Is the Friedman curve or World Health Organization (WHO) partogram still the first line?

From the Guidelines

The World Health Organization (WHO) partogram is currently considered the first-line tool for monitoring labor progress, having largely replaced the traditional Friedman curve in modern obstetric practice. The WHO partogram provides a more comprehensive visual representation of labor progress by tracking not only cervical dilation but also fetal descent, fetal heart rate, maternal vital signs, uterine contractions, and other important parameters. This integrated approach allows healthcare providers to identify deviations from normal labor patterns earlier and intervene appropriately. The Friedman curve, developed in the 1950s, established expectations for cervical dilation rates (1 cm/hour in active labor) that are now considered too rigid and may lead to unnecessary interventions.

Key Considerations

• Modern labor management recognizes that normal labor progression can be more variable than previously thought, with the first stage of labor often taking longer than the Friedman curve suggests, especially in first-time mothers.
• The WHO partogram incorporates this updated understanding with an "alert line" and "action line" that provide more flexible guidelines while still helping identify potentially problematic labor patterns.
• Recent studies, such as those by De Vries et al 1, have highlighted concerns with the methods used by Zhang et al, which may lead to inaccurate assessments of labor progress.
• The WHO partogram's ability to track multiple parameters and provide a more nuanced understanding of labor progress makes it a more effective tool for identifying potential issues and improving outcomes, as noted in studies such as those published in the American Journal of Obstetrics and Gynecology 1.

Implementation Recommendations

• Healthcare facilities should use the modified WHO partogram that begins plotting at 4 cm dilation (active labor) rather than the original version that started at 1 cm.
• Labor-delivery personnel should be trained to use the WHO partogram effectively, taking into account the potential for variability in labor progression and the importance of identifying deviations from normal labor patterns.
• The use of the WHO partogram should be integrated into a comprehensive approach to labor management, including regular assessments of fetal and maternal well-being, as well as prompt intervention when necessary.

From the Research

Partograph Use in Labour Management

The partograph, also known as the partogram, is a tool used to monitor labour progress and identify potential complications. According to 2, the World Health Organization (WHO) recommends the use of the partograph for monitoring labour wellbeing and progress.

Effectiveness of Partograph Use

Studies have shown that the use of the partograph can lead to improved outcomes for women in labour. For example, 3 found that the introduction of the partograph with an agreed labour-management protocol reduced prolonged labour, augmentation, and emergency caesarean sections. However, 4 found that the evidence for the effectiveness of partograph use is uncertain, and further trial evidence is required to establish its efficacy.

Design of the Partograph

The design of the partograph, including the placement of the action line, can affect its effectiveness. 4 compared different partograph designs, including those with two-hour, three-hour, and four-hour action lines, and found that the two-hour action line group was more likely to receive oxytocin augmentation. However, 5 suggests that the essence and purpose of the partograph is to ensure that labour progress is monitored to identify slow labour, and that the appropriateness of the intervention at the action line is the determinant of the outcome, not the delay.

Challenges in Partograph Use

Despite its potential benefits, the use of the partograph can be challenging, particularly in resource-limited settings. 6 notes that implementation rates and capacity to correctly use the partograph remain low in these settings, and that health-care systems must establish an environment that supports its correct use.

Key Findings

• The partograph is recommended by the WHO for monitoring labour wellbeing and progress 2.
• The use of the partograph can lead to improved outcomes for women in labour, including reduced prolonged labour and emergency caesarean sections 3.
• The evidence for the effectiveness of partograph use is uncertain, and further trial evidence is required to establish its efficacy 4.
• The design of the partograph, including the placement of the action line, can affect its effectiveness 4, 5.
• Challenges in partograph use, particularly in resource-limited settings, must be addressed to ensure its correct use 6.