Effect of partogram use on outcomes for women in spontaneous labour at term
The partogram is widely used in under-resourced settings as a simple and affordable tool to monitor labour. However, the Cochrane review did not find sufficient evidence to show that use of the partogram improves clinical outcomes for the mother.
RHL Commentary by Soni BL
It is estimated that 97% of reported stillbirths and 98% of reported neonatal deaths occur in less developed countries (1). In sub-Saharan Africa, women face a 1-in-22 chance of dying during childbirth (highest in Niger: one in seven), whereas the corresponding risk in industrialized countries is one in 8000 (lowest in Ireland: one in 48000) (2). Continuous monitoring of labour and provision of rapid care to deal with problems are most crucial for preventing adverse obstetric outcomes related to childbirth.
In 1954, Friedman (3) introduced the concept of a partogram by graphically depicting the dilation of the cervix during labour. In 1972, Philpott and Castle developed Friedman's concept into a tool for monitoring labour by adding the so-called "action" and "alert" lines to the graph (4).The current partogram is designed to monitor not only the progress of labour, but also the condition of the mother and the fetus during labour. The partogram includes different variables (fetal heart rate, dilation of the cervix, contractions, and pulse rate of the mother) plotted on a pre-printed paper. The plotted data allow the attending health-care practitioner to identify early deviations in the plotted parameters from the normal and make decisions regarding direct intervention or referral.
The partogram has been heralded as one of the most important advances in modern obstetric care. WHO advocates its use as a necessary tool in the management of labour and recommends its universal use during labour (5). However, some health-care practitioners, especially in high-income countries, have questioned its effectiveness. For example, Walraven has suggested that use of the partogram can be an unnecessary interference in clinical work (6). Also, Lavender and Malcolmson have argued that the partogram may restrict clinical practice, reducing midwives' autonomy and limiting their flexibility to treat each women as an individual (7). The present Cochrane review (8) had two objectives: to determine the effect of use of the partogram on perinatal and maternal morbidity and mortality; and to determine the effect of partogram design on perinatal and maternal morbidity and mortality.
A total of 11 trials were identified from the Cochrane Pregnancy and Child Birth Group’s Trial Register. However, six of the 11 trials were found to be available either in abstract form without sufficient information on study methods or did not meet other inclusion criteria and were therefore excluded. The remaining five (four randomized and one quasi-randomized) trials were included in the review. Participants in these studies were women in spontaneous labour at term, having a singleton pregnancy with cephalic presentation. Two trials assessed the use of a partogram versus routine care without the partogram. Another two compared partograms with a different placement of the action line. And one trial compared the effect of use of the partogram with only the alert line plus aggressive management versus the effect of use of the partogram with both the alert as well as action lines. Four of five trials were of good quality, while in one study the methods of randomization and allocation concealment were not clear. The primary outcomes for the mother were caesarean section, oxytocin augmentation, duration of the first stage of labour and negative experience of childbirth (as defined by trial authors). For the baby, the primary outcome was low Apgar score (less than seven at five minutes).
Two trials, involving 1590 women, that had assessed the effect of use and non-use of the partogram, found that there was no statistically significant difference between the two groups in terms of caesarean section rates [relative risk (RR) 0.64; 95% confidence interval (CI) 0.24–1.70], instrumental vaginal delivery (RR 1.00; 95% CI 0.85–1.17) or Apgar score less than seven at five minutes (RR 0.77; 95% CI 0.29–2.06). With regard to other maternal or neonatal outcomes, the data were insufficient to draw a conclusion.
Two trials, involving 3601 women, had compared the effects of the partograms with the action line set at two hours versus the action line set at four hours.These trials reported no significant difference in caesarean section rates between the groups (RR 1.06; 95% CI 0.85–1.32). However, women in the two-hour action line group were more likely to receive oxytocin augmentation (RR 1.14; 95% CI 1.05–1.22). There were no differences between the groups with regard to other maternal or neonatal outcomes.
The single trial involving 617 women that had compared a two-hour versus a three-hour action line on the partogram found no difference between the groups in caesarean section rates (RR 0.78; 95% CI 0.51–1.18) or any other maternal or neonatal outcomes. However, women in the two-hour action line group were less likely to report a negative experience of childbirth compared with those in the three-hour action line group (RR 0.49; 95% CI 0.27–0.90).
Another single trial, involving 613 women, had compared a three-hour versus a four-hour action line on the partogram. In this trial the caesarean section rate was higher in the three-hour action line group compared with the four-hour line group and the difference was statistically significant (RR 1.70; 95% CI 1.07–2.70). In this case too, there were no differences between the groups in any of the other maternal or neonatal outcomes.
One trial, involving 694 women, had compared the effects of use of a partogram with only an alert line versus one with an alert and action line. Carried out in an under-resourced setting, this trial reported a lower caesarean section rate in the only alert line group (RR 0.68; 95% CI 0.50–0.93). There were no differences between the groups in any of the other maternal or neonatal outcomes.
To examine the effect of early or late intervention in well-resourced and under-resourced settings, the authors pooled results from three trials (two trials that had compared two- and four-hour action lines in a well-resourced setting and one trial in an under-resourced setting that had compared partograms with only the alert line versus partograms with both alert and action lines. The pooling of data failed to show any differences between the groups in terms of caesarean section rate, Apgar score or instrumental delivery.
4.1 Applicability of results
The authors of the review state that, based on available evidence, "we cannot recommend routine use of the partogram as part of standard labour management and care", although they acknowledge that the "partograms may be useful in settings with poorer access to healthcare resources".
Only two of the six trials included in the review were conducted in under-resourced settings (Mexico and South Africa). Also, overall, data for each comparison were generally limited. Hence, it is not advisable to recommend any change in the current routine use of partogram or use of a specific type of partogram.
4.2 Implementation of the intervention
In under-resourced settings, prolonged labour and delay in decision-making are important causes of adverse obstetric outcomes. Owing to resource constraints in such settings, it is usually not possible to monitor each woman continuously throughout the duration of labour. In such settings, the partogram serves a simple and inexpensive tool to monitor labour in a cost-effective way. One case–control study from Pakistan found the partogram to reduce the frequency of prolonged labour, augmented labour, postpartum hemorrhage, ruptured uterus, puerperal sepsis perinatal and maternal morbidity and mortality (9). The present review does not provide conclusive evidence to change established practice in under-resourced settings.
4.3 Implication for research
There is a need to conduct large multicentre randomized trials using a uniform labour ward protocol, especially in under-resourced settings. Stratification of participants according to parity, previous obstetrical outcome, and associated high-risk factor should be done in the new trials. In further research, women' satisfaction and obstetrician or birth attendant’s experience with the use of the partogram should also be studied.
Source of support: All India Institute of Medical Sciences, New Delhi (India).
Acknowledgement: Prof Suneeta Mittal and Dr Neeta Singh for their technical advice and Mr Jitendra Khanna for editing the commentary.
- Zupan J. Perinatal Mortality in Developing Countries. New England Journal of Medicine 2005; 352:2047-2048.
- Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva: World Health Organization; 2007.
- Friedman E. Graphic analysis of labour. American Journal of Obstetrics and Gynecology 1954;68:1568-75.
- Philpott RH, Castle WM. Cervicographs in the management of labour in primigravidae. Journal of Obstetrics and Gynaecology of the British Commonwealth 1972;79:592-598.
- WHO. World Health Organization partograph in management of labour. The Lancet 1994; 343:1399-1404.
- Walraven GE. WHO partograph. The Lancet 1994;344:617.
- Lavender T, Malcolmson L. Is the partogram a help or a hindrance? The Practising Midwife 1999;2:23-27.
- Lavender T, Hart A, Symth RMD. Effect of partogram use on outcomes for women in spontaneous labour at term. Cochrane Database of systemic Review 2008, issue 4. Art No.:CD005461. DOI 10.1002/14651858. CD 005461.pub 2
- Javed I, Bhutta S, Shoaib T. Role of partogram in preventing prolonged labour. Journal of the Pakistan Medical Association 2007;57(8): 408-411.
This document should be cited as: Soni BL. Effect of partogram use on outcomes for women in spontaneous labour at term: RHL commentary (last revised: 1 June 2009). The WHO Reproductive Health Library; Geneva: World Health Organization.