Effect of partogram use on outcomes for women in spontaneous labour at term
3 November 2014
Prolonged labour is an important cause of maternal and perinatal mortality and morbidity. Where poor uterine contractions are the presumed cause of delayed labour, labour can be augmented (such as using intravenous oxytocin infusion, amniotomy or other methods). While augmentation can be effective, their inappropriate use can cause harm and unnecessary interventions can negatively affect the childbirth experience and the mother’s autonomy.
The WHO recommendations on augmentation of labour (2014) contain recommendations on diagnosis, prevention and treatment of delay in the first stage of labour.
Active phase partograph with a four-hour action line is recommended for monitoring the progress of labour. (Strong recommendation, very low quality of evidence)
- The GDG acknowledged the low quality of the supporting evidence but noted that many units in both high- and low- income settings currently use the partograph and, although no clinical benefits in health outcomes were reported in the RCTs, it is a useful tool for providing a pictorial overview of progress, clinical audit, training of health workers and facilitating the transfer of care. These considerations, in addition to the low resource implication of the intervention led the GDG to make a strong recommendation in favour of the partograph.
- The potential benefits of introducing the use of a partograph may be more apparent in under-resourced clinical settings where a standard protocol for labour management is either not used or is inconsistently used. However, the benefits of using the partograph can only be maximized when accompanied by adherence to a standard labour management protocol.
- Considering the variability among women with regard to rates of progress during labour, the GDG placed its emphasis on reducing the likelihood of unnecessary interventions and therefore chose to recommend the four-hour action line partograph rather than those with earlier action lines.
Evidence for this WHO recommendation was extracted from the below Cochrane review
WHO recommendations for augmentation of labour
Evidence base and GRADE tables for the WHO recommendations on augmentation of labour
Citation: Lavender T, Hart A, Smyth RMD. Effect of partogram use on outcomes for women in spontaneous labour at term. Cochrane Database of Systematic Review 2013, Issue 7. Art. No.: CD005461. DOI: 10.1002/14651858.CD005461.pub4.
The partogram (sometimes known as partograph) is usually a pre-printed paper form on which labour observations are recorded. The aim of the partogram is to provide a pictorial overview of labour, to alert midwives and obstetricians to deviations in maternal or fetal wellbeing and labour progress. Charts often contain pre-printed alert and action lines. An alert line represents the slowest 10% of primigravid women's labour progress. An action line is placed a number of hours after the alert line (usually two or four hours) to prompt effective management of slow progress of labour.
To determine the effect of use of partogram on perinatal and maternal morbidity and mortality. To determine the effect of partogram design on perinatal and maternal morbidity and mortality.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013).
Randomised and quasi-randomised controlled trials involving a comparison of partogram with no partogram, or comparison between different partogram designs.
Data collection and analysis
Three review authors independently assessed eligibility, quality and extracted data. When one review author was also the trial author, the two remaining authors assessed the studies independently.
We have included six studies involving 7706 women in this review; two studies assessed partogram versus no partogram and the remainder assessed different partogram designs. There was no evidence of any difference between partogram and no partogram in caesarean section (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.24 to 1.70); instrumental vaginal delivery (RR 1.00, 95% CI 0.85 to 1.17) or Apgar score less than seven at five minutes (RR 0.77, 95% CI 0.29 to 2.06) between the groups. When compared to a four-hour action line, women in the two-hour action line group were more likely to require oxytocin augmentation (RR 1.14, 95% CI 1.05 to 1.22). When the three- and four-hour action line groups were compared, caesarean section rate was lowest in the four-hour action line group and this difference was statistically significant (RR 1.70, 95% CI 1.07 to 2.70, n = 613, one trial). When a partogram with a latent phase (composite) and one without (modified) were compared, the caesarean section rate was lower in the partograph without a latent phase (RR 2.45, 95% CI 1.72 to 3.50, n = 743, one trial).
On the basis of the findings of this review, we cannot recommend routine use of the partogram as part of standard labour management and care. Given the fact that the partogram is currently in widespread use and generally accepted, it appears reasonable, until stronger evidence is available, that partogram use should be locally determined. Further trial evidence is required to establish the efficacy of partogram use.