Effect of partograph use on outcomes for women in spontaneous labour at term

What is the issue?

Does the use of the partograph during spontaneous labour at term improve the health outcomes for women and babies?
Do different partograph designs make any difference to the health outcomes for women and babies?

Why is this important?

A partograph is usually a pre-printed form, the aim of which is to provide a pictorial overview of labour progress and to alert health professionals to any problems with the mother or baby. It has been unclear whether a partograph should be used and, if so, which design of partograph is better for women and babies.

What evidence did we find?

We searched for evidence in August 2017 and have now included 11 studies involving 9475 women. Three studies looked at using a partograph versus no partograph, seven studies looked at different partograph designs, and one study looked at using a partograph versus a new labour scale.

Partograph versus no partograph (3 studies, 1703 women)

It is uncertain whether using a partograph has any effect on the number of women having a caesarean section or babies born with low Apgar scores (a score which measures the physical condition of the newborn, with a low score indicating poor condition) because the quality of evidence is very low. Using a partograph may make little or no difference to length of labour (low-quality evidence), or the number of women who receive oxytocin to speed up their labour (moderate-quality evidence).

Partograph with different placement of action lines (4 trials, 5051 women)

When compared to a four-hour action line, women in the two-hour action line group were more likely to have their labour speeded up using oxytocin. There was no clear difference between women in the two- and four-hour action line groups in having caesarean sections, the lengths of first stage of labour, maternal experiences of childbirth, or low Apgar scores.

When we compared a two-hour action line with a three-hour action line, fewer women reported negative childbirth experiences in the two-hour action line group. When we compared the three- and four-hour action line groups, the caesarean section rate was higher in the three-hour action line group. There were no clear differences between the two-, three-, or four-hour action line groups in any of the other outcomes measured.

Partograph with alert line only versus partograph with alert and action line (1 trial, 694 women)

The caesarean section rate was lower in the alert line only group. There were no clear differences between groups for oxytocin augmentation, low Apgar score, instrumental vaginal birth, and perinatal death.

Partograph with latent phase versus partograph without latent phase (1 trial, 743 women)

When we compared a partograph with the latent phase (including early stages of labour) and one without the latent phase, the caesarean section and oxytocin augmentation rates were higher in the partograph with a latent phase. There were no clear differences between groups for oxytocin augmentation, and Apgar score less than 7 at 5 minutes.

Partograph with two-hour action line versus partograph with stepped dystocia line (1 trial, 99 women)

When we compared a partograph with a two-hour action line and a stepped dystocia line, fewer women received oxytocin augmentation in the dystocia line group. We did not observe any clear differences in any of the other primary outcomes in this comparison.

Partograph versus labour scale (1 trial, 122 women)

The labour scale compared with the partograph resulted in fewer women receiving oxytocin augmentation, but did not produce any clear difference for any of the other primary outcomes.

What does this mean?

On the basis of the findings of this review, we cannot be certain of the effects of routine use of the partograph as part of standard labour care, or of the different partograph designs. Further trial evidence is required to establish the efficacy of partograph use per se and its optimum design.

Authors' conclusions: 

On the basis of the findings of this review, we cannot be certain of the effects of routine use of the partograph as part of standard labour management and care, or which design, if any, are most effective. Further trial evidence is required to establish the efficacy of partograph use per se and its optimum design.

Read the full abstract...
Background: 

The partograph (sometimes known as partogram) is usually a pre-printed paper form on which labour observations are recorded. The aim of the partograph is to provide a pictorial overview of labour, and to alert midwives and obstetricians to deviations in maternal or fetal well-being and labour progress. Charts have traditionally contained pre-printed alert and action lines. An alert line, which is based on the slowest 10% of primigravid women's labours, signifies slow 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.

This review is an update of a review last published in 2013.

Objectives: 

The primary objective was to determine the effectiveness and safety of partograph use on perinatal and maternal morbidity and mortality. The secondary objective was to determine which partograph design is most effective for perinatal and maternal morbidity and mortality outcomes.

Search strategy: 

We searched Cochrane Pregnancy and Childbirth's Trials Register (31 August 2017), ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (31 August 2017) and reference lists of retrieved studies.

Selection criteria: 

Randomised, cluster-randomised, and quasi-randomised controlled trials involving a comparison of partograph use with no partograph, or comparison between different partograph 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 review authors assessed the studies independently. We assessed the evidence using the GRADE approach.

Main results: 

We have included 11 studies, involving 9475 women in this review; three studies assessed partograph use versus no partograph, seven assessed different partograph designs, and one assessed partograph use versus labour scale. Risk of bias varied in all studies. It was infeasible to blind staff or women to the intervention. Two studies did not adequately conceal allocation. Loss to follow-up was low in all studies. We assessed the evidence for partograph use versus no partograph using the GRADE approach; downgrading decisions were due to study design, inconsistency, indirectness, and imprecision of effect estimates.

Most trials reported caesarean section rates and Apgar scores less than 7 at five minutes; all other outcomes were not consistently reported (e.g. duration of first stage of labour and maternal experience of childbirth).

Partograph versus no partograph (3 trials, 1813 women)

It is uncertain whether there is any clear difference between partograph use and no partograph in caesarean section rates (average risk ratio (RR) 0.77, 95% confidence interval (CI) 0.40 to 1.46; n = 1813; 3 trials; I² = 87%; very low-quality evidence); oxytocin augmentation (RR 1.02, 95% CI 0.95 to 1.10; n = 1156; 1 trial; moderate-quality evidence); duration of first stage of labour (mean difference (MD) 0.80 hours, 95% CI -0.06 to 1.66; n = 1156; 1 trial; low-quality evidence); or Apgar score less than 7 at five minutes (RR 0.76, 95% CI 0.29 to 2.03; n = 1596; 2 trials; I² = 87%; very low-quality evidence).

Partograph with different placement of action lines (4 trials, 5051 women)

When compared to a four-hour action line, women in the two-hour action line group were more likely to receive oxytocin augmentation (average RR 2.44, 95% CI 1.36 to 4.35; n = 4749; 4 trials; I² = 96%). There was no clear difference in caesarean section rates (RR 1.06, 95% CI 0.88 to 1.28; n = 4749; 4 trials); duration of first stage of labour (RR 0.81 hours, 95% CI 0.32 to 2.04; n = 948; 1 trial); maternal experience of childbirth (average RR 0.61, 95% CI 0.28 to 1.35; n = 2269; 2 trials; I² = 83%); or Apgar score less than 7 at five minutes (RR 0.93, 95% CI 0.61 to 1.42; n = 4749; 4 trials) between the two- and four-hour action line.

The following comparisons only include data from single studies. Fewer women reported negative childbirth experiences in the two-hour action line group compared to the three-hour action line group (RR 0.49, 95% CI 0.27 to 0.90; n = 348; 1 trial). When we compared the three- and four-hour action line groups, the caesarean section rate was higher in the three-hour action line group (RR 1.70, 95% CI 1.07 to 2.70; n = 613; 1 trial). We did not observe any clear differences in any of the other outcomes in these comparisons.

Partograph with alert line only versus partograph with alert and action line (1 trial, 694 women)

The caesarean section rate was lower in the alert line only group (RR 0.68, 95% CI 0.50 to 0.93). There were no clear differences between groups for oxytocin augmentation, low Apgar score, instrumental vaginal birth and perinatal death.

Partograph with latent phase (composite) versus partograph without latent phase (modified) (1 trial, 743 women)

The caesarean section and oxytocin augmentation rates were higher in the partograph with a latent phase (RR 2.45, 95% CI 1.72 to 3.50; and RR 2.18, 95% CI 1.67 to 2.83, respectively). There were no clear differences between groups for oxytocin augmentation, and Apgar score less than 7 at five minutes.

Partograph with two-hour action line versus partograph with stepped dystocia line (1 trial, 99 women)

Fewer women received oxytocin augmentation in the dystocia line group (RR 0.62, 95% CI 0.39 to 0.98). We did not observe any clear differences in any of the other primary outcomes in this comparison.

Partograph versus labour scale (1 trial, 122 women)

The use of the partograph compared with the labour scale resulted in fewer women receiving oxytocin augmentation (RR 0.32, 95% CI 0.18 to 0.54), but did not produce any clear differences for any of the other primary outcomes.

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