Partograph is the key commonly used tool for labour monitoring, it helps birth attendants to identify dysfunctions during labour and delivery and take appropriate actions. Correct and timely use of this tool, has shown to decrease both maternal and newborn adverse events including mortality (1). World Health Organization (WHO) advocates use of partograph for detection of labour that is not progressing normally (2). It is crucial to competently conduct and document specific assessments during monitoring of labour so as to make decisions for interventions if deviations are noted from the normal presentation.
In 1994, WHO launched the first version of partograph, (composite partograph) which is currently used in Tanzania as a standard of care. This version consists of three parts; fetal condition, labor progress and maternal condition (3). The composite partograph, include a latent phase of labor of up to 8 hours and an active phase begin when cervical dilatation reaches 3 cm. The active phase is provided with an alert and action line, drawn four hours apart. The alert line help staff to recognize signs of deviation from the normal while action line helps to initiate appropriate actions. However, staff have been reporting difficulties in differentiating false labour or Braxton hick’s contractions from latent phase and therefore are likely to conduct unnecessary interventions (4).
Based on emerging evidence from different scholars, in February 2018, WHO revised and published new references on intrapartum care, which include new definitions and durations for first and second stages of labor, whereby documentation on the partograph begins during the active phase when cervical dilatation is ≥ 5 cm. The recommendations suggest that, the duration of first and second stages of labor may vary from one woman to another and cervical dilation rate of 1 cm per hour is not realistic and it is not a good predictor of adverse birth outcomes, therefore should not be the only indication for obstetric intervention (5).
Owing to widespread incorrect and inconsistent use of partograph, in 2018, WHO experts revisited and revised the design of the partograph and developed the first version of the Labour Care Guide (LCG). This was done with intent to help birth attendants implement new recommendations. The new design is intended to encourage woman-centered care, motivate practitioners to think broadly around labor decision-making, and individualize labor monitoring. The LCG is designed to be used for all births in health facilities, including primary, secondary and tertiary care settings (6).
New features in the LCG include supportive care services such as birth companionship and use of pain relief, removing the 1 cm per hour cervical dilatation rate, non-consideration of the alert and action lines and documenting numerical values for monitored parameters. LCG is initiated during the active phase of the first stage of labour (five cm or more cervical dilatation) and there is no plotting and therefore no visual interpretation. The guide, aims to prevent unnecessary interventions and it is advised to be adopted for use (7). Currently there is paucity of information on whether LCG has different outcomes when used for monitoring labour as compared to composite partograph.
A systematic review done by Oladapo et al (2017) on the cervical dilatation patterns during spontaneous labour among low-risk women with normal perinatal outcomes observed that, the median time to advance by 1 cm in nulliparous women is longer than 1 hour. Similar labour progression patterns are observed in parous women, while some women reach 10 cm despite dilatation rates much slower than 1cm/hour threshold. Therefore, an expectation of a minimum cervical dilatation threshold of 1cm/hour throughout first stage of labour is considered to be unrealistic for most healthy primegravidae and multigravida women (8).
Abalos et al 2018, found that the duration of spontaneous labour in pregnant women with good labour outcomes varies from one woman to another. Some women may experience labour for longer period, and still accomplish a vaginal birth without adverse labour outcomes. These results make disagreement on the inflexible restrictions currently applied in clinical practice for the assessment of prolonged first or second stages of labour that deserve obstetric intervention (9). Bed well et al (2017) in their study on realist systematic review of partograph use, concentrated on finding limitations on the way the partograph is used in the clinical context and the potential impact on its use, this study revealed that health worker acceptability, health system support, effective referral systems, human resources and health worker competence, were important factors for successful use of the partograph (10).
Comparative study done by Ninama and Gandhi (2019) in India on usefulness of modified WHO Partograph in management of labour found that the use of partograph is associated with significant reduction in cesarean section rate, reduction in prolonged labor and reduction in neonatal intensive care admission. The study also suggest that it is possible that partogram suit in settings with poor access to healthcare resources (11). Nevertheless, a study done at a large referral center in Tanzania, the authors reported that low-risk women admitted during latent phase were subjected to higher rates of interventions including caesarian section compared to similar women admitted in active stage of labour (12).
A systematic review done by Lavender et al in 2013 on the effect of partogram use on outcomes for women in spontaneous labour at term, found that, overall, there is no evidence that using a partogram reduce or increase caesarean section rates or has any effect on other aspects of care in labour. Comparison of different partograph designs reveals that no design is better than the other in terms of maternal and newborn outcome. The review does not recommend routine use of the partograph as part of standard labour management and care. Due to the fact that, partograph is currently in widespread use and generally accepted, the study suggested that, its use cannot be abandoned and the need for it should be locally determined (13).
LCG is reported to be superior to standard of care in monitoring labor, it was introduced in order to monitor the progress of labor in a holistic approach by avoiding unnecessary interventions. It includes other components of women centered care such as psychological support and pain relief. Tanzania has not adopted the recommendations because there is no enough local evidence whether the LCG has an added value on maternal and newborn outcome as compared to composite partograph which is a National standard of care. There is only one study done in Tanzania on LCG. It was a multi-country, which focused on assessment of acceptability and usability of this tool, without consideration of maternal and newborn outcome in comparison with the standard of care (14).
Recent commentary on the LCG, argues that, neglecting the latent phase is worrisome as it may cause delay in recognizing complications or the onset of active labour, it further highlights that, placement of posture of the woman higher up on the LCG than the wellbeing of her unborn baby is thought not to be a proper practice. It is suggested that, with the purpose of improving quality of intrapartum care, other factors can must be strengthened instead of changing the partogram. Factors suggested for improvement includes health system factors such as shortage of human resource for health, availability of medical supplies and equipment and referral system (15).
Due to the fact that LCG is newly introduced, currently, there are no studies done to compare this tool with the composite partograph, hence there is lack of evidence on whether LCG has more advantage on labour outcome. High burden of maternal and newborn adverse events is related to issues of partograph design, how to use the partograph to monitor, detect and act on issues observed during labor and delivery. Labor monitoring using partograph has been useful, however the standard tool is reported to be less effective, as it has been associated with increased risk of unnecessary interventions leading to higher rate of caesarian delivery (16).
This study compared the WHO LCG and WHO composite partograph in terms of maternal and early newborn outcomes. It was guided by the null hypothesis that “there is no difference” in maternal and newborn outcomes when labor is monitored by using LCG versus composite partograph (17). Evidence from this study might be used by health researchers to design larger studies and by policy makers to evaluate its implementation in large scale.