Partogram Doesn’t Help in High-Resource Labor and Deliveries

Use of a partogram had no effect on rates of cesarean section or on other aspects of care during labor, according to the results of an intervention review conducted by the Cochrane Pregnancy and Childbirth Group.¹
   
The partogram, which is also known as a partograph, is designed to provide a graphical overview of the labor process. It usually consists of a single pre-printed paper form on which key data, such as fetal heart rate, dilation of the cervix, contractions, and maternal pulse rate, are entered against time. Most partograms contain “action” and “alert” lines. The alert line helps identify the slowest 10% of women’s labor progression, and the action line is placed 2 to 4 hours after the alert line to prompt interventions for slow labor progression. The idea is that the partogram can provide the attending clinician with an accurate overview of labor at a glance.
   
The WHO has recommended universal use of the partogram during labor,² but the partogram’s effectiveness in preventing or reducing adverse outcomes has been questioned, especially by clinicians in high-resource settings. To determine whether use of a partogram influences perinatal and maternal morbidity and mortality or whether different partogram designs are better than others, researchers reviewed 6 studies involving a total of 7706 women.¹ Two of the studies (n=1590) compared routine care alone with routine care plus partogram use. The other 4 studies (n=6116) compared different types of partograms.
   
There were no differences found in the rates of cesarean section, instrumental vaginal delivery, or Apgar score of less than 7 at 5 minutes between the partogram and the no-partogram groups. When a 4-hour action line was compared with a 2-hour action line, labor augmentation with oxytocin was required slightly more often for women in the 2-hour action line group (relative risk, 1.14). When a 3-hour action line was compared with a 4-hour action line, however, the rate of cesarean section was significantly lower in the group assigned to the 4-hour action line. In addition, partograms without a latent phase were associated with lower rates of cesarean section than those with a latent phase.
   
Based on the available evidence, the researchers concluded that the routine use of the partogram as part of standard care during labor cannot be recommended. However, partograms may have some utility in low-resource settings, but more research is required to determine their effectiveness.

Pertinent Points:
- Use of a partogram as part of routine care is not associated with improvements in the rates of cesarean section, instrumental vaginal delivery, or Apgar scores when compared with routine care without use of a partogram.
- Partogram use may have some utility in low-resource settings.
- Additional evidence is needed to definitively determine the efficacy of partogram use.

References:

1. Lavender T, Hart A, Smyth RMD. Effect of partogram use on outcomes for women in spontaneous labour at term. Cochrane Database Syst Rev. 2013;7:CD005461. DOI: 10.1002/14651858.CD005461.pub4.
2. World Health Organization. World Health Organization partograph in management of labour. Lancet. 1994;343:1399-1404.