What is the role of partographs (partographic records) in improving labor outcomes and reducing morbidity and mortality?

The Role of Partographs in Improving Labor Outcomes and Reducing Mortality

Partographs are effective tools for monitoring labor that can significantly reduce prolonged labor, emergency cesarean sections, and intrapartum stillbirths when properly implemented and utilized.

What is a Partograph?

• A partograph (or partogram) is a pre-printed paper form used to provide a pictorial overview of labor progress and maternal/fetal wellbeing 1
• It typically contains sections to record cervical dilation, fetal heart rate, uterine contractions, maternal vital signs, and other key parameters during labor 2
• The World Health Organization (WHO) recommends partographs as part of standard labor management to improve maternal and fetal outcomes 3

Evidence for Partograph Effectiveness

• A landmark WHO multicenter trial involving 35,484 women demonstrated that implementation of partographs with agreed labor management protocols reduced:
  • Prolonged labor from 6.4% to 3.4% of labors 3
  • Labor requiring augmentation from 20.7% to 9.1% 3
  • Emergency cesarean sections from 9.9% to 8.3% 3
  • Intrapartum stillbirths from 0.5% to 0.3% 3
• Among singleton pregnancies with no complicating factors, cesarean section rates fell from 6.2% to 4.5% 3
• These improvements were observed in both nulliparous and multiparous women 3

Limitations and Challenges

• Despite potential benefits, a Cochrane review could not definitively recommend routine partograph use due to limited high-quality evidence 2
• Poor completion rates have been documented in multiple settings, with one study showing correct completion of fetal heart rate in only 30.7% of partographs 4
• Barriers to effective partograph use include:
  • Inadequate training and supervision 4
  • Time constraints in busy labor wards 1
  • Lack of understanding of the tool's purpose 1
  • Insufficient health system support 1

Different Partograph Designs

• Various partograph designs have been studied with different outcomes:
  • Partographs with two-hour action lines (vs. four-hour) resulted in higher oxytocin augmentation rates (RR 2.44,95% CI 1.36 to 4.35) 2
  • Partographs with three-hour action lines showed higher cesarean section rates compared to four-hour action lines (RR 1.70,95% CI 1.07 to 2.70) 2
  • Partographs without a latent phase showed lower cesarean section rates compared to those with a latent phase (RR 2.45,95% CI 1.72 to 3.50) 2

Implementation Considerations

• Successful partograph implementation requires:
  • Adequate training of healthcare providers 1
  • Regular supportive supervision 4
  • Health system support including sufficient staffing 1
  • Effective referral systems when abnormalities are detected 1
  • Institutional policies mandating partograph use 4

Partographs in the Context of Reducing Maternal Mortality

• Maternal mortality remains unacceptably high in many settings, with approximately 700 women experiencing pregnancy-related deaths annually in the United States alone 5
• Two-thirds of pregnancy-related deaths are potentially preventable 5
• Partographs represent one component of comprehensive strategies to reduce maternal mortality and morbidity 5
• They should be implemented alongside other evidence-based practices such as maternal safety bundles, improved access to care, and addressing racial disparities in maternal outcomes 5

Recommendations for Clinical Practice

• Partographs should be implemented as part of standardized labor management protocols 3
• Healthcare providers need proper training on partograph completion and interpretation 4
• Regular audits of partograph completion should be conducted to ensure quality 4
• Partograph design should be selected based on local context and needs, with four-hour action lines potentially offering lower cesarean section rates 2
• Integration of partographs with other maternal safety initiatives is essential for maximum impact on reducing maternal and fetal mortality 5