard to education, despite the amount of reports with-
out this information, 38.5% of the women at NBC de-
clared to have concluded High School, against 28% at
TOC.
In respect to obstetric history, parturient women were
between 37 and 42 weeks of pregnancy, in that most of
them were primigravidae (69.2% at NBC and 55% at
TCO).
In reference to filling-in variables of the partogram,
the device started, in 100% of the NBC cases, when
women were in the active phase of labor, whereas in
TOC, 76.4% of the in-labor women were not in the ac-
tive phase of labor (Table 1).
Additionally for the beginning of the partogram regis-
tration, 89.9% of NBC cases against 17.4% of TCO cases
occurred in an incorrect column in relation to line of alert.
This data was statistically significant (p = 0.000/OR =
42.2/IC = 10.3 - 191.5) when both institutions were
compared (Table 1).
A discontinuation in registration was observed in
71.8% of the cases at TOC and, therefore, this result was
statistically significant (p = 0.000/OR = 53.3/IC = 7 -
1117) (Table 1).
In relation to clinical findings and interventions, the
fetal heart beat (FHB), uterine contraction patterns, wa-
ter-bag integrity, and amniotic liquid aspects were regis-
tered in 100% of the NBC cases. Such registrations were
present for most of the population studied in the TOC.
However, despite its statistical significance (p = 0.004/
OR = 9.2/IC = 1.3 - 78.7), both institutions had few reg-
istrations about variation in positioning (17.4% at NBC
and 2.2% at TOC) (Table 1).
Registration of non-pharmacological methods for pain
elief was statistically significant when both institutions r

C. de Azevedo Aguiar et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 1-8 4
Date:
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PARTOGRAM
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I
II
III
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Area IArea IIArea III
Figure 1. Model of partogram recommended by the Brazilian Ministry of Health [5].
are compared (p = 0.000/OR = 93.2/IC = 11.8 - 1987),
which demonstrated that a better result was achieved at
NBC (Table 1).
Another relevant data with statistical significance (p =
0.000/OR = 300/IC = 20.1 - 11451) was the use and con-
trol of oxytocin infusion. Fifty-two (52) women at TOC
underwent the use of this drug, and only 02 (3.8%) of
them had this fact registered in the partogram (Table 1).
With reference to the moment of obstetric interven-
tions, they occurred, primarily, in area I of the partogram
(before line of alert), either at TOC or NBC (Tables 2
and 3).

C. de Azevedo Aguiar et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 1-8 5
Table 1. Frequency, value of p, Odds Ratio (OR) and confidence interval (CI) in regard to filling-in the partogram variables by health
institutions. São Paulo, Brazil (2010).
NBC TOC
Yes No Yes No
Filling-in partogram variables
(Brazilian Ministry of Health model)
N (%) N (%) N (%) N (%)
Value of p OR CI
Beginning of the partogram in active phase 23 (100%)- 21 (23.6%)68 (76.4%)* * *
Opening in correct column in relation to line of alert 19 (82.6%)4 (17.4%) 9 (10.1%) 80 (89.9%)0.000 42.2 10.3 - 191.5
Continued registration (1 hour per column) 22 (95.6%)1 (4.4%) 26 (29.2%)63 (71.8%)0.000 53.3 7 - 1117
Registrations of findings and interventions:
Cervix dilationA (cm) 22 (95.6%)1 (4.4%) 63 (71.8%)26 (29.2%)0.013 9.1 1.2 - 190.0
Descent of presentationA 22 (95.6%)1 (4.4%) 63 (71.8%)26 (29.2%)0.013 9.1 1.2 - 190.0
Variation of positioning 4 (17.4%) 19 (82.6%)2 (2.2%) 87 (97.8%)0.004 9.2 1.3 - 78.7
FHBB 23 (100%)- 87 (97.8%)2 (2.2%) * * *
Uterine contraction patternsC 23 (100%)- 73 (82.0%)16 (18.0%)* * *
Integrity of water-bags 23 (100%)- 88 (98.9%)1 (1.1%) * * *
Aspect of amniotic liquid 23 (100%)- 84 (94.4%)5 (5.6%) * * *
Oxytocin (drip method/quantity)D 12 (92.3%)1 (7.7%) 2 (3.8%) 50 (96.2%)0.000 300 20.1 - 11451
Non-pharmacological methods 22 (95.6%)1 (4.4%) 17 (19.1%)72 (80.9%)0.000 93.2 11.8 - 1987
AEvery 2 hours, at least; BEvery hour, at least; CQuantity and duration, at least, before and during oxytocin infusion and during registration of cervix dilation and
descent of fetal presentation; DReferred to women who received oxytocin (NBC N = 13/TOC N = 73); *Value of p, CI and OR not defined for not having been
observed during one of the events.
Table 2. Initial use of obstetric interventions, in relation to Partogram Area in Tradicional Obstetric Center (HOC). São Paulo, Brazil
(2010).
Partogram areas
I II III
Total of women who
underwent the procedure
TOC interventions
N % N % N % N %*
Use of oxytocin 52 100.0 00 0.0 0 0.0 52 58.4
Use of amniotomy 38 95.0 02 5.0 0 0.0 40 44.9
Use of non-pharmacological methods 21 95.5 01 4.5 0 0.0 22 24.7
Caesarian delivery indication 79 88.8 10 11.2 0 0.0 89 100.0
*Percentage in relation to the total number of women (n = 89).
Table 3. Initial use of obstetric interventions, in relation to Partogram Area in Natural Birth Center (NBC). São Paulo, Brazil (2010).
Partogram areas
I II III
Total of women who underwent
the procedure
NBC interventions
N % N % N % N %*
Use of oxytocin 13 100.0 0 0.0 0 0.0 13 56.5
Use of amniotomy 13 92.9 1 7.1 0 0.0 14 60.9
Use of non-pharmacological methods 17 100.0 0 0.0 0 0.0 17 73.9
Caesarian delivery indication 14 60.9 6 26.1 3 13.0 23 100.0
*Percentage in relation to the total of women of the sample (n = 23).

C. de Azevedo Aguiar et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 1-8 6
4. DISCUSSION
In this study, the restricted amount of numbers was a
limitation, primarily in regard to NBC data. This restric-
tion may be responsible for the large dispersion of Odds
Ratio in some results. However, it is important to em-
phasize that the data refer only to a one-year period and
that, even so, does not invalidate this study.
In accordance with the WHO [11] and the Brazilian
Ministry of Health recommendations [5], partogram reg-
istration must start at the beginning of the active phase of
labor, that is to say, after more than 3 - 4 cm of cervix
dilation, with 2 or 3 efficient uterine contractions every
10 minutes. When this occurs, in latent phase (period
when, physiologically, cervix dilation and descent of
fetal presentation slowly develop), lines of alert and ac-
tion are easily surpassed and further interventions can be
applied.
Unlike NBC that started partogram registration when
every in-labor woman was in active phase of labor, TOC
drew attention for having started 76.4% of the parto-
grams during the latent phase of labor, although these
women had been admitted and diagnosed as in the active
phase of labor. This data is significant because an early
start of partogram registrations predicts equally early
interventions or, even, an elective caesarian delivery, due
to a higher probability of an incorrect recognition of dys-
tocia.
Obstetric interventions during latent phase of labor
have undesirable effects. New interventions are fre-
quently performed to ease or abolish such effects and,
hence, a “splurge of interventions” is established, namely,
a chain of events that include, among others, artificial
rupture of membranes (amniotomy) and the use of hor-
mones to accelerate delivery [12].
In case of low-risk pregnancies, the latent phase of la-
bor must be conducted with expectation, guaranteeing
vitality for mother and fetus. For monitoring labor, the
phase or functional division of interest to apply the par-
togram is dilation, also referred to as the active phase
during which the expected progression for cervix dilation
is 1 cm/hour approximately. Accordingly, partogram reg-
istration in the latent phase or at the beginning of dilation
(before 3 - 4 cm) could lead to unnecessary and iatro-
genic interventions [5].
Other possibilities of incorrect use of the partogram
are: registration of data in a wrong column in relation to
lines of alert and action and of evolution in intervals
longer than 1 hour per column1. In analysis of records,
there was statistical significance when both institutions
were compared (p = 0.000, OR = 42.2 and p = 0.000, OR
= 53.3, respectively), showing that the use of the parto-
gram at NBC follows, more frequently, the filling-in of
data as recommended by the Brazilian Ministry of
Health.
Philpott and Castle [2] established that a line of alert
in the partogram should be in the same line of the first
register of cervix dilation, however in the following hour.
After four hours, the line of action must be taken. Con-
sequently, when the partogram has entries in the wrong
column in relation to the lines, it can result in an incor-
rect identification and correction of a dystocia. On the
other hand, as observed in Ta b l es 2 and 3, the fact that,
most interventions were performed in Area I of the par-
togram, reveals that, in both institutions, there was little
influence of lines of alert and action regarding the inter-
vention clinical decision.
In-labor women must undergo subsequent vaginal ex-
aminations every two hours in accordance with the Bra-
zilian Ministry of Health [5], except in situations of inter-
currences, considering the time expressed in chart for
each registration. Cervix dilation, height of fetal presen-
tation, positioning variety, and water-bag conditions are
necessary to be evaluated and registered in the partogram
for each one of the gynecologic examinations. The best
result attributed to the NBC, in relation to registrations of
labor progress (cervix dilation, descent of presentation,
uterine contractions pattern, water-bag integrity) and
fetal conditions (FHB and aspect of amniotic liquid) in-
dicate that the model adopted in this Natural Birth Center
respects the basic care recommendations regarding the
use of the partogram.
Recent systematic review [13] compared NBC (named
as “alternatives”) with “conventional institutional set-
tings for birth”. They concluded that the alternative
model does not present risk to mother or baby, is associ-
ated with reduced risk of medical interventions, has a
higher probability of spontaneous vaginal delivery, has
an increase in maternal satisfaction, and leads to a higher
probability of breast-feeding after labor.
The registrations of usage of oxytocin are considered
data of extreme relevance because of the imminence of
risks in the indiscriminate use of this drug. This synthetic
hormone was included in the list of the 11 high-alert
medications of the Institute for Safe Medication Prac-
tices (ISMP)—a nonprofit organization that evaluates
safety of medication available worldwide. This institute
indicates that oxytocin result in further risks of damages
when misused [14].
In accordance with the Brazilian Ministry of Health
[5], the use of oxytocin must be registered in a parto-
gram—instrument that favors the rational use of oxyto-
cics, to wit, in the active phase or long pelvic periods. As
a result, 5UI of hormone in 500 ml of physiological se-
1In situations when cervix assessment is not performed in the subse-
quent hour, the partogram column remains blank. This means that
vaginal examination can be performed in intervals longer than 1 hour
however; the space for this hour in partogram must be preserved (each
column of the instrument corresponds to 1 hour).

C. de Azevedo Aguiar et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 1-8 7
rum or glucose serum at 5% is recommended at initial
infusion of 4 drops/minute (2 µU/minute), two-folding
the dripping method every 30 minutes until the desired
uterine contraction is obtained. It was observed in this
study that, 58.4% of TOC women and 56.5% of NBC
women underwent oxytocin use. However, TOC pre-
sented less concern in registering the infusion velocity, as
well as the dosage of oxytocin infused. This event proves
to be worrisome as the lack of registration does not en-
dorse professionals of possible maternal-fetal intercur-
rences resultant of oxytocin infusion, and it likewise
hinders the communication between teams in hospital
shift changes, increasing maternal and fetal risks.
In another way, when Tables 2 and 3 are observed,
both institutions presented initial infusion of oxytocin in
Area I of the partogram. This means that in all cases the
labor progress occurred apparently in accordance with
normal expected patterns, which do not justify the possi-
bility of trying to correct uterine contractions with oxy-
tocin2. Justifications for isolated professional conduct are
to accelerate delivery and shorten mother suffering, al-
though the use of oxytocin, for this end, increases the
pain of contractions (women frequently complain about
this effect) and it can contribute to a “splurge of inter-
ventions” [12,14]. Additionally, other studies [15] have
shown that the use of oxytocin is associated with the way
of birth. According to these authors, there is twice the
risk of caesarian delivery when in-labor women undergo
oxytocin use.
Non-pharmacological methods to relieve pain are on
the WHO evidence list of useful practices to be stimu-
lated during labor [5,10]. Several studies were performed
to ratify the efficiency of such methods. In systematic
review where 38 studies about the use of pain-relief
techniques were included, among them, the bath, move-
ment and massage concluded that they are safe, efficient
and satisfactory for many women [16].
The bath momentarily reduces uterine contraction
pains. In the first phase of labor, moving, remaining in
vertical positions and freely changing positions can
speed-up the active labor, as well as, women with low
obstetric risk can have some comfort in the squatting
position during the expulsion period [16,17]. Mamede
[18] studied the deambulation effect on labor, verifying
that the longer the walks at the beginning of active labor
are, the shorter the labor period is.
TCO used non-pharmacological methods in only
19.1% of in-labor/pregnant women, and this data had no
statistical significance, demonstrating that the NBC care
model has a higher potential to stimulate non-invasive
methods to relieve pain and, consequently, promote de-
livery. The layout of a Natural Birth Center, with ante-
partum, labor and post-partum rooms, for example, en-
courages women to walk about the room or remain in the
bath. Contrarily, professionals (obstetricians, obstetric
nurses and doctors) are believed to be able to stimulate
non-pharmacological methods to women even in small
unfavorable spaces.
When also considering the use of the partogram with
its tracked lines in hospitals, “there is no need of inter-
ventions when dilation is achieved or crosses the line of
alert. Alert simply implies the necessity of a better clini-
cal observation” ([5]: p. 48). Only in cases when the cer-
vix dilation curve achieves the line of action, a medical
intervention, not necessarily surgical, must be taken to
improve the labor progression and/or correct possible
dystocias that have been already started.
In the study of Rocha [9] performed in a natural birth
center, obstetric interventions timely occurred, like in the
case of amniotomy, for example, when a higher fre-
quency occurred in the Areas II and III of the partogram.
In this research, on the contrary, as described in Tables 2
and 3, there was a predominance of invasive interven-
tions (oxytocin, amniotomy and caesarian section) in
Area I of the partogram. For a population of low obstet-
ric risk, hospitalized with an in-labor diagnosis, a higher
number of registrations for intrapartum caesarian deliv-
eries were expected in Area III of the partogram. This
finding leads to questioning about obstetric practices in
both institutions, regardless of the possible intercurrences
occurred at the beginning of the labor registration.
5. CONCLUSIONS
As a conclusion of this study, the hospital with Natural
Birth Center presented better results in regard to filling-
in data the partogram, but did not present different results
in comparison to the hospital with Traditional Obstetric
Centers in relation to the moment of the interventions.
Accordingly, regardless of the care model, the partogram
is being used bureaucratically and not as a care guiding
instrument aimed toward safe and opportune practices.
In populations considered low obstetric risk, these in-
vasive interventions are expected to be more present in
Areas II and III of the partogram (after line of alert).
When they are present mainly in Area I of this instru-
ment, even before using non-pharmacological methods,
it is inferred that a rapid outcome of labor was sought
and, as a consequence, often unnecessary or inappropri-
ate technologies/interventions were used earlier than nec-
essary.
2It is worth emphasizing that the population studied is compound o
f
women who were diagnosed in labor; therefore it does not apply for
women who received indication of oxytocin to induce labor (for exam-
p
le, pos
t
-term pregnancy with favorable conditions of the cervix). In
this situation, such intervention should to be registered in the parto-
gram from the beginning of the process respecting the track of lines o
f
alert and action only when the active phase of labor is achieved (6).
This study questions safety, efficiency and efficacy of
care practices, which are insufficiently guided in scien-

C. de Azevedo Aguiar et al. / Open Journal of Obstetrics and Gynecology 3 (2013) 1-8 8
[9] Rocha, I.M.S., Oliveira, S.M.J.V. and Schneck, C.A.
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http://www.scielo.br/pdf/reeusp/v43n4/a20v43n4.pdf
http://dx.doi.org/10.1590/S0080-62342009000400020
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essential role in guaranteeing maternal and perinatal
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