Cochrane Database of Systematic Reviews

Effect of partograph use on outcomes for women in

spontaneous labour at term and their babies (Review)

Lavender T, Cuthbert A, Smyth RMD

Lavender T, Cuthbert A, Smyth RMD.

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies.
Cochrane Database of Systematic Reviews 2018, Issue 8. Art. No.: CD005461.
DOI: 10.1002/14651858.CD005461.pub5.

www.cochranelibrary.com

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review)
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS

HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . . 4
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Analysis 1.1. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource settings),
Outcome 1 Caesarean section (overall). . . . . . . . . . . . . . . . . . . . . . . . . . 59
Analysis 1.2. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource settings),
Outcome 2 Oxytocin augmentation. . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Analysis 1.3. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource settings),
Outcome 3 Duration of first stage of labour. . . . . . . . . . . . . . . . . . . . . . . . 60
Analysis 1.4. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource settings),
Outcome 4 Low Apgar score (less than 7 at 5 minutes). . . . . . . . . . . . . . . . . . . . 61
Analysis 1.5. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource settings),
Outcome 5 Instrumental vaginal birth. . . . . . . . . . . . . . . . . . . . . . . . . . 62
Analysis 1.6. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource settings),
Outcome 6 Regional analgesia - epidural. . . . . . . . . . . . . . . . . . . . . . . . . 63
Analysis 1.7. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource settings),
Outcome 7 Performance of artificial rupture of membranes during labour. . . . . . . . . . . . . . 63
Analysis 1.8. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource settings),
Outcome 8 Antibiotic use. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Analysis 1.9. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource settings),
Outcome 9 Duration of second stage of labour (hours). . . . . . . . . . . . . . . . . . . . 65
Analysis 1.10. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource settings),
Outcome 10 Number of vaginal examinations. . . . . . . . . . . . . . . . . . . . . . . 65
Analysis 1.11. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource settings),
Outcome 11 Admission to special care nursery. . . . . . . . . . . . . . . . . . . . . . . 66
Analysis 2.1. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried
out in a high- and low-resource settings), Outcome 1 Caesarean section (overall). . . . . . . . . . . 67
Analysis 2.2. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried
out in a high- and low-resource settings), Outcome 2 Oxytocin augmentation. . . . . . . . . . . . 68
Analysis 2.3. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried
out in a high- and low-resource settings), Outcome 3 Duration of first stage of labour (length of labour greater than
18 hours, length of labour greater than 12 hours). . . . . . . . . . . . . . . . . . . . . . 69
Analysis 2.4. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies
carried out in a high- and low-resource settings), Outcome 4 Maternal experience of childbirth - negative childbirth
experience. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Analysis 2.5. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried
out in a high- and low-resource settings), Outcome 5 Low Apgar score (less than 7 at 5 minutes). . . . . . 71
Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) i
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 2.6. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried
out in a high- and low-resource settings), Outcome 6 Serious maternal morbidity or death. . . . . . . . 72
Analysis 2.7. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried
out in a high- and low-resource settings), Outcome 7 Caesarean section (distress). . . . . . . . . . . 72
Analysis 2.8. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried
out in a high- and low-resource settings), Outcome 8 Caesarean section (delay). . . . . . . . . . . . 73
Analysis 2.9. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried
out in a high- and low-resource settings), Outcome 9 Instrumental vaginal delivery. . . . . . . . . . . 74
Analysis 2.10. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried
out in a high- and low-resource settings), Outcome 10 Postpartum haemorrhage - blood loss > 500 mL. . . . 75
Analysis 2.11. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried
out in a high- and low-resource settings), Outcome 11 Regional analgesia - epidural. . . . . . . . . . 76
Analysis 2.12. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried
out in a high- and low-resource settings), Outcome 12 Performance of artificial rupture of the membranes during
labour. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Analysis 2.13. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried
out in a high- and low-resource settings), Outcome 13 Number of vaginal examinations in labour. . . . . 78
Analysis 2.14. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried
out in a high- and low-resource settings), Outcome 14 Serious neonatal morbidity or perinatal death. . . . 79
Analysis 2.15. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried
out in a high- and low-resource settings), Outcome 15 Admission to special care nursery. . . . . . . . . 80
Analysis 2.16. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried
out in a high- and low-resource settings), Outcome 16 Cord blood arterial pH less than 7.1. . . . . . . . 81
Analysis 3.1. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried
out in a high-resource setting), Outcome 1 Caesarean section (overall). . . . . . . . . . . . . . . 81
Analysis 3.2. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried
out in a high-resource setting), Outcome 2 Oxytocin augmentation. . . . . . . . . . . . . . . . 82
Analysis 3.3. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried
out in a high-resource setting), Outcome 3 Maternal experience of childbirth - negative childbirth experience. 82
Analysis 3.4. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried
out in a high-resource setting), Outcome 4 Low Apgar score (less than 7 at 5 minutes). . . . . . . . . 83
Analysis 3.5. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried
out in a high-resource setting), Outcome 5 Serious maternal morbidity or death. . . . . . . . . . . . 83
Analysis 3.6. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried
out in a high-resource setting), Outcome 6 Caesarean section (distress). . . . . . . . . . . . . . . 84
Analysis 3.7. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried
out in a high-resource setting), Outcome 7 Caesarean section (delay). . . . . . . . . . . . . . . 84
Analysis 3.8. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried
out in a high-resource setting), Outcome 8 Instrumental vaginal delivery. . . . . . . . . . . . . . 85
Analysis 3.9. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried
out in a high-resource setting), Outcome 9 Postpartum haemorrhage - blood loss > 500 mL. . . . . . . . 85
Analysis 3.10. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried
out in a high-resource setting), Outcome 10 Regional analgesia - epidural. . . . . . . . . . . . . . 86
Analysis 3.11. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried
out in a high-resource setting), Outcome 11 Performance of artificial rupture of membranes during labour. . 86
Analysis 3.12. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried
out in a high-resource setting), Outcome 12 Vaginal examinations. . . . . . . . . . . . . . . . 87
Analysis 3.13. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried
out in a high-resource setting), Outcome 13 Serious neonatal morbidity or perinatal death. . . . . . . . 87
Analysis 3.14. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried
out in a high-resource setting), Outcome 14 Admission to special care nursery. . . . . . . . . . . . 88
Analysis 3.15. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried
out in a high-resource setting), Outcome 15 Cord blood arterial pH less than 7.1. . . . . . . . . . . 88
Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) ii
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 4.1. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried
out in a high-resource setting), Outcome 1 Caesarean section (overall). . . . . . . . . . . . . . . 89
Analysis 4.2. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried
out in a high-resource setting), Outcome 2 Oxytocin augmentation. . . . . . . . . . . . . . . . 89
Analysis 4.3. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried
out in a high-resource setting), Outcome 3 Maternal experience of childbirth - negative childbirth experience. 90
Analysis 4.4. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried
out in a high-resource setting), Outcome 4 Low Apgar score (less than 7 at 5 minutes). . . . . . . . . 90
Analysis 4.5. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried
out in a high-resource setting), Outcome 5 Serious maternal morbidity or death. . . . . . . . . . . . 91
Analysis 4.6. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried
out in a high-resource setting), Outcome 6 Caesarean section (distress). . . . . . . . . . . . . . . 91
Analysis 4.7. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried
out in a high-resource setting), Outcome 7 Caesarean section (delay). . . . . . . . . . . . . . . 92
Analysis 4.8. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried
out in a high-resource setting), Outcome 8 Instrumental vaginal delivery. . . . . . . . . . . . . . 92
Analysis 4.9. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried
out in a high-resource setting), Outcome 9 Postpartum haemorrhage - blood loss > 500 mL. . . . . . . . 93
Analysis 4.10. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried
out in a high-resource setting), Outcome 10 Regional analgesia - epidural. . . . . . . . . . . . . . 93
Analysis 4.11. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried
out in a high-resource setting), Outcome 11 Performance of artificial rupture of membranes during labour. . 94
Analysis 4.12. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried
out in a high-resource setting), Outcome 12 Number of vaginal examinations in labour. . . . . . . . . 94
Analysis 4.13. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried
out in a high-resource setting), Outcome 13 Serious neonatal morbidity or perinatal death. . . . . . . . 95
Analysis 4.14. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried
out in a high-resource setting), Outcome 14 Admission to special care nursery. . . . . . . . . . . . 95
Analysis 4.15. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried
out in a high-resource setting), Outcome 15 Cord blood arterial pH less than 7.1. . . . . . . . . . . 96
Analysis 5.1. Comparison 5 Partograph with alert line only versus partograph with alert and action line (study carried out
in a low-resource setting), Outcome 1 Caesarean section (overall). . . . . . . . . . . . . . . . . 96
Analysis 5.2. Comparison 5 Partograph with alert line only versus partograph with alert and action line (study carried out
in a low-resource setting), Outcome 2 Oxytocin augmentation. . . . . . . . . . . . . . . . . . 97
Analysis 5.3. Comparison 5 Partograph with alert line only versus partograph with alert and action line (study carried out
in a low-resource setting), Outcome 3 Low Apgar score (less than 7 at 5 minutes). . . . . . . . . . . 97
Analysis 5.4. Comparison 5 Partograph with alert line only versus partograph with alert and action line (study carried out
in a low-resource setting), Outcome 4 Instrumental vaginal delivery. . . . . . . . . . . . . . . . 98
Analysis 5.5. Comparison 5 Partograph with alert line only versus partograph with alert and action line (study carried out
in a low-resource setting), Outcome 5 Serious neonatal morbidity or perinatal death. . . . . . . . . . 98
Analysis 6.1. Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a
low-resource setting), Outcome 1 Caesarean section (overall). . . . . . . . . . . . . . . . . . 99
Analysis 6.2. Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a
low-resource setting), Outcome 2 Oxytocin augmentation. . . . . . . . . . . . . . . . . . . 99
Analysis 6.3. Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a
low-resource setting), Outcome 3 Low Apgar score (less than 7 at 5 minutes). . . . . . . . . . . . . 100
Analysis 6.4. Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a
low-resource setting), Outcome 4 Caesarean section (distress). . . . . . . . . . . . . . . . . . 101
Analysis 6.5. Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a
low-resource setting), Outcome 5 Caesarean section (delay). . . . . . . . . . . . . . . . . . . 101
Analysis 6.6. Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a
low-resource setting), Outcome 6 Instrumental vaginal delivery. . . . . . . . . . . . . . . . . 102

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) iii
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 6.7. Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a
low-resource setting), Outcome 7 Admission to special care nursery. . . . . . . . . . . . . . . . 103
Analysis 6.8. Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a
low-resource setting), Outcome 8 Usability: user-friendliness score. . . . . . . . . . . . . . . . 103
Analysis 7.1. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia line, Outcome 1
Caesarean section. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Analysis 7.2. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia line, Outcome 2
Oxytocin augmentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Analysis 7.3. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia line, Outcome 3
Duration of first stage of labour (labour longer than 12 hours). . . . . . . . . . . . . . . . . . 105
Analysis 7.4. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia line, Outcome 4
Maternal experience of childbirth (BSS-R score). . . . . . . . . . . . . . . . . . . . . . . 106
Analysis 7.5. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia line, Outcome 5
Low Apgar score (less than 4 at 4 min). . . . . . . . . . . . . . . . . . . . . . . . . . 106
Analysis 7.6. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia line, Outcome 6
Instrumental vaginal birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Analysis 7.7. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia line, Outcome 7
Postpartum haemorrhage (> 500 mL). . . . . . . . . . . . . . . . . . . . . . . . . . 107
Analysis 7.8. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia line, Outcome 8
Regional analgesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Analysis 7.9. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia line, Outcome 9
Opioid use. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Analysis 7.10. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia line, Outcome 10
Need for intubation at birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Analysis 8.1. Comparison 8 Partograph versus labour scale (study carried out in a low-resource setting), Outcome 1
Caesarean section (overall). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Analysis 8.2. Comparison 8 Partograph versus labour scale (study carried out in a low-resource setting), Outcome 2
Oxytocin augmentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Analysis 8.3. Comparison 8 Partograph versus labour scale (study carried out in a low-resource setting), Outcome 3
Duration of first stage of labour. . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Analysis 8.4. Comparison 8 Partograph versus labour scale (study carried out in a low-resource setting), Outcome 4 Low
Apgar score (less than 7 at 5 minutes). . . . . . . . . . . . . . . . . . . . . . . . . . 111
Analysis 8.5. Comparison 8 Partograph versus labour scale (study carried out in a low-resource setting), Outcome 5
Caesarean section (delay). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Analysis 8.6. Comparison 8 Partograph versus labour scale (study carried out in a low-resource setting), Outcome 6
Stillbirth, neonatal death or neonatal morbidity. . . . . . . . . . . . . . . . . . . . . . . 112
Analysis 8.7. Comparison 8 Partograph versus labour scale (study carried out in a low-resource setting), Outcome 7 Birth
injuries and PPH (non-prespecified outcome). . . . . . . . . . . . . . . . . . . . . . . 112
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . 114
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) iv
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]

Effect of partograph use on outcomes for women in

spontaneous labour at term and their babies

Tina Lavender1 , Anna Cuthbert2 , Rebecca MD Smyth1

1 Division of Nursing Midwifery and Social Work, The University of Manchester, Manchester, UK. 2 Cochrane Pregnancy and Childbirth

Group, Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK

Contact address: Tina Lavender, Division of Nursing Midwifery and Social Work, The University of Manchester, Oxford Road,
Manchester, M13 9PL, UK. [email protected].

Editorial group: Cochrane Pregnancy and Childbirth Group.

Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 8, 2018.

Citation: Lavender T, Cuthbert A, Smyth RMD. Effect of partograph use on outcomes for women in spontaneous labour at term and
their babies. Cochrane Database of Systematic Reviews 2018, Issue 8. Art. No.: CD005461. DOI: 10.1002/14651858.CD005461.pub5.

Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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 methods

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.
Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 1
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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.
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.

PLAIN LANGUAGE SUMMARY

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 2
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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.
Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 3
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]

Partograph compared to no partograph (studies carried out in high- and low- resource settings) for women in spontaneous labour at term

Patient or population: wom en in spontaneous labour at term

Setting: hospital settings in Canada, India, and M exico
Intervention: partograph
Comparison: no partograph (studies carried out in high- and low-resource settings)

Outcomes Anticipated absolute effects∗ (95% CI) Relative effect of participants Quality of the evidence Comments
(95% CI) (studies) (GRADE)

Risk with no parto- Risk with partograph

graph (studies carried
out in high- and low-
resource settings)

Caesarean section Study population Average RR 0.77 1813 ⊕

(overall) (0.40 to 1.46) (3 RCTs) VERY LOW abc
214 per 1000 164 per 1000
(85 to 312)

Oxytocin augmentation Study population RR 1.02 1156 ⊕⊕⊕

(0.95 to 1.10) (1 RCT) M ODERATE d
715 per 1000 730 per 1000
(680 to 787)

Duration of first stage The m ean duration of The m ean duration of In the partograph group, 1156 ⊕⊕
of labour f irst stage of labour f irst stage of labour m ean duration of f irst (1 RCT) LOW cd
was 16 hours (SD 7.6) was 16.8 hours (SD 7. stage was 0.80 hours
3) longer (0.06 hours
shorter to 1.66 hours
longer)

M aternal experience of Study population - (0 study) - No trials reported this

childbirth (as defined outcom e.
by trial authors)
4
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review)

See com m ent See com m ent

Apgar score less than Study population RR 0.76 1596 ⊕

7 at 5 minutes (0.29 to 2.03) (2 RCTs) VERY LOW efg
11 per 1000 9 per 1000
(3 to 24)

Serious maternal mor- Study population - (0 study) - No trials reported this

bidity or death (e.g. outcom e.
ruptured uterus, ad-
mission to intensive
care unit, septicaemia,
organ failure) See com m ent See com m ent

Stillbirth or neonatal Study population - (0 study) - No trials reported this

death or neonatal mor- outcom e.
bidity, excluding fa-
tal malformations (e.
g. seizures, birth as-
phyxia, neonatal en-
cephalopathy) See com m ent See com m ent

* The risk in the intervention group (and its 95% conf idence interval) is based on the assum ed risk in the com parison group and the relative effect of the intervention (and its
95% CI).

CI: conf idence interval; RCT: random ised controlled trial; RR: risk ratio; SD: standard deviation.

GRADE Working Group grades of evidence

High quality: we are very conf ident that the true ef f ect lies close to that of the estim ate of the ef f ect
M oderate quality: we are m oderately conf ident in the ef f ect estim ate; the true ef f ect is likely to be close to the estim ate of the ef f ect, but there is a possibility that it is
substantially dif f erent
Low quality: our conf idence in the ef f ect estim ate is lim ited; the true ef f ect m ay be substantially dif f erent f rom the estim ate of the ef f ect
Very low quality: we have very little conf idence in the ef f ect estim ate; the true ef f ect is likely to be substantially dif f erent f rom the estim ate of ef f ect
a Two out of three studies have design lim itations, serious design lim itations less than 40% of pooled ef f ect (-1).
b Severe heterogeneity > 60% (-1).
c Wide conf idence intervals crossing the line of no ef f ect (-1).
d One trial included which only included low-risk wom en (-1).
5
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review)
e One study with serious design lim itations but only contributes 17% to pooled analysis (not downgraded).
f Studies only included term , low risk wom en (-1).
g Wide conf idence intervals crossing the line of no ef f ect and f ew events (-2).

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6
BACKGROUND health services (Neilson 2003). Although, for some women, ac-
celeration of labour is possible with amniotomy and oxytocin, an
increase in associated pains is more likely to result in an epidural,
Description of the condition vaginal instrumental birth or caesarean section (Nystedt 2014).
Thus accurate diagnosis of prolonged labour which prompts ap-
The optimum length of labour has been a source of debate that propriate action is pivotal.
stems back to the early days of Friedman (Friedman 1954), and
is still being re-evaluated today (Oladapo 2017). The lack of a
definition of normal labour has resulted in challenges in defining
and detecting prolonged labour. Nevertheless, prolonged labour is
known to be a complication that affects around 8% of all labour-
Description of the intervention
ing women and negatively affects obstetric outcome and women’s The partograph (or partogram) is a simple, inexpensive tool to
experiences (Nystedt 2014). Detection of prolonged labour is im- provide a continuous pictorial overview of labour. The partograph
portant, as longer labours are associated with short- and long-term is a pre-printed form, usually in paper version, on which midwives
morbidity. In the shorter term, postpartum haemorrhage and in- and obstetricians record labour observations. Most partographs
fection are more common in women with long labours and in have three distinct sections where observations are entered on ma-
the longer term, fistulas are more prevalent (Neilson 2003). These ternal condition, fetal condition and labour progress; this last sec-
risks are greater in low-income countries with poorly-resourced tion assists in the detection of prolonged labour (Figure 1).

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 7
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Figure 1. Modified partograph

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 8
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
The first obstetrician to describe the progress of labour graphically
was Friedman (Friedman 1954), following his study of the cervi- tive non-randomised study of 35,484 women in South-East Asia
cal dilatation of 100 African primigravidae at term. The women (WHO 1994), and concluded that the partograph was a necessary
were given frequent rectal examinations and their progress was tool in the management of labour, and recommended its univer-
recorded in centimetres of dilatation per hour, producing a slope sal application. In this study, four pairs of hospitals participated
resembling a sigmoid curve (’S’ shaped). This became know as (two pairs in Indonesia, one each in Thailand and Malaysia). A
the cervicograph. In an attempt to utilise midwives efficiently in staged approach was adopted, whereby for the first five months
a hospital and clinic service in Zimbabwe (then Rhodesia), where of the study, all eight centres collected baseline data; after five
doctors were in short supply, Philpott 1972a developed a parto- months, the partograph was randomly introduced into one of each
graph from this original cervicograph. This provided a practical pair; in the remaining five months, the partograph was introduced
tool for recording all intrapartum details, not just cervical dilata- into all hospital sites. Introduction of the partograph, and agreed
tion. An ’alert line’ was added following the results of a prospective management protocol, reduced prolonged labour (from 6.4% to
study of 624 women (Philpott 1972b). The alert line was straight, 3.4%), the proportion of labours requiring augmentation (20.7%
not curved, and was a modification of the mean rate of cervical to 9.1%), emergency caesarean section (from 9.9% to 8.3%), and
dilatation of the slowest 10% of primigravid women who were in stillbirths (from 0.5% to 0.3%).
the active phase of labour. This line represented a progress rate A belief that partograph use is not affected by racial, cultural and
of 1 cm per hour. Should a woman’s cervical dilatation progress socioeconomic differences, led to the approach finding favour in
more slowly, it would cross this alert line and arrangements were both high-income and low- to middle-income countries. However,
made to transfer her from a peripheral unit to a central unit where in practice, it is conceivable that such variations in care between
prolonged labour could be managed. The next stage of partograph countries, and even units, may alter the use of the partograph
development was the introduction of an ’action line’, four hours and subsequent effectiveness, in terms of maternal and neonatal
to the right of the alert line (Philpott 1972c). This line was devel- outcomes. As a consequence, some practitioners have questioned
oped to identify primary inefficient uterine activity to prompt ap- its effectiveness, particularly when used in high-income countries
propriate management. Correction of primary inefficient uterine (Groeschel 2001; Walsh 1994).
activity would usually be with an intervention such as amniotomy There is some evidence to suggest that the partograph has prac-
or oxytocin infusion, or both. tical benefits in terms of aiding referral and transfer, ease of use,
There have been a number of challenges associated with parto- time resourcefulness, continuity of care, educational assistance
graph completion, including shortages of human resources, low and professional accountability (Lavender 1999; Orhue 2012;
status within labour wards and inadequate training (Bedwell 2017; Rakotonirina 2013; Rotich 2011; Yisma 2013). These positive as-
Fatusi 2007; Lavender 2011). These challenges have resulted in a pects may contribute to improving maternal and fetal outcomes.
number of adaptations to the original partograph, one of which is Conversely, it has been reported that the partograph’s status within
the simplified partograph, which does not include monitoring of some obstetric units is such that they may restrict clinical practice,
the latent phase of labour (WHO 2003). In a small cross-over trial, create unnecessary interference, reduce midwife autonomy and
this simplified partograph was shown to be more ’user-friendly’ limit the flexibility to treat each woman as an individual (Lavender
(Mathews 2007). More recently, a randomised controlled trial, in 1999; Lavender 2011; Walraven 1994; Walsh 1994), factors which
India (Kenchaveeriah 2011), comparing the simplified (not in- could also impact on clinical and psychological outcomes.
cluding latent phase) with the traditional partograph (including Barriers and facilitators of partograph use were explored in a recent
latent phase), confirmed a preference amongst medical staff for realist review (Bedwell 2017), which included 92 papers describing
using the simplified version. studies from low- and high-income settings. A realist review looks
to explore what it is about a particular intervention that works or
How the intervention might work
does not work, who it works for, and in which settings (Pawson
The partograph has been heralded as one of the most important 2004). Importantly, this realist review highlighted the fact that
advances in modern obstetric care (Agarwal 2013); however, this health provider support for using the partograph often did not
was prior to any rigorous evaluation. Furthermore, the majority of translate into practice. The review highlighted the essential core
early studies took place in hospital settings where most maternal components necessary within the healthcare environment which
deaths occur among women admitted with severe complications are required to support partograph use. These components can be
and often neglected labour (Lennox 1995). More than 20 years af- broadly categorised into health worker acceptability, health system
ter its introduction, and using a partograph adapted from that for- support, effective referral systems, human resources and health
mulated by Philpott and Castle (Philpott 1972b; Philpott 1972c), worker competence.
the World Health Organization (WHO) conducted a prospec-

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 9
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Why it is important to do this review Types of interventions
The partograph has become an integral part of routine labour care We compared labour management using a partograph with labour
in most parts of the world; assessment of its efficacy is therefore management where no partograph was used. The two groups had
imperative. to differ only in the partograph usage and not in other labour ward
Different designs of partograph exist, and Cartmill 1992 hypoth- interventions, such as psychological support, early amniotomy or
esised that the way a partograph is presented may affect an ob- use of analgesia.
stetrician’s perception of the labour progress and thus influence To meet the second objective, we included studies reporting com-
decision-making. This hypothesis has received some support from parisons between different designs of partograph.
others (Lavender 1998b; Tay 1996), who have suggested that the These are complex interventions. The partograph will be used in a
slope and position of the action line have an impact on caesarean way dictated by the accompanying guidelines and this may influ-
section and intervention rates and maternal satisfaction. ence outcomes. Therefore, wherever possible, we have contextu-
The aim of this review is to assess the benefits and harms of par- alised trial findings by describing the associated clinical guidelines.
tograph use on women in labour and to enable women and clin-
icians to make informed evidence-based decisions. This review is
Types of outcome measures
the latest update of a review that was first published in 2008.

Primary outcomes

OBJECTIVES Outcomes for mother

The primary objective was to determine the effectiveness and sa-

fety of partograph use on perinatal and maternal morbidity and
mortality. The secondary objective was to determine which par- Short-term maternal outcomes
tograph design is most effective for perinatal and maternal mor- • Caesarean section
bidity and mortality outcomes. • Oxytocin augmentation
• Duration of first stage of labour (length of labour greater
than 18 hours, length of labour greater than 12 hours)
• Maternal experience of childbirth (as defined by trial
METHODS authors)

Criteria for considering studies for this review Outcome for baby
Short-term neonatal outcomes
Types of studies • Low Apgar score (less than 7 at 5 minutes)
We included in this review all published, unpublished and ongoing
randomised, quasi-randomised, and cluster-controlled trials that Secondary outcomes
compared outcomes, as listed below, between partograph use and
non-use. We included randomised controlled trials of different
designs of partograph for secondary analysis. We included trials Outcomes for mother
that used quasi-random allocations (e.g. alternation). We excluded
studies reported in abstract form, without sufficient information
on study methods or where results were not clear, only after an
unsuccessful attempt to contact the study author for further in- Short-term maternal outcomes
formation. We also excluded cross-over trials. • Serious maternal morbidity or death (e.g. ruptured uterus,
admission to intensive care unit, septicaemia, organ failure)
• Caesarean section for fetal distress
• Caesarean section for delay in labour
Types of participants
• Instrumental vaginal birth
All women with singleton pregnancies and cephalic presentations, • Vaginal birth not achieved within 24 hours, from onset of
in spontaneous labour at term. labour (as defined by trial authors)

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 10
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 • Postpartum haemorrhage (as defined by the trial authors) Search methods for identification of studies
• Blood transfusion
The following methods section of this review is based on a standard
• Regional analgesia
template used by Cochrane Pregnancy and Childbirth.
• Opioid use
• Duration of rupture of the membranes at the time of birth
• Performance of artificial rupture of the membranes during
labour Electronic searches
• Deep venous thrombosis We searched Cochrane Pregnancy and Childbirth’s Trials Register
• Pulmonary embolism by contacting their Information Specialist (31 August 2017).
• Antibiotic use The Register is a database containing over 24,000 reports of con-
• Duration of second stage of labour trolled trials in the field of pregnancy and childbirth. For full search
• Number of vaginal examinations in labour methods used to populate Pregnancy and Childbirth’s Trials Regis-
• Episiotomy ter, including the detailed search strategies for CENTRAL, MED-
• Third- and fourth-degree tears LINE, Embase and CINAHL; the list of handsearched journals
• Shoulder dystocia and conference proceedings, and the list of journals reviewed via
the current awareness service, please follow this link to the edi-
torial information about Cochrane Pregnancy and Childbirth in
the Cochrane Library and select the ’Specialized Register’ section
Long-term maternal outcomes from the options on the left side of the screen.
• Postnatal depression (as defined by trial authors) Briefly, Cochrane Pregnancy and Childbirth’s Trials Register is
• Breastfeeding failure (as defined by trial authors) maintained by their Information Specialist and contains trials
• Fistulae identified from:
• Perineal pain 1. monthly searches of the Cochrane Central Register of
• Dyspareunia Controlled Trials (CENTRAL);
• Abdominal pain 2. weekly searches of MEDLINE (Ovid);
• Backache reported six weeks postnatal 3. weekly searches of Embase (Ovid);
• Prolapse or urinary incontinence 4. monthly searches of CINAHL (EBSCO);
• Faecal incontinence 5. handsearches of 30 journals and the proceedings of major
• Relationship with baby (as defined by trial authors) conferences;
• Subsequent pregnancy complications 6. weekly current awareness alerts for a further 44 journals
• Postpartum rehospitalisation plus monthly BioMed Central email alerts.
Two people screen the search results and review the full text of
all relevant trial reports identified through the searching activities
Outcomes for baby described above. Based on the intervention described, each trial re-
port is assigned a number that corresponds to a specific Pregnancy
• Stillbirth or neonatal death or neonatal morbidity,
and Childbirth review topic (or topics), and is then added to the
excluding fatal malformations (e.g. seizures, birth asphyxia,
Register. The Information Specialist searches the Register for each
neonatal encephalopathy)
review using this topic number rather than keywords. This results
• Admission to special care nursery
in a more specific search set that has been fully accounted for in
• Need for intubation at birth
the relevant review sections (Included studies; Excluded studies;
• Neonatal septicaemia
Studies awaiting classification; Ongoing studies).
• Intrapartum fetal death
In addition, we searched ClinicalTrials.gov and the World Health
• Jaundice (as defined by trial authors)
Organization ( WHO) International Clinical Trials Registry Plat-
• Cord blood arterial pH less than 7.1
form ( ICTRP) (31 August 2017), for unpublished, planned and
• Birth trauma (e.g. Erb’s palsy, fractured skull,
ongoing trial reports using the search string: partogram OR par-
cephalhaematoma, fractured clavicle)
tograph.
• Childhood disability (as defined by trial author)

Staff Searching other resources

• Usability We searched the reference lists of retrieved studies. We did not
• Ability to audit apply any language or date restrictions.

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 11
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Data collection and analysis (2) Allocation concealment (checking for possible selection
bias)
For methods used in the previous version of this review, see
Lavender 2013. For each included study we described the method used to con-
For this update, we used the following methods for assessing the ceal allocation to interventions prior to assignment and assessed
13 relevant reports that we identified as a result of the updated whether intervention allocation could have been foreseen in ad-
search. vance of, or during recruitment, or changed after assignment.
The following methods section of this review is based on a standard We assessed the methods as being at:
template used by Cochrane Pregnancy and Childbirth. • low risk of bias (e.g. telephone or central randomisation;
consecutively numbered sealed opaque envelopes);
• high risk of bias (open random allocation; unsealed or non-
opaque envelopes, alternation; date of birth);
Selection of studies
• unclear risk of bias.
Two review authors independently assessed for inclusion all the
potential studies identified as a result of the search strategy. We
resolved any disagreement through discussion or, if required, we (3.1) Blinding of participants and personnel (checking for
consulted the third review author. When one review author was possible performance bias)
also the trial author (Lavender 1998a; Lavender 2006), the two For each included study we described the methods used, if any, to
remaining authors assessed the studies independently. blind study participants and personnel from knowledge of which
intervention a participant received. We considered that studies
were at low risk of bias if they were blinded, or if we judged that the
Data extraction and management lack of blinding was unlikely to affect results. We assessed blinding
separately for different outcomes or classes of outcomes.
We designed a form to extract data. For eligible studies, two re- We assessed the methods as being at:
view authors extracted the data using the agreed form. We resolved • low, high or unclear risk of bias for participants;
discrepancies through discussion or, if required, we consulted the • low, high or unclear risk of bias for personnel.
third review author. We entered data into Review Manager 5 soft-
ware (Review Manager 2014), and checked for accuracy.
When information regarding any of the above was unclear, we (3.2) Blinding of outcome assessment (checking for possible
planned to contact authors of the original reports to provide fur- detection bias)
ther details.
For each included study we described the methods used, if any, to
blind outcome assessors from knowledge of which intervention a
participant received. We assessed blinding separately for different
Assessment of risk of bias in included studies outcomes or classes of outcomes.
Two review authors (AC, RS) independently assessed risk of bias We assessed methods used to blind outcome assessment as being
for each study using the criteria outlined in the Cochrane Hand- at:
book for Systematic Reviews of Interventions (Higgins 2011). Any • low, high or unclear risk of bias.
disagreement was resolved by discussion or by involving the third
review author (TL).
(4) Incomplete outcome data (checking for possible attrition
bias due to the amount, nature and handling of incomplete
outcome data)
(1) Random sequence generation (checking for possible
For each included study, and for each outcome or class of out-
selection bias)
comes, we described the completeness of data, including attrition
We described the method used to generate the allocation sequence and exclusions from the analysis. We stated whether attrition and
in sufficient detail to allow an assessment of whether it should exclusions were reported and the numbers included in the analysis
produce comparable groups. at each stage (compared with the total randomised participants),
For each included study we assessed the method as being at: reasons for attrition or exclusion where reported, and whether
• low risk of bias (any truly random process, e.g. random missing data were balanced across groups or were related to out-
number table; computer random number generator); comes. Where sufficient information was reported, or could be
• high risk of bias (any non-random process, e.g. odd or even supplied by the trial authors, we planned to re-include missing
date of birth; hospital or clinic record number); data in the analyses that we undertook.
• unclear risk of bias. We assessed methods as being at:

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 12
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 • low risk of bias (e.g. no missing outcome data; missing Continuous data
outcome data balanced across groups); We used the mean difference (MD) if outcomes were measured
• high risk of bias (e.g. numbers or reasons for missing data in the same way between trials. If necessary, in future updates we
imbalanced across groups; ‘as treated’ analysis done with will use the standardised mean difference (SMD) to combine trials
substantial departure of intervention received from that assigned that measured the same outcome, but used different methods.
at randomisation);
• unclear risk of bias.
Unit of analysis issues

(5) Selective reporting (checking for reporting bias)

For each included study we described how we investigated the Cluster-randomised trials
possibility of selective outcome reporting bias and what we found. We did not identify any cluster-randomised trials. In future up-
We assessed the methods as being at: dates, if we identify any cluster-randomised trials, we will include
• low risk of bias (where it was clear that all of the study’s them in the analyses along with individually-randomised trials. We
prespecified outcomes and all expected outcomes of interest to will adjust their sample sizes using the methods described in the
the review have been reported); Cochrane Handbook for Systematic Reviews of Interventions (Higgins
• high risk of bias (where not all the study’s prespecified 2011), Section 16.3.4, using an estimate of the intracluster corre-
outcomes were reported; one or more reported primary lation coefficient (ICC) derived from the trial (if possible), from a
outcomes were not prespecified; outcomes of interest were similar trial or from a study of a similar population. If we use ICCs
reported incompletely and so could not be used; study failed to from other sources, we will report this and conduct sensitivity anal-
include results of a key outcome that would have been expected yses to investigate the effect of variation in the ICC. If we identify
to have been reported); both cluster-randomised trials and individually-randomised trials,
• unclear risk of bias. we plan to synthesise the relevant information. We will consider
it reasonable to combine the results from both if there is little het-
erogeneity between the study designs and the interaction between
the effect of intervention and the choice of randomisation unit is
(6) Other bias (checking for bias due to problems not
considered to be unlikely.
covered by (1) to (5) above)
We will also acknowledge heterogeneity in the randomisation unit
For each included study we described any important concerns we and perform a sensitivity analysis to investigate the effects of the
had about other possible sources of bias. randomisation unit.

(7) Overall risk of bias Cross-over trials

Cross-over trials are not a valid design for this review and we
We made explicit judgements about whether studies were at high
excluded them.
risk of bias, according to the criteria given in the Cochrane Hand-
book for Systematic Reviews of Interventions (Higgins 2011). With
reference to (1) to (6) above, we planned to assess the likely mag-
Other unit of analysis issues
nitude and direction of the bias and whether we considered it was
likely to have an impact on the findings. In future updates, we
will explore the impact of the level of bias through undertaking
sensitivity analyses (Sensitivity analysis). Multiple pregnancies
Women with a multiple pregnancy were not eligible for inclusion
in this review.
Measures of treatment effect

Trials with multiple treatment arms

Lavender 1998a was a three-arm trial. For each analysis, we used
Dichotomous data the data of one intervention pair and excluded the others, following
For dichotomous data, we presented results as summary risk ratio methods outlined in section 16.5.4 of the Cochrane Handbook for
(RR) with 95% confidence intervals (CIs). Systematic Reviews of Interventions (Higgins 2011).

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 13
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Dealing with missing data whether an overall summary was meaningful, and if it was, we
For included studies, we noted levels of attrition. In future updates, used random-effects analysis.
if we include more eligible studies, we will explore the impact of We planned to carry out the following subgroup analyses.
including studies with high levels of missing data in the overall • Resource setting: low-resource setting versus high-resource
assessment of treatment effect by using sensitivity analysis. setting.
For all outcomes, we carried out analyses, as far as possible, on an We planned to use the following outcomes in subgroup analyses:
intention-to-treat basis, i.e. we attempted to include all partici- caesarean section, oxytocin augmentation, duration of first stage
pants randomised to each group in the analyses. The denominator of labour, maternal experience of childbirth, Apgar score and ad-
for each outcome in each trial was the number randomised minus mission to special care nursery.
any participants whose outcomes were known to be missing. We planned to assess subgroup differences by interaction tests
available within Review Manager (Review Manager 2014), and to
Assessment of heterogeneity report the results of subgroup analyses, quoting the Chi² statistic
and P value, and the interaction test I² value.
We assessed statistical heterogeneity in each meta-analysis using
Given the small number of studies in each analysis, we did not
the Tau², I² and Chi² statistics. We regarded heterogeneity as sub-
perform our planned subgroup analysis as it would not produce
stantial if I² was greater than 30% and either Tau² was greater than
a meaningful analysis. We did, however, present the data under
zero, or there was a low P value (less than 0.10) in the Chi² test
high- and low-resource setting subheadings. If more studies are
for heterogeneity. If we identified substantial heterogeneity (above
identified in future updates, we will perform a subgroup analysis.
30%), we planned to explore it by prespecified subgroup analysis.

Sensitivity analysis
Assessment of reporting biases
We planned to carry out sensitivity analyses to explore the effect
In future updates, if there are 10 or more studies in the meta-
of allocation concealment and attrition bias on overall analyses, so
analysis we will investigate reporting biases (such as publication
that studies at high risk of bias for these domains were excluded
bias) using funnel plots. We will assess funnel plot asymmetry
from the analyses to see if this made any difference to the overall
visually. If asymmetry is suggested by a visual assessment, we will results. Two studies did not conceal allocation adequately (Sinha
perform exploratory analyses to investigate it. 2017; Walss Rodriguez 1987), and we removed them as part of
this sensitivity analysis.
Data synthesis
We carried out statistical analysis using the Review Manager 5 soft- Assessment of the quality of the evidence using the
ware (Review Manager 2014). We used fixed-effect meta-analysis GRADE approach
for combining data where it was reasonable to assume that studies For this update, we assessed the quality of the evidence using the
were estimating the same underlying treatment effect, i.e. where GRADE approach, as outlined in the GRADE handbook in order
trials were examining the same intervention, we judged the trials’ to assess the quality of the body of evidence relating to the fol-
populations and methods sufficiently similar. lowing outcomes for the main comparison: partograph compared
If there was clinical heterogeneity sufficient to expect that the un- to no partograph (studies carried out in high- and low-resource
derlying treatment effects differed between trials, or if substan- settings).
tial statistical heterogeneity was detected, we used random-effects • Caesarean section (overall)
meta-analysis to produce an overall summary if we considered • Oxytocin augmentation
an average treatment effect across trials clinically meaningful. We • Duration of first stage of labour (length of labour greater
treated the random-effects summary as the average range of possi- than 18 hours, length of labour greater than 12 hours)
ble treatment effects and we planned to discuss the clinical impli- • Maternal experience of childbirth (as defined by trial
cations of treatment effects differing between trials. If the average authors)
treatment effect was not clinically meaningful, we planned not to • Low Apgar score (less than 7 at 5 minutes)
combine trials. If we used random-effects analyses, we presented • Serious maternal morbidity or death (e.g. ruptured uterus,
the results as the average treatment effect with 95% CIs, and the admission to intensive care unit, septicaemia, organ failure)
estimates of Tau² and I². • Stillbirth or neonatal death or neonatal morbidity,
excluding fatal malformations (e.g. seizures, birth asphyxia,
Subgroup analysis and investigation of heterogeneity neonatal encephalopathy)
If we identified substantial heterogeneity, we planned to investigate We used GRADEpro Guideline Development Tool to import data
it using subgroup analyses and sensitivity analyses and to consider from Review Manager 5 (Review Manager 2014), in order to create

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 14
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
’Summary of findings’ tables. We produced a summary of the RESULTS
intervention effect and a measure of quality for each of the above
outcomes using the GRADE approach. The GRADE approach
uses five considerations (study limitations, consistency of effect,
imprecision, indirectness and publication bias) to assess the quality Description of studies
of the body of evidence for each outcome. The evidence can be
downgraded from ’high quality’ by one level for serious (or by
two levels for very serious) limitations, depending on assessments
for risk of bias, indirectness of evidence, serious inconsistency, Results of the search
imprecision of effect estimates or potential publication bias. See: Figure 2.

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 15
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Figure 2. Study flow diagram.

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 16
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
We retrieved 13 relevant reports of 10 trials from an updated search
in August 2017. Five of the trials met our inclusion criteria and Three studies compared partograph use with no partograph (Rani
have contributed data to this update (Lee 2015; Orhue 2013; Rani 2015; Walss Rodriguez 1987; Windrim 2006). The Rani 2015
2015; Shazly 2017; Sinha 2017). study took place in India, the Windrim 2006 study in Canada,
This review now includes 11 studies involving 9475 women and the Walss Rodriguez 1987 study in Mexico; therefore, they
(Kenchaveeriah 2011; Lavender 1998a; Lavender 2006; Lee 2015; were from very different settings. The Windrim 2006 and Walss
Orhue 2013; Pattinson 2003; Rani 2015; Shazly 2017; Sinha Rodriguez 1987 studies both compared their usual descriptive,
2017; Walss Rodriguez 1987; Windrim 2006). Three stud- sequential, recording of intrapartum details, with an experimental
ies are ongoing (NCT02714270; NCT02741141; NTR5543), arm, i.e. the partograph. The Rani 2015 study compared noting
and we excluded eight (Ajoodani 2011; Cartmill 1992; Fahdhy progress in the women’s case notes with utilising the World Health
2005; Hamilton 2001; Hamilton 2004; Kogovsek 2000; Mathews Organization (WHO) modified partograph. In the Windrim 2006
2007; WHO 1994), two in this update (Ajoodani 2011; WHO study, the partograph used incorporated a two-hour alert line, but
1994). Following the updated search, one study is awaiting as- no action line. The Walss Rodriguez 1987 study used a ’Friedman’
sessment as we are awaiting further information from authors partograph (Friedman 1954). The partograph was not currently
(NCT02911272). in use in either unit in the Walss Rodriguez 1987 or Windrim
2006 studies; it is unclear if the partograph was used routinely in
the Rani 2015 study.
Included studies
Four studies compared partographs with different placement of
action lines (Lavender 1998a; Lavender 2006; Orhue 2013; Sinha
2017). The Lavender 2006 study was a two-arm trial and the
Methods
Lavender 1998a study was a three-arm trial. Other than the place-
All trials were randomised controlled trials with individual ran- ment of the action line, labour management remained consistent.
domisation. The Walss Rodriguez 1987 trial was quasi-ran- If progress crossed the action line, a diagnosis of prolonged labour
domised. The studies by Kenchaveeriah 2011 and Walss Rodriguez was made and managed according to standard protocol; this in-
1987 generally lacked detail, making assessment of quality and volved clinical assessment and augmentation, as appropriate.
contextualisation of the results difficult. One study in South Africa compared a partograph with an alert and
action line with one which contained an alert line only (Pattinson
2003). In this study, the group that received a partograph with only
Participants and settings an alert line received more aggressive intrapartum management; a
Included studies took place in hospital settings in Australia (Lee vaginal examination was carried out every two hours and oxytocin
2015), Canada (Windrim 2006), Egypt (Shazly 2017), India ( infusion advocated when progress crossed the line. Those with
Kenchaveeriah 2011; Rani 2015; Sinha 2017), Mexico (Walss an alert and action line had more expectant management, vagi-
Rodriguez 1987), Nigeria (Orhue 2013), South Africa (Pattinson nal examinations every four hours, and commencement of oxy-
2003), and the UK (Lavender 1998a; Lavender 2006). tocin if progress crossed the four-hour action line. The Pattinson
Three studies took place between 1995 and 2005 (Lavender 2003 study was financially supported by the South African Medi-
1998a; Lavender 2006; Windrim 2006), two between 2005 and cal Research Council but did not report whether the authors dis-
2015 (Kenchaveeriah 2011; Rani 2015), two between 2015 and closed any conflicts of interest. The Kenchaveeriah 2011 study,
2016 (Lee 2015; Shazly 2017), and one took place in 1985 (Walss conducted in India, compared two partographs - a composite par-
Rodriguez 1987). The Orhue 2013, Pattinson 2003, and Sinha tograph including the latent phase with a modified one without
2017 trials did not report the dates of their studies. the latent phase. This trial was carried out in India were the use
Most studies only included primiparous women with uncom- of the partograph has not been incorporated and practiced widely,
plicated, low-risk pregnancies in spontaneous labour (Lavender even at the tertiary level. The plotting of the composite partograph
1998a; Lavender 2006; Lee 2015; Orhue 2013; Pattinson 2003; was started as soon as the woman was in labour. In the modified
Shazly 2017; Sinha 2017; Windrim 2006). The Kenchaveeriah partograph, the plotting of the partograph was started with at least
2011 and Walss Rodriguez 1987 studies did not specify parity, but 4 cm of cervical dilatation. Prolonged labour was defined when
only included women with uncomplicated pregnancies. The Rani the woman was in labour for more than 12 hours in the active
2015 study only included high-risk primiparous women. phase.
One study (Shazly 2017), conducted in a hospital in Egypt, com-
pared a labour scale with a traditional WHO partograph. The
Interventions and comparisons labour scale was developed from the WHO partograph, and was

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 17
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
designed to help clinicians recognise determinants and manage hours, from onset of labour (as defined by trial authors), blood
potential labour dystocia (Shazly 2014). The labour scale has par- transfusion, duration of rupture of the membranes at the time of
ticular trigger points throughout first and second stage where man- birth, deep venous thrombosis, pulmonary embolism, episiotomy,
agement is reviewed instead of having a fixed action line. Vaginal third- and fourth-degree tears, shoulder dystocia, neonatal septi-
examinations took place two-hourly in this trial. The labour scale caemia, jaundice, ability to audit, or any of the review’s long-term
monitors labour by filling in boxes, corresponding with cervical maternal or baby outcomes.
dilatation with dots, lines, or shading, depending on if there is long
progress (> 2 cm in two hours), short progress (1 cm in two hours),
or no progress, respectively. Progress can be ’reset’ if long progress Funding and conflicts of interest
is identified regardless of previous progress. No progress after two The Windrim 2006 study was supported by a grant from the Physi-
hours was followed either by artificial rupture of membranes, or cians’ Services Incorporated Foundation, Canada, The Lavender
oxytocin augmentation. For women undergoing artificial rupture 1998a and Lavender 2006 studies were funded by the Liverpool
of membranes, oxytocin augmentation was not started unless there Women’s Hospital, and the Pattinson 2003 study had financial
was no change in dilatation at the next examination. Dashed lines support from the South African Medical Research Council. None
at points throughout the scale recommend clinical re-evaluation: of the other studies reported their funding sources.
“after 8 hours of the latent phase, at the membrane line, at the None of the studies reported if any authors had conflicts of interest.
augmentation line and after 1 hour of the second stage” (Shazly
2014). We took most of the data for this trial from an unpublished
trial report provided by the authors. Excluded studies
One pilot study took place in Australia and compared a traditional We excluded eight studies from this review: two trials lacked suffi-
partograph with a two-hour action line (Lee 2015), with a dystocia cient detail to assess them adequately (Hamilton 2001; Kogovsek
line. The dystocia line partograph starts when the woman’s cervix 2000), and we were unable to contact the authors; two studies did
is a minimum of 4 cm dilated. The stepped line steepens at 6 not have partographs as an intervention (Fahdhy 2005; Hamilton
cm to account for the “progressive acceleration” of labour. If the 2004); one used partographs in both trial arms (Ajoodani 2011);
action line or vertical step line were crossed, a vaginal examination one was a cross-over trial (Mathews 2007); and two were not ran-
was performed in two hours to assess whether the line had been domised controlled trials (Cartmill 1992; WHO 1994).
crossed, and oxytocin augmentation was then discussed.
Risk of bias in included studies
Outcomes We assessed included studies for methodological quality on the
Only two outcomes were reported by all trials; caesarean section basis of sequence generation, allocation concealment, blinding,
rates and Apgar score. Other outcomes were not consistently re- attrition and other concerns about bias (see Methods section above,
ported; no trials reported vaginal birth not achieved within 24 and Figure 3).

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 18
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Figure 3. Risk of bias summary: review authors’ judgements about each risk of bias item for each included
study.

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 19
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Allocation
Selective reporting
We graded sequence generation as adequate (and therefore at low
Seven studies appeared to report all planned outcomes and we
risk of bias) in seven studies, with studies reporting the use of
judged them to be at low risk of bias (Kenchaveeriah 2011;
either a random number table or a computer random number
Lavender 1998a; Lavender 2006; Lee 2015; Pattinson 2003; Rani
generator (Kenchaveeriah 2011; Lavender 1998a; Lavender 2006;
2015; Windrim 2006). Reporting bias was unclear in the Walss
Pattinson 2003; Rani 2015; Shazly 2017; Windrim 2006), high
Rodriguez 1987 trial due to lack of prespecified outcomes re-
risk in two due to quasi-randomisation and lack of information
ported. There was too little information in the Orhue 2013 and
provided (Sinha 2017; Walss Rodriguez 1987), and unclear in
Sinha 2017 trials to assess this domain adequately. We judged the
two (Lee 2015; Orhue 2013). The Lee 2015 study used block
Shazly 2017 study at high risk of reporting bias as some of the
randomisation, and the Orhue 2013 study gave no information.
trial’s primary outcomes were not reported.
Allocation concealment was unclear in four trials (Kenchaveeriah
2011; Orhue 2013; Pattinson 2003; Rani 2015); low risk in five
trials (Lavender 1998a; Lavender 2006; Lee 2015; Shazly 2017;
Windrim 2006); and high risk in the Sinha 2017 and Walss Other potential sources of bias
Rodriguez 1987 trials. The Walss Rodriguez 1987 study was quasi- We judged the Lee 2015, Kenchaveeriah 2011, Rani 2015, and
randomised but the method of randomisation was not reported. Shazly 2017 studies as being at low risk of other sources of bias. Six
The method of randomisation was not clear in the Sinha 2017 trials were at unclear risk: the Lavender 1998a and Lavender 2006
study, however they reported the participants were “equally divided trials did not randomise all eligible women; the Orhue 2013, Sinha
into two groups” which suggests quasi-randomisation. There was 2017, and Walss Rodriguez 1987 trials did not provide sufficient
also no information in either study on how women were allocated information to adequately asses this domain; and the Windrim
to groups. 2006 trial gave no information on the number of women ap-
proached or the numbers of eligible women declining participa-
tion. We considered the Pattinson 2003 study to be at high risk
Blinding of bias as recruitment was stopped before the required sample size
Due to the nature of the intervention, it was not feasible to blind was reached due to funding constraints.
the women or clinical staff in any of the studies. Blinding of out-
come assessors was not attempted in three studies (Orhue 2013;
Effects of interventions
Rani 2015; Sinha 2017), and was not mentioned in five stud-
ies (Kenchaveeriah 2011; Pattinson 2003; Shazly 2017; Walss See: Summary of findings for the main comparison Partograph
Rodriguez 1987; Windrim 2006). Three studies were at low risk of compared to no partograph (studies carried out in high- and low-
detection bias due to the blinding of the statistician or researcher resource settings) for women in spontaneous labour at term
involved in outcome assessment (Lavender 1998a; Lavender 2006; No trials reported: vaginal birth not achieved within 24 hours,
Lee 2015). from onset of labour (as defined by trial authors); blood transfu-
sion; duration of rupture of the membranes at the time of birth;
deep venous thrombosis; pulmonary embolism; episiotomy, third-
and fourth-degree tears; shoulder dystocia; neonatal septicaemia;
Incomplete outcome data
jaundice; ability to audit; or any of the review’s long-term maternal
We judged attrition to be low in seven studies (Kenchaveeriah or baby outcomes.
2011; Lavender 1998a; Lavender 2006; Lee 2015; Pattinson 2003;
Walss Rodriguez 1987; Windrim 2006), with less than 1% of
participants excluded or lost to follow-up. In one trial (Lavender
1. Partograph versus no partograph
1998a), there were higher levels of missing data (13.5%) for the
maternal experience outcome. In this study, maternal experience We included three randomised trials in this comparison, with
was only assessed in a subset of women (n = 615); this comprised all 1813 women participating (Rani 2015; Walss Rodriguez 1987;
women recruited over a prespecified 12-month period, of whom Windrim 2006). The Walss Rodriguez 1987 study reported only
519 responded. Four studies were at unclear risk of attrition bias three outcomes, and the Rani 2015 study only two outcomes rele-
either due to lack of information in the trials reports (Orhue vant to this review, therefore we only pooled results for these out-
2013; Rani 2015; Sinha 2017), or a small number of women comes. We assessed evidence using the GRADE approach for this
withdrawing prior to the intervention and analysis (Shazly 2017). comparison (see Summary of findings for the main comparison).

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 20
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Primary outcomes Instrumental vaginal birth
There was no clear difference between groups in instrumental
vaginal birth in high- or low-resource settings (RR 0.99, 95% CI
0.84 to 1.15; n = 1813; 3 trials; Analysis 1.5).
Caesarean section There was insufficient evidence of benefit or harm in any of the
There was no clear difference between groups in caesarean section other secondary maternal or neonatal outcomes, reported by the
rates (average risk ratio (RR) 0.77, 95% confidence interval (CI) Windrim 2006 study.
0.40 to 1.46; n = 1813; 3 trials; I² = 87%; very low-quality evi- • Regional analgesia - epidural (RR 1.01, 95% CI 0.98 to
dence; Analysis 1.1). There were high levels of heterogeneity for 1.05; n = 1156; 1 trial; Analysis 1.6).
this result (heterogeneity: Tau² = 0.28; Chi² = 15.07 (P = 0.0005); • Performance of artificial rupture of membranes (RR 0.99,
I² = 87%) so this result should be interpreted with caution. 95% CI 0.88 to 1.11; n = 1156; 1 trial; Analysis 1.7).
• Antibiotic use (RR 1.23, 95% CI 0.88 to 1.73; n = 1156; 1
trial; Analysis 1.8).
• Duration of second stage of labour (MD 0.00 hours, 95%
Oxytocin augmentation CI -0.21 to 0.21; n = 1156; 1 trial; Analysis 1.9).
The Windrim 2006 study reported no clear difference between • Number of vaginal examinations in labour (mean of 4
groups in oxytocin augmentation (RR 1.02, 95% CI 0.95 to 1.10; examinations in labour for both groups; Analysis 1.10).
n = 1156; 1 trial; moderate-quality evidence; Analysis 1.2). • Admission to special care nursery (RR 0.94, 95% CI 0.51
to 1.75; n = 1156; 1 trial; Analysis 1.11).

Duration of first stage of labour Sensitivity analysis

The Windrim 2006 study reported no clear difference between The Walss Rodriguez 1987 study had poor allocation concealment
groups in duration of first stage of labour (mean difference (MD) and provided very little information on study methods. In view
0.80 hours, 95% CI -0.06 to 1.66; n = 1156; 1 trial; low-quality of the high risk of bias associated with this study, we carried out
evidence; Analysis 1.3). a sensitivity analysis excluding it from Analysis 1.1, Analysis 1.4,
and Analysis 1.5. There were no clear differences between groups
when we removed this study.

Maternal experience of childbirth

2. Partograph with two-hour action line versus
Not reported in this comparison.
partograph with four-hour action line
Four randomised trials were included in this comparison with
4749 women participating (Lavender 1998a; Lavender 2006;
Low Apgar score (less than 7 at 5 minutes) Orhue 2013; Sinha 2017). Two studies were carried out in the
There was no clear difference between groups in Apgar score less same high-resource setting (Lavender 1998a; Lavender 2006); two
than 7 at five minutes (RR 0.76, 95% CI 0.29 to 2.03; n = 1596; studies were carried out in a low-resource setting (Orhue 2013;
2 trials; very low-quality evidence; Analysis 1.4). Sinha 2017).

Primary outcomes
Secondary outcomes

In addition to the general list of outcomes not reported in any of

the trials (see under heading ‘Effects of Interventions’), no trials Caesarean section
reported the following secondary outcomes for this comparison: There was no clear difference in caesarean section rates between
serious maternal morbidity or death; caesarean section for fetal the groups (average RR 1.06, 95% CI 0.88 to 1.28; n = 4749; 4
distress; caesarean section for delay in labour; instrumental vaginal trials; Analysis 2.1).
birth; postpartum haemorrhage; opioid use; antibiotic use; still-
birth or neonatal death or neonatal morbidity, excluding fatal mal-
formations; need for intubation at birth; intrapartum fetal death; Oxytocin augmentation
cord blood arterial pH less than 7.1; birth trauma; childhood dis- Women in the two-hour action line group were more likely to
ability; usability. receive oxytocin augmentation (average RR 2.44, 95% CI 1.36 to

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 21
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
4.35; n = 4749; 4 trials; I² = 96%; Analysis 2.2). There is high het- • Regional analgesia - epidural (average RR 1.06, 95% CI
erogeneity in this outcome and the results should be interpreted 0.92 to 1.21; n = 3601; 2 trials; I² = 35%; Analysis 2.11).
with caution (Tau² = 0.29; I² = 96%). The effect was much greater Heterogeneity is over 30% for this outcome (Tau² = 0.00; I² =
for the women in the two-hour action line group in the low-re- 35%) and the results should be interpreted cautiously.
source setting (average RR 7.22, 95% CI 2.49 to 20.91; n = 1148; • Performance of artificial rupture of membranes (average RR
2 trials; I² = 78%), than in the high-resource setting (average RR 1.00, 95% CI 0.84 to 1.18; n = 3801; 3 trials; I² = 55%; Analysis
1.14, 95% CI 1.05 to 1.22; n = 3601; 2 trials). However there 2.12). Heterogeneity is over 30% for this outcome (Tau² = 0.01;
was high heterogeneity within the low-resource setting subgroup I² = 55%) and the results should be interpreted cautiously.
(Tau² = 0.46; I² = 78%) and this should be interpreted with cau- • Number of vaginal examinations in labour (MD -0.08, 95%
tion. CI -0.37 to 0.21; random-effects; n = 3601; 2 trials; I² = 70%;
Tau² = 0.03; Analysis 2.13). High heterogeneity has been noted
for this outcome and the results should be interpreted cautiously.
Duration of first stage of labour • Serious neonatal morbidity or perinatal death (no events in
One trial reported “prolonged labour” (Orhue 2013). No clear either group; Analysis 2.14).
difference was observed between groups (RR 0.81, 95% CI 0.32 • Admission to special care nursery (RR 0.83, 95% CI 0.51
to 2.04; n = 948; 1 trial; Analysis 2.3). to 1.34; n = 3801; 3 trials; Analysis 2.15).
• Cord blood arterial pH less than 7.1 (RR 0.73, 95% CI
0.44 to 1.22; n = 3601; 2 trials; Analysis 2.16).
Maternal experience of childbirth (reported as negative
childbirth experience)
Sensitivity analysis
There was no clear difference in number of women reporting nega-
tive childbirth experience between groups (average RR 0.61, 95% The Sinha 2017 trial did not give clear information on allocation
CI 0.28 to 1.35; n = 2269; 2 trials; I² = 83%; Analysis 2.4). Het- concealment but states that women were “equally divided into two
erogeneity was high for the outcome (Tau² = 0.27; I² = 83%) and groups” which suggests quasi-randomisation was used. In view of
the results should be interpreted with caution. the high risk of bias associated with this study, we carried out a
sensitivity analysis, excluding it from Analysis 2.1, Analysis 2.2,
Analysis 2.5, Analysis 2.9, Analysis 2.12, and Analysis 2.15. There
Low Apgar score (less than 7 at 5 minutes) were no clear differences between groups when we removed this
study. Performance of artificial rupture of membranes (Analysis
There was no clear difference between groups in babies with low
2.12), appeared to favour the four-hour partograph when the
Apgar scores (RR 0.93, 95% CI 0.61 to 1.42; n = 4749; 4 trials;
Sinha 2017 trial was removed, however, the lower CI still touched
Analysis 2.5).
the line of no effect.

Secondary outcomes 3. Partograph with two-hour action line versus

In addition to the general list of outcomes not reported in any partograph with three-hour action line
of the trials (see under heading ‘Effects of Interventions’), no tri- Only one randomised trial (carried out in a high-resource setting)
als reported the following secondary outcomes for this compari- compared a two-hour versus a three-hour action line, with 617
son: opioid use; antibiotic use; duration of second stage of labour; women participating (Lavender 1998a).
need for intubation at birth; intrapartum fetal death; birth trauma;
childhood disability; usability.
There were no clear differences in any of the secondary maternal Primary outcomes
or neonatal outcomes reported in these trials.
• Serious maternal morbidity or death (no events in either
group; Analysis 2.6). Caesarean section
• Caesarean section for fetal distress (RR 1.30, 95% CI 0.86 There was no clear difference in overall caesarean section rate (RR
to 1.96; n = 3601; 2 trials; Analysis 2.7). 0.78, 95% CI 0.51 to 1.18; n = 617; 1 trial; Analysis 3.1).
• Caesarean section for delay in labour (RR 0.98, 95% CI
0.77 to 1.25; n = 3601; 2 trials; Analysis 2.8).
• Instrumental vaginal birth (RR 0.92, 95% CI 0.81 to 1.04; Oxytocin augmentation
n = 3801; 3 trials; Analysis 2.9). There was no clear difference between groups for oxytocin aug-
• Postpartum haemorrhage - blood loss > 500 mL (RR 1.06, mentation (RR 1.02, 95% CI 0.85 to 1.21; n = 617; 1 trial;
95% CI 0.90 to 1.25; n = 4549; 3 trials; Analysis 2.10). Analysis 3.2).

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Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Duration of first stage of labour 4. Partograph with three-hour action line versus
Not reported in this comparison. partograph with four-hour action line
Only one randomised trial, again carried out in a high-resource
setting, compared a three-hour versus a four-hour action line, with
613 women participating (Lavender 1998a).
Maternal experience of childbirth (reported as negative
childbirth experience)
Women in the two-hour action line group were less likely to report Primary outcomes
a negative childbirth experience than those in the three-hour action
line group (RR 0.49, 95% CI 0.27 to 0.90; n = 348; 1 trial;
Analysis 3.3). Caesarean section
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; Analysis
Low Apgar score (less than 7 at 5 minutes) 4.1).

There was no clear difference between the groups in the number

of babies with Apgar scores of less than 7 at five minutes (RR 1.44, Oxytocin augmentation
95% CI 0.41 to 5.05; n = 617; 1 trial; Analysis 3.4). There was no clear difference in oxytocin augmentation between
the groups (RR 1.09, 95% CI 0.91 to 1.30; n = 613; 1 trial;
Analysis 4.2).
Secondary outcomes
In addition to the general list of outcomes not reported in any Duration of first stage of labour
of the trials (see under heading ‘Effects of Interventions’), this
Not reported in this comparison.
trial did not report the following secondary outcomes for this
comparison: opioid use; antibiotic use; duration of second stage
of labour; need for intubation at birth; intrapartum fetal death; Maternal experience of childbirth (reported as negative
birth trauma; childhood disability; usability. childbirth experience)
There were no clear differences in any of the secondary maternal There was no clear difference in negative childbirth experiences
or neonatal outcomes reported in this trial. between the groups (RR 0.80, 95% CI 0.51 to 1.27; n = 340; 1
• Serious maternal morbidity or death (no events in either trial; Analysis 4.3). Loss to follow-up was noticeably high for this
group; Analysis 3.5). outcome.
• Caesarean section for fetal distress (RR 0.96, 95% CI 0.44
to 2.10; n = 617; 1 trial; Analysis 3.6).
• Caesarean section for delay in labour (RR 0.71, 95% CI Low Apgar score (less than 7 at 5 minutes)
0.42 to 1.19; n = 617; 1 trial; Analysis 3.7). There was no clear difference between the groups in the number
• Instrumental vaginal birth (RR 0.93, 95% CI 0.69 to 1.26; of babies with Apgar scores of less than 7 at five minutes (RR 0.82,
n = 617; 1 trial; Analysis 3.8). 95% CI 0.22 to 3.04; n = 613; 1 trial; Analysis 4.4).
• Postpartum haemorrhage - blood loss > 500 mL (RR 0.96,
95% CI 0.63 to 1.45; n = 617; 1 trial; Analysis 3.9).
• Regional analgesia - epidural (RR 1.16, 95% CI 0.94 to Secondary outcomes
1.44; n = 617; 1 trial; Analysis 3.10). In addition to the general list of outcomes not reported in any
• Performance of artificial rupture of membranes during of the trials (see under heading ‘Effects of Interventions’), this
labour (RR 0.94, 95% CI 0.77 to 1.15; n = 617; 1 trial; Analysis trial did not report the following secondary outcomes for this
3.11). comparison: opioid use; antibiotic use; duration of second stage
• Number of vaginal examinations in labour (MD 0.00, 95% of labour; need for intubation at birth; intrapartum fetal death;
CI -0.29 to 0.29; n = 617; 1 trial; Analysis 3.12). birth trauma; childhood disability; usability.
• Serious neonatal morbidity or perinatal death (no events in There were no clear differences between the groups for any of the
either group; Analysis 3.13). reported secondary outcomes.
• Admission to special care nursery (RR 3.83, 95% CI 0.43 • Serious maternal morbidity or death (no events in either
to 34.12; n = 617; 1 trial; Analysis 3.14). group; Analysis 4.5).
• Cord blood arterial pH less than 7.1 (RR 0.38, 95% CI • Caesarean section for fetal distress (RR 1.77, 95% CI 0.70
0.07 to 1.96; n = 617; 1 trial; Analysis 3.15). to 4.42; n = 613; 1 trial; Analysis 4.6).

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 23
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 • Caesarean section for delay in labour (RR 1.68, 95% CI Low Apgar score (less than 7 at five minutes)
0.97 to 2.91; n = 613; 1 trial; Analysis 4.7). There was no clear difference in number of low Apgar scores at five
• Instrumental vaginal birth (RR 0.96, 95% CI 0.72 to 1.28; minutes between the groups (RR 7.12, 95% CI 0.37 to 137.36;
n = 613; one trial; Analysis 4.8). n = 694; 1 trial; Analysis 5.3).
• Postpartum haemorrhage - blood loss > 500 mL (RR 1.03,
95% CI 0.68 to 1.56; n = 613; 1 trial; Analysis 4.9).
• Regional analgesia - epidural (RR 1.01, 95% CI 0.80 to Secondary outcomes
1.27; n = 613; 1 trial; Analysis 4.10). In addition to the general list of outcomes not reported in any of
• Performance of artificial rupture of membranes during the trials (see under heading ‘Effects of Interventions’), no trials
labour (RR 1.04, 95% CI 0.85 to 1.26; n = 613; 1 trial; Analysis reported the following secondary outcomes for this comparison:
4.11). serious maternal morbidity or death; caesarean section for fetal
• Number of vaginal examinations in labour (MD 0.10, 95% distress; caesarean section for delay in labour; postpartum haemor-
CI -0.19 to 0.39; n = 613; 1 trial; Analysis 4.12). rhage; regional analgesia; opioid use; performance of artificial rup-
• Serious neonatal morbidity or perinatal death (no events in ture of the membranes during labour; antibiotic use; duration of
either group; Analysis 4.13). second stage of labour; number of vaginal examinations in labour;
• Admission to special care nursery (RR 0.51, 95% CI 0.05 stillbirth or neonatal death or neonatal morbidity, excluding fatal
to 5.65; n = 613; 1 trial; Analysis 4.14). malformations; admission to special care nursery; need for intu-
• Cord blood arterial pH less than 7.1 (RR 2.57, 95% CI bation at birth; intrapartum fetal death; cord blood arterial pH
0.50 to 13.17; n = 613; 1 trial; Analysis 4.15). less than 7.1; birth trauma; childhood disability; usability
There were no clear differences in any of the secondary maternal
or neonatal outcomes reported in this trial.
5. Partograph with alert line only versus partograph • Instrumental vaginal birth (RR 0.87, 95% CI 0.66 to 1.15;
with alert and action line n = 694; 1 trial; Analysis 5.4).
Only one randomised trial compared a partograph with an alert • Perinatal death (RR 7.12, 95% CI 0.37 to 137.36; n = 694;
line only versus a partograph with an alert and action line, with 1 trial; Analysis 5.5).
694 women participating (Pattinson 2003). This trial was carried
out in a low-resource setting.
6. Partograph with latent phase versus partograph
without latent phase
Primary outcomes Only one study examined the comparison between partograph
with latent phase (composite) versus partograph without latent
phase (modified) (Kenchaveeriah 2011), and 743 women partici-
pated.
Caesarean section
The caesarean section rate was lower in the alert line only group
(RR 0.68, 95% CI 0.50 to 0.93; n = 694; 1 trial; Analysis 5.1). Primary outcomes

Oxytocin augmentation Caesarean section

There was no clear difference when oxytocin augmentation was The caesarean section rate was higher in the partograph with latent
managed aggressively, with the use of a single alert and action line, phase (composite) group (95% RR 2.45, 95% CI 1.72 to 3.50; n
or conservatively with separate alert and action lines (RR 0.81, = 743; 1 trial; Analysis 6.1).
95% CI 0.62 to 1.05; n = 694; 1 trial; Analysis 5.2).
Oxytocin augmentation
Duration of first stage of labour The partograph with latent phase condition produced more inci-
dences of augmentation of labour (RR 2.18, 95% CI 1.67 to 2.83;
Not reported in this comparison. n = 743; 1 trial; Analysis 6.2).

Maternal experience of childbirth Duration of first stage of labour

Not reported in this comparison. Not reported in this comparison.

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 24
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Maternal experience of childbirth Usability: user-friendliness score
Not reported in this comparison. In the modified partograph group there was a higher user-friend-
liness score (mean difference (MD) -7.89, 95% CI -8.14 to -7.64;
n = 743; 1 trial; Analysis 6.8); 93% of staff felt the partograph
with latent phase (composite) was more difficult to use. The par-
Low Apgar score (less than 7 at 5 minutes) tographs were scored on ease of teaching, usefulness, interpreta-
There was no clear advantage for one condition with respect to tion and overall rating.
Apgar score less than 7 at five minutes (RR 0.75, 95% CI 0.21 to
2.63; n = 743; 1 trial; Analysis 6.3).
7. Partograph with two-hour action line versus
partograph with stepped dystocia line
Secondary outcomes One pilot study involving 99 women took place in Australia (Lee
2015), and compared a traditional partograph with a two-hour
In addition to the general list of outcomes not reported in any of
action line, with a dystocia line. The dystocia line partograph
the trials (see under heading ‘Effects of Interventions’), no trials
starts when the woman’s cervix is a minimum of 4 cm dilated.
reported the following secondary outcomes for this comparison:
The stepped line steepens at 6 cm to account for the “progressive
serious maternal morbidity or death; postpartum haemorrhage;
acceleration” of labour. If the action line or vertical step line were
regional analgesia; opioid use; performance of artificial rupture of
crossed, a vaginal examination was performed in two hours to as-
the membranes during labour; antibiotic use; duration of second
sess whether the line had been crossed, and oxytocin augmenta-
stage of labour; number of vaginal examinations in labour; still-
tion was then discussed.
birth or neonatal death or neonatal morbidity, excluding fatal mal-
formations; need for intubation at birth; intrapartum fetal death;
cord blood arterial pH less than 7.1; birth trauma; childhood dis-
Primary outcomes
ability.

Caesarean section
Caesarean section for fetal distress
There was no clear difference between the groups in rates of cae-
The level of caesarean section fetal distress was higher in the par-
sarean section (RR 1.10, 95% CI 0.46 to 2.62; n = 99; 1 trial;
tograph with latent phase (composite) (RR 4.87, 95% CI 2.83 to
Analysis 7.1).
8.37; n = 743; 1 trial; Analysis 6.4).

Oxytocin augmentation
Caesarean section for delay in labour
Fewer women in the dystocia line group received oxytocin aug-
There was no clear difference between the groups in the caesarean mentation than those in the two-hour action line group (RR 0.62,
section rate for delay in labour (RR 1.35, 95% CI 0.59 to 3.08; n 95% CI 0.39 to 0.98; n = 99; 1 trial; Analysis 7.2).
= 743; 1 trial; Analysis 6.5).

Duration of first stage of labour (labour longer than 12

hours)
Instrumental vaginal birth
There was no clear difference between the groups in duration of
There was no clear advantage for one condition with respect to
the first stage of labour (labour longer than 12 hours) (RR 0.76,
instrumental vaginal birth (RR 1.04, 95% CI 0.61 to 1.77; n =
95% CI 0.31 to 1.89; n = 99; 1 trial; Analysis 7.3).
743; 1 trial; Analysis 6.6).

Maternal experience of childbirth (Birth Satisfaction Score

Admission to special care nursery (BSS-R))
There were fewer admissions to special care nursery in the parto- Women in both groups gave similar birth satisfaction scores in a
graph without latent phase condition (RR 1.84, 95% CI 1.29 to survey completed in the immediate postpartum period (MD 0.00,
2.63; n = 743; 1 trial; Analysis 6.7). 95% CI -3.58 to 3.58; n = 90; 1 trial; Analysis 7.4).

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 25
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Low Apgar score (less than 4 at 4 minutes) (non-prespecified Oxytocin augmentation
outcome) Fewer women in the labour scale group received oxytocin augmen-
One baby in each group had an Apgar score less than 4 at four tation (RR 0.32, 95% CI 0.18 to 0.54; n = 122; 1 trial; Analysis
minutes (RR 0.98, 95% CI 0.06 to 15.23; n = 99; 1 trial; Analysis 8.2).
7.5). An Apgar score below 7 at five minutes was not reported.

Duration of first stage of labour

Secondary outcomes The Shazly 2017 trial reported duration of active stage of labour.
There was no clear difference between the labour scale and parto-
In addition to the general list of outcomes not reported in any of
graph groups (MD 0.44 hours, 95% CI -0.40 to 1.28; n = 110; 1
the trials (see under heading ‘Effects of Interventions’), no trials trial; Analysis 8.3).
reported the following secondary outcomes for this comparison:
serious maternal morbidity or death; caesarean section for fetal
distress; caesarean section for delay in labour; performance of ar- Maternal experience of childbirth
tificial rupture of the membranes during labour; antibiotic use;
Not reported in this comparison.
duration of second stage of labour; number of vaginal examina-
tions in labour; stillbirth or neonatal death or neonatal morbidity,
excluding fatal malformations; admission to special care nursery; Low Apgar score (less than 7 at 5 minutes)
intrapartum fetal death; cord blood arterial pH less than 7.1; birth
No babies in either group had Apgar scores of less than 7 at five
trauma; childhood disability; usability.
minutes (110 babies; Analysis 8.4).
There were no clear differences between groups for any of the
secondary outcomes reported.
• Instrumental vaginal birth (RR 0.75, 95% CI 0.37 to 1.56; Secondary outcomes
n = 99; 1 trial; Analysis 7.6).
In addition to the general list of outcomes not reported in any of
• Postpartum haemorrhage - blood loss > 500 mL (RR 1.57,
the trials (see under heading ‘Effects of Interventions’), no trials
95% CI 0.55 to 4.46; n = 99; 1 trial; Analysis 7.7).
reported the following secondary outcomes for this comparison:
• Regional analgesia (RR 0.86, 95% CI 0.56 to 1.32; n = 99;
serious maternal morbidity or death; caesarean section for fetal
1 trial; Analysis 7.8).
distress; instrumental vaginal birth; postpartum haemorrhage; re-
• Opioid use (RR 0.98, 95% CI 0.45 to 2.14; n = 99; 1 trial;
gional analgesia; opioid use; performance of artificial rupture of
Analysis 7.9).
the membranes during labour; antibiotic use; duration of second
• Need for intubation at birth. Described as “active
stage of labour; number of vaginal examinations in labour; ad-
resuscitation” (RR 0.44, 95% CI 0.14 to 1.32; n = 99; 1 trial;
mission to special care nursery; need for intubation at birth; in-
Analysis 7.10).
trapartum fetal death; cord blood arterial pH less than 7.1; birth
trauma; childhood disability; usability.

8. Partograph versus labour scale

Only one small study compared a labour scale versus a traditional Caesarean section for delay in labour
WHO partograph (Shazly 2017). One-hundred and twenty-two Fewer women in the labour scale group had a caesarean section
women were randomised, though six women in each group with- for delay in labour (RR 0.20, 95% CI 0.05 to 0.88; n = 122; 1
drew prior to analysis. We have used the number randomised for trial; Analysis 8.5).
all outcomes except for Apgar score less than 7 at five minutes,
neonatal death, and duration of first stage of labour.
Stillbirth or neonatal death or neonatal morbidity
The trial reported that there were no neonatal complications (110
Primary outcomes babies; Analysis 8.6).

Birth injuries and postpartum haemorrhage (PPH) (non-

Caesarean section prespecified outcome)
There were no clear differences between the groups for overall There was no clear difference between the groups for birth injuries
caesarean section (RR 0.42, 95% CI 0.16 to 1.11; n = 122; 1 trial; and PPH (RR 3.00, 95% CI 0.32 to 28.04; n = 122; 1 trial;
Analysis 8.1). Analysis 8.7).

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 26
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DISCUSSION Duration of first stage of labour, and maternal experience of child-
birth were not reported in this trial.

Summary of main results

Partograph with latent phase versus partograph
A total of 9475 women were recruited from 11 trials comparing without latent phase (Comparison 6: one trial, 743
partograph use; three trials comparing partograph use with no women)
partograph, seven trials comparing different partograph designs, When we compared a partograph with a latent phase (composite)
and one trial comparing a labour scale versus partograph. and one without (modified), 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
Partograph use versus no partograph (Comparison 1:
augmentation, or Apgar score less than 7 at five minutes.
3 trials, 1703 women)
Duration of the first stage of labour, and maternal experience of
There was no evidence of any clear difference between partograph childbirth were not reported.
use and no partograph in caesarean section rates (very low-quality
evidence); oxytocin augmentation (moderate-quality evidence);
duration of first stage of labour (low-quality evidence); or Apgar Partograph with two-hour action line versus
score less than 7 at five minutes (very low-quality evidence). partograph with stepped dystocia line (Comparison 7:
Serious maternal morbidity or death (e.g. ruptured uterus, admis- 1 trial, 99 women)
sion to intensive care unit, septicaemia, organ failure) and stillbirth When we compared a two-hour action line and a stepped dystocia
or neonatal death or neonatal morbidity, excluding fatal malfor- line, fewer women received oxytocin augmentation in the dystocia
mations (e.g. seizures, birth asphyxia, neonatal encephalopathy) line group. We did not observe any clear differences in caesarean
were not reported under this comparison. section rates, duration of the first stage of labour, maternal expe-
rience of childbirth, or low Apgar scores.
Partograph with different placement of action lines
(Comparisons 2 - 4: 4 trials, 5051 women) Partograph use versus labour scale (Comparison 8: 1
When compared to a four-hour action line, women in the two- trial, 122 women)
hour action line group were more likely to receive oxytocin aug- The labour scale compared with the partograph resulted in fewer
mentation. There was no clear difference in caesarean section rates; caesarean sections for delay in labour, and fewer women receiving
duration of first stage of labour; maternal experience of childbirth; oxytocin augmentation, but did not produce any clear difference
or Apgar score less than 7 at five minutes between the two- and for overall caesarean section rate, duration of first stage of labour,
four-hour action line. or low Apgar score.
The following comparisons only include data from single studies.
Fewer women reported negative childbirth experiences in the two-
hour action line group than the three-hour action line group but
Overall completeness and applicability of
there were no clear differences between the groups in caesarean
evidence
section, oxytocin augmentation, or low Apgar score. Duration of
first stage of labour was not reported. Based on the limited evidence from the 11 trials included in this
When we compared the three- and four-hour action line groups, review, there remains uncertainty regarding the effectiveness of
the caesarean section rate was higher in the three-hour action line partograph use.
group. We did not observe any clear differences in oxytocin aug- Only three trials compared partograph use with no partograph
mentation, maternal experience of childbirth, or low Apgar score. use. These trials were conducted in different settings; one in a
Duration of first stage of labour was not reported. high-resourced setting (Windrim 2006), and the other two in a
low-resourced setting (Rani 2015: Walss Rodriguez 1987). In two
studies (Walss Rodriguez 1987; Windrim 2006), the partograph
Partograph with alert line only versus partograph was the experimental arm. It is not clear in the Rani 2015 study
with alert and action line (Comparison 5: one trial, whether this was the experimental arm or not. These findings
694 women) cannot be extrapolated to units where the partograph is currently
The caesarean section rate was lower in the alert line only group. in use; removing the partograph as opposed to introducing it may
There were no clear differences between groups for oxytocin aug- produce different findings.
mentation, low Apgar score, instrumental vaginal birth, or peri- Seven trials compared the use of different designs of partograph
natal death. for women in spontaneous labour. Combined evidence from four

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 27
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
trials comparing the different placement of action lines showed be preferable.
little difference in caesarean section rates and few differences in Important clinical outcomes were absent from the included trials,
other maternal outcomes (Lavender 1998a; Lavender 2006; Orhue particularly in low-resourced settings, e.g. length of first and sec-
2013; Sinha 2017). When we compared the two-hour action line ond stage of labour. None of the trials examined the impact of the
with the four-hour action line, the only difference we found was partograph on resource utilisation; a factor particularly important
an increase in oxytocin augmentation in the two-hour arm. This is in low-resourced settings. Only the Lavender studies reported mea-
unsurprising given that the associated guidelines advocated earlier sures of maternal childbirth experience (Lavender 1998a; Lavender
use of oxytocin. When we compared the two-hour action line and 2006). None of the studies reported quality of care as an outcome.
three-hour action line, we found differences in the self-reported
maternal experience, with less women in the two-hour arm report-
ing a negative experience. The relevance of these findings is un- Quality of the evidence
certain, especially as the comparison between the two-hour versus
four-hour arm and three-hour versus four-hour arm revealed no Evidence from this review is inconclusive. Evidence from trials
differences. It may be that women in the two-hour arm perceived comparing partograph use with no partograph was limited to only
their labours to be shorter, as the three-hour action line was current three trials with 1813 women of varying risk of bias (Rani 2015;
local policy. Alternatively, it may be that because those women Walss Rodriguez 1987; Windrim 2006). We assessed prespecified
whose labours were managed with the two-hour action line re- outcomes using the GRADE approach for this comparison; we
ceived more intervention, they also received more labour support. graded evidence for caesarean section, and low Apgar score (less
There were no differences in any neonatal outcomes. Although the than 7 at five minutes) very low-quality, evidence for oxytocin
findings of these studies were fairly consistent, both studies were augmentation was moderate-quality, and duration of first stage of
from the same setting, and therefore their generalisability needs labour was low-quality. Maternal experience of childbirth, serious
consideration. maternal and neonatal morbidity or death were not reported under
We did not combine the South African trial with the previous trials this comparison. We downgraded evidence for limitations in study
(Pattinson 2003), as this was a trial which compared a partograph designs, high heterogeneity, indirectness, and imprecision in effect
with an alert line and aggressive management versus one with an estimates.
alert and action line, with more conservative management. This Overall, risk of bias varied in the included trials and no trial blinded
trial described a package of care for labour management along- women or staff. Two studies did not adequately conceal allocation.
side the partograph use, which advocated more frequent vaginal Loss to follow-up was low in all studies. The strongest study, in
examinations (two-hourly) for women in the aggressive manage- terms of quality, was that conducted by the Windrim 2006 study,
ment group, thereby suggesting a more complex intervention. This which showed no differences in any clinical outcomes measured
study compared different partograph designs that clearly demon- (caesarean section rate, duration of labour, oxytocin augmenta-
strated a difference in caesarean section rates; the more aggressive tion, amniotomy, epidural use, use of antibiotics in labour, Ap-
arm having the lower rate. Given that the partograph is a complex gar scores, or admissions to neonatal intensive care unit) follow-
intervention, used in conjunction with labour guidelines, the ap- ing introduction of the partograph. However, as acknowledged by
proach used in this study may be more appropriate. Utilising a re- the study authors, the findings may have been influenced by the
ductionist approach, to what is in essence a complex intervention, relatively high percentage of non-compliance in completing the
may produce less meaningful findings. partograph (20%) or the cross-contamination of care by staff, or
Kenchaveeriah 2011 compared two partographs - a composite both.
partograph including the latent phase with a modified one without
the latent phase. The trial confirmed that a partograph without a
latent phase was associated with a lower rate of caesarean section, Potential biases in the review process
indicating labour can be managed without a latent phase being
We accept the possibility of introducing bias in the review process,
plotted on the partograph.
however we have taken steps to minimise this. Two review authors
Only two of the trials included multiparous women (
independently assessed for inclusion all the potential studies iden-
Kenchaveeriah 2011; Walss Rodriguez 1987), one trial only in-
tified as a result of the search strategy. We resolved any disagree-
cluded women with high-risk pregnancies (Rani 2015), all other
ment through discussion or, if required, we consulted the third
trials included women with uncomplicated pregnancies in spon-
review author. Two review authors independently also assessed risk
taneous labour. However, in reality, the partograph is used for a
of bias for each study. Any disagreement was resolved by discus-
wide spectrum of women in the intrapartum period. Considera-
sion or by involving a third assessor.
tion needs to be given to the applicability of these review findings
Tina Lavender was investigator of two trials included in this review
to pregnant women who fall outside the inclusion criteria of the
(Lavender 1998a; Lavender 2006); therefore, two other reviewers
included trials. Further research on different populations would
(Smyth and Cuthbert) evaluated these studies.

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 28
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Agreements and disagreements with other used, as current evidence, from the included trials, fails to provide
studies or reviews robust guidance. Trials comparing different partograph designs,
are therefore needed.
We did not find any reviews that directly addressed clinical out-
comes related to partograph use. However, two recent reviews ex- Although the partograph is a low cost, low-invasive intervention, it
ploring barriers and facilitators to partograph use may assist any forms part of the overall management of labour care, making it part
ongoing work (Bedwell 2017; Ollerhead 2014). Both reviews ac- of a complex intervention. This complexity may, in part, account
knowledge the challenges of using current partographs but also for the heterogeneity within the results, particularly related to the
highlight the multifaceted factors which may be contributing to differences between high- and low-resourced settings. As such, any
its success or failure as a labour monitoring tool. future trials should be designed to consider the clinical environ-
A review of vaginal examinations has some relevance to this current ment in which it will be used. Standard care should be clearly de-
review (Downe 2013), particularly related to the cervicograph part scribed to allow for judgements on transferability of findings, to be
of the partograph, however the evidence currently presented is made. A cluster-randomised trial would be the most appropriate
limited to two small studies. design, as this would enable consideration of key organisational
There is a plethora of local, national and international guide- issues (e.g. training of individuals, hospital practices and clinical
lines, policies and training manuals which advocate partograph protocols). Using a cluster design would also reduce any contam-
use; most of these would recommend the World Health Orga- ination between facility-based health professionals who would be
nization (WHO) modified partograph. Until further evidence is supporting many women in labour at the same time; this was an
published, these remain relevant. Emerging evidence which chal- issue raised in the included trials.
lenges beliefs about normal patterns of labour progress are likely
to result in changes to partograph designs and subsequent recom- Given the limitations of existing trials, future studies could con-
mendations (Oladapo 2017). sider the inclusion of both primigravid and multigravid women,
as, in most units which use the partograph, the same chart is used
irrespective of parity. Any future trials should stratify participants
according to parity, services with low (20 or less per 1000) and
high perinatal mortality (more than 20) and low versus high in-
AUTHORS’ CONCLUSIONS
tervention rates in the first stage of labour. This clarity would also
allow for more accurate comparability, both clinically, and also be-
Implications for practice
tween trials for the purposes of systematic review by meta-analy-
There is no clear evidence that partographs improve outcomes and sis, allowing for more robust conclusions. The trials in this review
no clear evidence that one type of partograph is greatly superior to included women at urban hospitals only. Whether the partograph
another. However, we acknowledge that many units, in high- and is beneficial for women across all facilities is unclear and needs
low-income settings, currently use a partograph and have reported further investigation.
quality of care benefits in terms of ease of recording, provision of
pictorial overview of progress, auditing of care, training of clini- It is essential to involve consumers in all stages of future trials, and
cians and transferring of care (Bedwell 2017). Furthermore, there most significantly during the planning stages, in order to identify
has been evidence from non-randomised trials of potential bene- those outcomes which are deemed most relevant. Important out-
fits of partograph use (Bedwell 2017; Bosse 2002; Fawole 2008). comes are absent from the existing trials and should be considered
Given the fact that the partograph is currently in widespread use, in future protocols. Important clinical outcomes, for example, re-
it appears reasonable, until stronger evidence is available, for de- late to recognition of prolonged labour and include the length of
cisions regarding whether or not to use a partograph and which the first and second stage of labour. Moreover, maternal experience
one to use, to be locally determined following consultation with is of crucial importance and should be investigated using recog-
women and clinicians. nised validated tools in order to allow women to make informed
choices about their care. There was no information in any of the
Implications for research included trials regarding long-term outcomes for women and ba-
bies. We propose that future trialists should consider instituting
Whether or not there is a need for a trial of partograph use versus some form of long-term follow-up which is feasible and appropri-
no partograph is open for debate. One could argue that a trial of ate for the study population in question. Any future trials should
partograph use versus no partograph could be conducted in set- be of adequate size and data on economic outcomes should be
tings where a partograph is not used or by removing the parto- obtained, to allow for allocation of resources and service planning.
graph in some settings and comparing it to those where it remains.
However, a consensus of international experts proposed that this is As detailed earlier, in one study (Windrim 2006), there was a
no longer an important question (Fistula Care 2012), suggesting relatively high percentage of non-compliance in completing the
that a more important question is which partograph should be partograph; we were unable to draw any conclusions about why

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 29
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
this may have happened. In future trials, consideration should be Sherif Shazly for kindly providing further information regarding
given to the inclusion of a nested qualitative study, which would the SLiP trial (Shazly 2017).
enable the capture of comprehensive information on the barriers
Anna Hart for her contributions to earlier versions of the review.
and facilitators to partograph use.
As part of the pre-publication editorial process, this review has
been commented on by three peers (an editor and two referees
who are external to the editorial team), a member of Cochrane
Pregnancy and Childbirth’s international panel of consumers and
ACKNOWLEDGEMENTS the Group’s Statistical Adviser.

Eckhart Buchmann and Cheryl Nikodem for an earlier draft of the This project was supported by the National Institute for
protocol. Patrick O’Brien for the existing protocol which guided Health Research (NIHR), via Cochrane Infrastructure funding
this review. to Cochrane Pregnancy and Childbirth. The views and opinions
expressed therein are those of the authors and do not necessarily
Therese Dowswell for help with assessment of risk of bias, data reflect those of the Systematic Reviews Programme, NIHR, Na-
extraction, and technical assistance. tional Health Service (NHS) or the Department of Health.

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10.1002/14651858.CD010088.pub2 Oladapo OT, Diaz V, Bonet M, Abalos E, Thwin SS, Souza
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Tay 1996 Lavender 2005
Tay SK, Yong TT. Visual effect of partogram designs on Lavender T, O’Brien P, Hart A. Effect of partogram use
the management and outcome of labour. Australian and on outcomes for women in spontaneous labour at term.
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395–400. DOI: 10.1002/14651858.CD005461
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∗
Indicates the major publication for the study

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 33
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CHARACTERISTICS OF STUDIES

Characteristics of included studies [ordered by study ID]

Kenchaveeriah 2011

Methods 1-year randomised controlled trial. Conducted between November 2008 and October
2009

Participants 743 women with uncomplicated pregnancy in spontaneous labour with term, singleton,
vertex gestation

Interventions Composite partograph including the latent phase versus a modified partograph without
the latent phase

Outcomes • Rate of caesarean section

• Augmentation of labour
• Labour crossing the alert and action line
• Perinatal outcome
• User-friendliness
• Maternal complications

Notes Declarations of interest: none declared

Funding source: not reported

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Computer-generated random number ta-
bias) ble.

Allocation concealment (selection bias) Unclear risk No information on how women were allo-
cated to groups following random sequence
generation

Blinding of participants and personnel High risk Not feasible to blind women or clinical
(performance bias) staff.
All outcomes

Blinding of outcome assessment (detection Unclear risk Blinding not reported.

bias)
All outcomes

Incomplete outcome data (attrition bias) Low risk No apparent loss to follow-up.
All outcomes

Selective reporting (reporting bias) Low risk All outcomes prespecified in methods re-
ported.

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 34
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Kenchaveeriah 2011 (Continued)

Other bias Low risk Additional analysis performed, not pre-

specified in methods section of publication
regarding indication for caesarean section

Lavender 1998a

Methods Prospective randomised clinical trial. Random allocation by sealed, opaque envelopes.
Conducted between January 1996 and August 1997

Participants 928 primigravid women from the North-West of England, with uncomplicated preg-
nancies who presented in spontaneous labour at term

Interventions Women were randomised to have their progress of labour recorded on a partogram with
an action line 2, 3 or 4 hours to the right of the alert line

Outcomes • Caesarean section rate

• Maternal satisfaction
• Instrumental delivery rate
• Need for augmentation
• Randomisation to delivery interval
• Use of epidural
• Cord blood gas analysis
• Blood loss > 500 mL
• Number of vaginal examinations
• Apgar score
• Admission to special care baby unit

Notes Maternal satisfaction was only assessed in a subset of women, i.e. all women recruited
over a prespecified 12 month period (n = 615)
Declarations of interest: not reported
Funding source: study took place at the Liverpool Women’s Hospital

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Table of random numbers.

bias)

Allocation concealment (selection bias) Low risk Consecutively numbered, sealed, opaque
envelopes.

Blinding of participants and personnel High risk Not feasible to blind women or clinical
(performance bias) staff.
All outcomes

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 35
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Lavender 1998a (Continued)

Blinding of outcome assessment (detection Low risk Statistician blind to treatment allocation.
bias)
All outcomes

Incomplete outcome data (attrition bias) Low risk Small loss to follow-up after randomisation
All outcomes (less than 1% attrition) for outcomes mea-
sured in labour. Higher attrition rates for
the maternal satisfaction outcomes mea-
sured in the postnatal period

Selective reporting (reporting bias) Low risk All outcomes prespecified in methods re-
ported.

Other bias Unclear risk 10% (who were otherwise eligible) were
not approached (overall, 57% of eligible
women were randomised)

Lavender 2006

Methods Prospective randomised clinical trial. Random allocation by sealed, opaque envelopes.
Conducted between August 1998 and March 2005

Participants 2975 primigravid women from the North-West of England, with uncomplicated preg-
nancies, in spontaneous labour at term

Interventions Women were randomised to have their progress of labour recorded on a partogram with
an action line 2 or 4 hours to the right of the alert line

Outcomes Outcomes were stratified according to intended place of birth (midwife-led unit or
obstetric unit)
• Caesarean section rate
• Maternal satisfaction
• Instrumental delivery rate
• Need for augmentation
• Randomisation to delivery interval
• Use of epidural
• Cord blood gas analysis
• Blood loss > 500 mL
• Number of vaginal examinations
• Apgar score
• Admission to special care baby unit

Notes Declarations of interest: not reported

Funding source: Liverpool Women’s Hospital

Risk of bias

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 36
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Lavender 2006 (Continued)

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Table of random numbers. Randomisation
bias) stratified by intended place of birth (2 par-
ticipating units)

Allocation concealment (selection bias) Low risk Consecutively numbered, sealed, opaque
envelopes.

Blinding of participants and personnel High risk Not feasible to blind women or clinical
(performance bias) staff.
All outcomes

Blinding of outcome assessment (detection Low risk Statistician blind to treatment allocation.
bias)
All outcomes

Incomplete outcome data (attrition bias) Low risk Less than 1% attrition after randomisation.
All outcomes

Selective reporting (reporting bias) Low risk All outcomes prespecified in methods re-
ported.

Other bias Unclear risk Large numbers of women who were other-
wise eligible were not approached to partic-
ipate. The numbers not approached varied
depending on the recruiting unit, 26% not
approached in the midwifery and 61% in
the delivery unit

Lee 2015

Methods Pilot parallel (1:1), randomised, single-blinded study. Conducted January until May
2015 at a metropolitan hospital in Brisbane, Australia

Participants 99 nulliparous women with spontaneous labour onset at term gestation (37 to 41 + 6
weeks) with a single cephalic presentation
Exclusion criteria
• History of 3 or more consecutive miscarriages
• Previous fetal death in utero
• Previous mid-trimester loss/cervical incompetence/cone biopsy/known uterine
anomaly
• Rhesus isoimmunisation
• Complications during the current pregnancy (such as multiple pregnancy or fetal
abnormality)
• Precluding medical conditions such as cardiac disease, essential hypertension,
renal disease, pre-existing diabetes, previous gestational diabetes, epilepsy, severe
asthma, substance use, significant psychiatric disorders, age 40 years, or a body mass

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 37
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Lee 2015 (Continued)

index at beginning of pregnancy 35 (WHO Obesity Class II or higher)

Interventions Women were randomised to have their progress of labour recorded on a partograph with
a stepped dystocia line partograph with steps beginning at 4 cm cervical dilatation or a
2-hour action line rising at 1 cm per hour

Outcomes • Compliance
• Rate of artificial rupture of membranes
• Oxytocin augmentation
• Operative birth
• Postpartum haemorrhage
• Adverse effects
• Apgar score < 7 at 5 minutes
• NICU admission
• Need for neonatal resuscitation
• Neonatal systemic infection

Notes Participants’ labours were assessed as per the unit’s standard care, i.e. vaginal exams
every 4 hours, or more frequently if deemed necessary. Amniotomies were not routinely
performed among women with epidurals. Providing the plot of the progress of labour
stayed to the left of the Action or Dystocia line, augmentation was not indicated. If the
plot of progress reached the Action line, or the vertical ’step’ of the dystocia line, a vaginal
assessment was performed in 2 hours to determine if the line had been crossed; this
triggered discussion regarding the need for oxytocic augmentation (following amniotomy
if membranes still intact). If individual maternal/fetal status warranted, augmentation
could be initiated earlier according to clinician judgement
Funding: this study was supported by a grant provided by the Mater Research Institute,
Mater Health Services, Brisbane, Australia
Declarations of interest: the authors report that there is no conflict of interest

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Block randomisation (block size 4) was pre-
bias) pared by an independent statistician

Allocation concealment (selection bias) Low risk Opaque envelopes containing either in-
struction to use a standard care partograph,
upon which an Action line was drawn by
the midwife or a preprinted dystocia line
partograph were prepared by an indepen-
dent person in the Mater Research Support
Unit. Envelopes were stored in a locked
cupboard on the Birth Suite, with the key
held by the midwifery team leader. Regard-
less of allocation, each envelope contained
the same number of pages to prevent dif-
ferentiation by weight

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 38
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Lee 2015 (Continued)

Blinding of participants and personnel High risk Although the attending clinicians were
(performance bias) aware of the allocation, the participants
All outcomes were blinded to the treatment group. Staff
monitoring labour and prompting inter-
ventions were unblinded

Blinding of outcome assessment (detection Low risk Researchers conducting the analysis were
bias) blinded to the treatment group, however
All outcomes the staff recording the outcomes were un-
blinded

Incomplete outcome data (attrition bias) Low risk Data for all women are reported. 46/50 and
All outcomes 44/49 maternal surveys completed

Selective reporting (reporting bias) Low risk All outcomes reported for protocol.

Other bias Low risk Baseline characteristics are similar.

Orhue 2013

Methods Prospective controlled study. Dates of study not reported.

Participants 948 term nulliparous women were allocated to a partograph with 2-hour and 4-hour
action lines and the same protocol was used for labour care

Interventions Partograph with 2-hour action line versus partograph with a 4-hour action line

Outcomes • Caesarean section rate

• Primary postpartum haemorrhage
• Five minutes neonatal asphyxia
• Prolonged labour

Notes Awaiting response from authors for more information - contacted 21/04/2017
By the protocol, admission was in active labour by the midwife at 4 cm dilatation and
amniotomy performed. Vaginal examinations were repeated 2 hourly on the 2-hour or
4 hourly on the 4-hour action line partograph and plotted
Declarations of interest: not reported
Funding source: not reported

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Not reported.

bias)

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 39
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Orhue 2013 (Continued)

Allocation concealment (selection bias) Unclear risk It was stated in the protocol that alloca-
tion was random and masked but no details
given

Blinding of participants and personnel High risk The protocol stated that the study was
(performance bias) masked, but blinding not usually feasible
All outcomes for this type of intervention

Blinding of outcome assessment (detection High risk Blinding not feasible for this type of inter-
bias) vention and outcomes would be recorded
All outcomes by those providing clinical care who would
be aware of the intervention

Incomplete outcome data (attrition bias) Unclear risk No information on dropouts or missing
All outcomes data in the brief study report

Selective reporting (reporting bias) Unclear risk A protocol was available (trial registration)
but there was too little information in the
study report to assess whether the study was
carried out according to protocol

Other bias Unclear risk Too little information to assess.

Pattinson 2003

Methods Prospective randomised clinical trial. Random allocation by sealed, opaque envelopes.
Details of dates of study not provided

Participants 694 healthy nulliparous women from South Africa, who were in active spontaneous
labour, at term, with a healthy singleton pregnancy and cephalic presentation

Interventions Women were randomised to either aggressive or expectant management protocols

Aggressive management entailed: using a single line partograph, a vaginal examination
every 2 hours and use of oxytocin if the line was crossed
Expectant management entailed: using a 2-line partograph, with the alert line and a
parallel action line 4 hours to the right, with a vaginal examination every 4 hours. If the
action line was reached, oxytocin was started

Outcomes • Caesarean section rate

• Operative deliveries
• Oxytocin use
• Received analgesia
• Apgar score
• Perinatal death

Notes Declarations of interest: not reported

Funding source: financial support came from the South African Medical Research Coun-
cil

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 40
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Pattinson 2003 (Continued)

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Computer-generated list of random num-
bias) bers.

Allocation concealment (selection bias) Unclear risk Sealed, opaque envelopes.

Blinding of participants and personnel High risk Not feasible to blind women or clinical
(performance bias) staff.
All outcomes

Blinding of outcome assessment (detection Unclear risk Not reported.

bias)
All outcomes

Incomplete outcome data (attrition bias) Low risk Low attrition after randomisation (less than
All outcomes 1%). Where women did not receive the al-
located intervention, there was intention-
to-treat analyses

Selective reporting (reporting bias) Low risk All outcomes prespecified in methods re-
ported.

Other bias High risk Recruitment stopped before required sam-

ple size reached due to funding constraints

Rani 2015

Methods Prospective randomised controlled study.

Trial conducted at Patna Medical College and Hospital (tertiary hospital), Bihar, from
October 2006 to August 2008

Participants 400 mothers with high-risk pregnancy, enrolled in active labour - 223 women with
spontaneous onset
Inclusion criteria
• Primigravidas with high-risk pregnancies like pregnancy-induced hypertension
• Gestational diabetes mellitus
• Oligohydramnios
• Post-dates
• Cholestasis
• Hypothyroidism
• Patients with medical illness like seizure disorder, viral infections, at 37 weeks’
gestation with spontaneous or induced labour.
• Patients with 1 previous LSCS willing for trial of labour after taking informed
consent
Exclusion criteria

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 41
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Rani 2015 (Continued)

• Multiple pregnancy
• Malpresentation
• Heart disease
• Severe anaemia (Hb <6 gm/dl), antepartum eclampsia or haemorrhage
• Major degree of cephalopelvic disproportion
• Epidural analgesia
• elective LSCS or emergency LSCS in latent phase in high-risk pregnancy group

Interventions Partograph use versus no partograph.

Partograph group: progress of labour along with maternal vitals were recorded as stan-
dard notes on case record file as well as on modified WHO partograph. n = 200 (only
women with spontaneous onset of labour are included in our data and analyses n = 110)
No partograph group: the course of labour and maternal condition were documented
only as notes in case record file. n = 200 (only women with spontaneous onset of labour
are included in our data and analyses n = 113)

Outcomes • Duration of first and second stage of labour

• Oxytocin augmentation
• Mode of delivery
• Neonatal Apgar scores
• Meconium staining of liquor
• Fetal heart rate abnormalities
• Incidence of NICU admission
• Maternal complications, i.e. prolonged labour, postpartum haemorrhage and
puerperal sepsis

Notes Active phase of labour was diagnosed as regular contractions every 10 min or less, lasting
more than 40 secs, with cervical effacement more than 80 % and cervical dilatation of
4 cm
Vaginal examinations were performed 2-hourly or when indicated. Standard care in-
cluded early amniotomy
Funding: no funding reported
Declarations of interest: none declared

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk It was reported that women were ran-
bias) domised to either group by computer-gen-
erated random number. Cases were strati-
fied into 2 groups as with spontaneous on-
set of labour or following induced labour

Allocation concealment (selection bias) Unclear risk Not reported.

Blinding of participants and personnel High risk Not mentioned, assumed not possible to
(performance bias) blind.
All outcomes

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 42
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Rani 2015 (Continued)

Blinding of outcome assessment (detection High risk Not reported, assumed not due to nature
bias) of intervention. Outcomes likely to be re-
All outcomes ported by unblinded clinicians

Incomplete outcome data (attrition bias) Unclear risk Loss to follow-up and missing data were
All outcomes not mentioned; there was no study flow di-
agram

Selective reporting (reporting bias) Low risk All outcomes prespecified in methods re-
ported. Protocol not seen

Other bias Low risk Baseline characteristics are similar between

groups.

Shazly 2017

Methods A single centre, double-blinded, randomised trial conducted between July 2015 and June
2016 at Assiut University Hosptal, Egypt

Participants 122 nulliparous women randomised (data analysed for 110 women)
Inclusion criteria
• Nulliparous women
• Women who experienced spontaneous onset of labour
• Pregnant women 38 to 41 weeks with a singleton viable fetus
• Women with vertex presented
• Estimated fetal weights between 2500 g and 3800 g
Exclusion criteria
• Women with medical and obstetric comorbidities or fetal abnormalities
• Women with pre-labour rupture of membranes

Interventions Women either had labour managed by labour scale or by the traditional WHO partograph
The labour scale was developed from the WHO partograph with the NICE Intrapartum
Guidelines. It is designed to help clinicians recognise determinants and management of
potential labour dystocia. Instead of having a fixed 4-hour action line, the labour scale
has particular trigger points throughout first and second stage where management is
reviewed. The labour scale aims to collect more detailed reporting of labour than the
traditional partograph

Outcomes • Successful vaginal delivery

• Proportion who delivered vaginal versus those indicated for caesarean section for
labour dystocia
• Intrapartum maternal distress
• Maternal birth injuries
• Primary postpartum haemorrhage
• Maternal fever/postpartum infections
• Intrapartum fetal distress
• Birth injuries of the newborn

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 43
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Shazly 2017 (Continued)

• Neonatal distress “asphyxia” (as reported 1 and 5 minutes Apgar score,

resuscitation event, umbilical artery pH, admission to NICU, length of stay and any
further medical complications)

Notes Data from unpublished draft kindly provided by Sherif Shazly

Funding: no funding sources
Declarations of interest: none declared

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk A computer-generated randomisation list

bias) was created by one of the investigators
(AMA)

Allocation concealment (selection bias) Low risk Opaque sequentially numbered envelopes
were sealed and delivered to the nurse in
duty who assigned every new patient to the
next envelope

Blinding of participants and personnel High risk Blinding of women and clinicians not fea-
(performance bias) sible
All outcomes

Blinding of outcome assessment (detection Unclear risk Blinded for the principal investigator who
bias) received the final data, a computer-gen-
All outcomes erated randomisation list was created by
one of the investigators (AMA). Assign-
ment was single-blinded; double-blindness
was not logistically applicable. Randomisa-
tion number was used to collect and anal-
yse data afterwards

Incomplete outcome data (attrition bias) Unclear risk 55/61 in each group were analysed: 7
All outcomes women decided to withdraw from the
study before management was initiated (3
from labour scale, 4 from WHO parto-
graph) and 5 women decided to proceed
directly to caesarean section (3 in labour
scale, 2 in WHO partograph). Eventually,
55 women remained in each arm and data
were collected for analysis. No further loss
to follow-up

Selective reporting (reporting bias) High risk Vaginal/assisted vaginal births not re-
ported. Maternal complications were re-
ported as a composite and most neonatal
outcomes, such as admission to special care

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 44
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Shazly 2017 (Continued)

unit were not mentioned

Other bias Low risk Similar baseline characteristics between

groups.

Sinha 2017

Methods Prospective hospital based randomised study. Dates of trial not given

Participants 200 women randomised

Inclusion criteria
• Primigravida
• Aged 19 to 29 at term (had crossed 37 weeks of gestation) with singleton live,
term, cephalic presentation
• Uncomplicated pregnancy in spontaneous labour
Exclusion criteria
• Multipara
• Short stature < 140 cm
• Teenage pregnancy
• Elderly primigravida
• Multiple pregnancy
• Malpresentation
• Post-caesarean pregnancy
• Post-term pregnancy
• Preterm labour
• Oligohydramnios
• Intrauterine death
• Associated medical complications, i.e. diabetes, essential hypertension, heart
disease, anaemia
• Associated obstetrical complications, i.e. antepartum haemorrhage, placenta
previa, pre-eclampsia/eclampsia

Interventions 100 womens’ labour was monitored with 4-hour action line on WHO modified parto-
graph (group A), the other group (B) had the whole duration of labour monitored with
2-hour action line on the partograph

Outcomes • Duration of labour

• Need for augmentation
• Caesarean section rate
• Postpartum haemorrhage
• Fetal outcome in terms of Apgar score
• Admission to NICU

Notes The study was carried out in the department of Obstetrics and Gynecology, Gauhati
Medical College and Hospital, Guwahati, Assam, India. Both groups recording of labour
on WHO modified partograph were started only in active phase of labour. According to
guidelines of WHO modified partograph, active phase has been considered at 4 cm of
cervical dilatation
The management of labouring women in both groups was unaffected if labour followed

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 45
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Sinha 2017 (Continued)

the expected rate of progress. However, if cervical dilatation crossed the allocated action
line, a clinical assessment was made and guidelines for the management of prolonged
labour were followed. Where augmentation was required, this involved oxytocin alone
when membranes were ruptured or amniotomy followed by oxytocin in the presence of
intact membranes
Funding: no funding sources
Conflict of interest: none declared

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection High risk Not described - “randomised study” al-
bias) though it states groups were “divided
equally” into 2 groups which describes a
quasi-randomisation process

Allocation concealment (selection bias) High risk No clear information given but “equally di-
vided into two groups” suggests quasi-ran-
domisation

Blinding of participants and personnel High risk Not mentioned, but blinding of staff is not
(performance bias) feasible with this type of intervention
All outcomes

Blinding of outcome assessment (detection High risk Not reported, assumed not due to nature
bias) of intervention. Outcomes likely to be re-
All outcomes ported by unblinded clinicians

Incomplete outcome data (attrition bias) Unclear risk Loss to follow-up was not mentioned. No
All outcomes study flow diagram.

Selective reporting (reporting bias) Unclear risk Duration of labour not reported in this pa-
per. Protocol not available and little infor-
mation on methods

Other bias Unclear risk Baseline characteristics of groups not men-

tioned.

Walss Rodriguez 1987

Methods Prospective study in which women “at random” were distributed in 1 of 2 groups.
Conducted between 15 September to 25 October 1985

Participants 434 women in Mexico, with term pregnancies who presented in labour (cervix 2 cm or
more dilated) with live, singleton, cephalic presentation

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 46
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Walss Rodriguez 1987 (Continued)

Interventions One group had their labour managed according to the Friedman partogram and the
other had labour managed using a non-graphic, descriptive record

Outcomes • Caesarean section

• Forceps delivery
• Normal delivery
• Apgar score

Notes This study was translated into English.

Declarations of interest: not mentioned in translation
Funding source: not mentioned in translation

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection High risk Quasi-randomised study. No information

bias) on how randomisation was achieved

Allocation concealment (selection bias) High risk No information on how women were allo-
cated to groups, not clear that group allo-
cation was truly random

Blinding of participants and personnel High risk Not feasible to blind women or clinical
(performance bias) staff.
All outcomes

Blinding of outcome assessment (detection Unclear risk Not reported.

bias)
All outcomes

Incomplete outcome data (attrition bias) Low risk No apparent loss to follow-up.
All outcomes

Selective reporting (reporting bias) Unclear risk Unable to assess from translation.

Other bias Unclear risk Very little information on study methods

was provided.

Windrim 2006

Methods Prospective randomised clinical trial. Computerised allocation, by telephone. Conducted

between July 1997 and December 1999

Participants 1932 primiparous women, in Toronto, Canada, with uncomplicated pregnancies at term,
with contractions every 3 to 5 minutes and cervix at least 3 cm dilated. Outcomes were
stratified according to whether labour was spontaneous or induced. Only data from
women not induced were included (n = 1156)

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 47
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Windrim 2006 (Continued)

Interventions Women were randomised to 1 of 2 groups: the standard group, who had the progress of
labour charted in written notes, or the partograph group, whose progress in labour was
recorded using a bedside graphical partograph as well as written notes

Outcomes • Rate of caesarean section

• Operative vaginal delivery
• Spontaneous vaginal delivery
• Duration of first stage of labour
• Duration of second stage of labour
• Number of vaginal examinations
• Epidural analgesia use
• Artificial rupture of membranes
• Oxytocin augmentation
• Evaluation for non-reassuring fetal heart tracing
• Maternal and neonatal morbidity

Notes Only data from those in spontaneous labour are included in the review
Declarations of interest: none declared
Funding source: trial was supported by Grant # 96-33 from the Physicians’ Services
Incorporated Foundation, Canada

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Stratified randomisation by off-site com-
bias) puterised randomisation service

Allocation concealment (selection bias) Low risk By telephone to off-site service.

Blinding of participants and personnel High risk Not feasible to blind women or clinical
(performance bias) staff. Used bedside charts
All outcomes

Blinding of outcome assessment (detection Unclear risk Not reported.

bias)
All outcomes

Incomplete outcome data (attrition bias) Low risk No missing data apparent.
All outcomes

Selective reporting (reporting bias) Low risk All outcomes prespecified in methods re-
ported.

Other bias Unclear risk No information on the number of women

approached or the numbers of eligible
women declining participation

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 48
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
LSCS: lower segment caesarean section
NICE: National Institute for Health and Care Excellence
NICU: neonatal intensive care unit
WHO: World Health Organization

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Ajoodani 2011 Both groups had labour monitored by a partograph.

Cartmill 1992 A report of a hypothetical study. No research conducted and no data presented

Fahdhy 2005 This was a cluster-randomised trial in which midwives were randomised to receive training, alongside using the
partograph. The intervention was therefore the training and not the partograph. There is no description of what
midwives in the control group received

Hamilton 2001 This study was presented in abstract form only and lacked detail. It was particularly unclear whether participants
were in spontaneous labour and whether they were at term. We attempted to contact the trial author, without
success

Hamilton 2004 The study intervention was a computerised reference range, not a partograph

Kogovsek 2000 It was unclear from the presentation of data which outcome data were from women in spontaneous labour. We
were unable to contact any of the authors

Mathews 2007 This was a cross-over trial comparing 2 partographs; 1 which included a latent phase and 1 which did not. In this
study all physicians posted to the labour ward used the first partograph (composite or simplified depending on the
random allocation) for 10 days. After 1 week’s break, all physicians used the second partograph. Study participants
were therefore physicians and not women

WHO 1994 This was an observational study, not a randomised controlled trial

Characteristics of studies awaiting assessment [ordered by study ID]

NCT02911272

Methods Randomised controlled trial in a university teaching hospital in Nigeria

Participants Nulliparous women in labour at term

Inclusion criteria
• Healthy nulliparous women at term in spontaneous active phase labour with singleton pregnancies and intact
fetal membranes at first vaginal examination in labour ward
Exclusion criteria
• Multiparous patients
• Multiple pregnancies
• Pre-existing medical conditions complicating pregnancy

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 49
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
NCT02911272 (Continued)

• Non-cephalic presenting fetus at term

• Prelabour rupture of membrane at term
• Preterm labour
• Poor fetal growth in pregnancy

Interventions Partograph with 2-hour action line versus partograph with a 4-hour action line

Outcomes Prolonged labour, mode of birth, neonatal outcome.

Notes Awaiting more information from authors - contacted 21/04/2017 ’[email protected]’ as could not locate Dr Orhue’s
personal email

Characteristics of ongoing studies [ordered by study ID]

NCT02714270

Trial name or title A randomised clinical trial of paperless versus modified World Health Organization partograph in management
of first stage of labour

Methods Single-blind, parallel randomised controlled trial

Participants Inclusion criteria

• Age: 18 to 40 years
• Gestational age 38 to 42 weeks
• Singleton pregnancy
• Vertex presentation
• Women who agree to participate in the study
Exclusion criteria
• Malpresentation
• Induced labour
• Multiple pregnancy
• Medical diseases with pregnancy

Interventions Modified partograph versus paperless partograph

Outcomes Vaginal births

Starting date April 2016

Contact information Ahmed Mohamed Abbas, Assiut University

No contact details given

Notes Estimated completion date: August 2017

Trial conducted in Egypt

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 50
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
NCT02741141

Trial name or title A comparative study of the effect of two partographs on the cesarean section rate in women in spontaneous
labour (PARTODYS)

Methods Randomised controlled trial

Participants Inclusion criteria

• Age ≥ 18 years
• Affiliation to a social security insurance
• Written consent given
• Singleton pregnancy
• Cephalic presentation
• ≥ 37 gestational weeks
• Spontaneous onset of labour
Exclusion criteria
• Previous caesarean section
• Induction of labour
• Intrauterine growth restriction
• In utero fetal death
• Congenital malformation
• Chorioamnionitis
• Placenta praevia
• Need for an emergency delivery (fetal heart rate abnormalities at admission)
• Contraindication for vaginal delivery
• Patient under temporary guardianship, guardianship or judicial protection
• Patient included in another study which could interfere with the results of this study

Interventions Classic partograph (labour dystocia is diagnosed when cervical dilation is less than 1 cm per hour or after 3
hours at complete cervical dilation without engagement of the presentation. In this case, active management
of labour is started with introduction of oxytocin, artificial rupture of membranes and supportive therapy)
versus new partograph (the second strategy is based on the partograph developed by Neal and Lowe. An active
management of labour is started when crossing the dystocia line or when there are no cervical modifications
after 4 hours beyond 5 cm of cervical dilation. In this case, active management of labour is started with
introduction of oxytocin, artificial rupture of membranes and supportive therapy.)

Outcomes Primary outcome

• Caesarean section rate
Secondary outcomes
• Total amount of oxytocin used
• Uterine hyperstimulation
• Postpartum haemorrhage
• Uterine rupture
• Retained placenta
• Need for artificial rupture of membranes
• Duration of labour
• Rate of vaginal birth
• Need for epidural
• Transfusion rate
• Maternal fever
• Apgar score < 7 at 5 minutes

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 51
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
NCT02741141 (Continued)

• Neonatal intensive care unit admission

• Neonatal death
• Neonatal infection rate

Starting date January 2016

Contact information Contact: Adrien GAUDINEAU, MD 03 88 12 74 61

[email protected]

Notes Estimated end date: January 2018

Trial conducted at University Hospital, Strasbourg, France

NTR5543

Trial name or title Randomised controlled trial comparing the currently used Friedman partogram with a 4-hour action line to
the newly developed SIMPLE partogram, based on the 95th percentile normogram of the Consortium on
Safe Labor to evaluate early versus delayed cesarean section (SIMPLE III)

Methods Randomised controlled trial

Participants Inclusion criteria

• Nulliparous
• Singleton pregnancy
• Cephalic presentation
• ≥ 37 weeks of pregnancy
• ≥ 4 cm dilatation
• Non-progressing labour (< 1 cm/hour)
Exclusion criteria
• < 18 years of age
• Unable to read or understand informed consent
• Fetus with relevant congenital malformation
• Planned caesarean section
• Non-reassuring fetal condition
• Inadequate pain medication (as judged by the women herself, no absolute need for epidural, but pain
needs to be considered manageable for continuation of delivery)

Interventions When after all regular interventions for non-progressing labour (amniotomy, oxytocin augmentation, empty
bladder, pain medication) the Friedman partogram action line is crossed, randomisation occurs in which
performing a caesarean section is the regular conduct. Women in the intervention group wait until the Simple
partogram action line is crossed (based on the 95th percentile of the nomogram of the Consortium on Safe
Labor)

Outcomes Primary outcomes

• Mortality and composite morbidity
◦ maternal intensive care unit admittance
◦ Apgar score < 7 after 5 minutes
◦ pH < 7.10
◦ neonatal intensive care unit admittance
Secondary outcomes
Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 52
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
NTR5543 (Continued)

• Delivery mode
• Shoulder dystocia
• Anal sphincter lesions
• Blood loss
• Need for blood transfusion
• Maternal infection
• Neonatal infection
• Duration of admission to the hospital
• Total number of caesarean sections in the target population (including non-participating women)
• Cost evaluation
• Budget impact
• Patient preference
• Patient satisfaction

Starting date December 2015

Contact information [email protected]

Notes Estimated end date: December 2018

Trial website: http://www.studies-obsgyn.nl/simple3

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 53
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DATA AND ANALYSES

Comparison 1. Partograph versus no partograph (studies carried out in high- and low-resource settings)

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Caesarean section (overall) 3 1813 Risk Ratio (M-H, Random, 95% CI) 0.77 [0.40, 1.46]
1.1 Low-resource setting 2 657 Risk Ratio (M-H, Random, 95% CI) 0.65 [0.22, 1.91]
1.2 High-resource setting 1 1156 Risk Ratio (M-H, Random, 95% CI) 1.03 [0.82, 1.28]
2 Oxytocin augmentation 1 1156 Risk Ratio (M-H, Fixed, 95% CI) 1.02 [0.95, 1.10]
2.1 High-resource setting 1 1156 Risk Ratio (M-H, Fixed, 95% CI) 1.02 [0.95, 1.10]
3 Duration of first stage of labour 1 1156 Mean Difference (IV, Fixed, 95% CI) 0.80 [-0.06, 1.66]
3.1 High-resource setting 1 1156 Mean Difference (IV, Fixed, 95% CI) 0.80 [-0.06, 1.66]
4 Low Apgar score (less than 7 at 5 2 1596 Risk Ratio (M-H, Fixed, 95% CI) 0.76 [0.29, 2.03]
minutes)
4.1 Low-resource setting 1 440 Risk Ratio (M-H, Fixed, 95% CI) 0.46 [0.04, 5.00]
4.2 High-resource setting 1 1156 Risk Ratio (M-H, Fixed, 95% CI) 0.85 [0.29, 2.52]
5 Instrumental vaginal birth 3 1813 Risk Ratio (M-H, Fixed, 95% CI) 0.99 [0.84, 1.15]
5.1 Low-resource setting 2 657 Risk Ratio (M-H, Fixed, 95% CI) 1.05 [0.75, 1.48]
5.2 High-resource setting 1 1156 Risk Ratio (M-H, Fixed, 95% CI) 0.97 [0.81, 1.15]
6 Regional analgesia - epidural 1 1156 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.98, 1.05]
6.1 High-resource setting 1 1156 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.98, 1.05]
7 Performance of artificial rupture 1 1156 Risk Ratio (M-H, Fixed, 95% CI) 0.99 [0.88, 1.11]
of membranes during labour
7.1 High-resource setting 1 1156 Risk Ratio (M-H, Fixed, 95% CI) 0.99 [0.88, 1.11]
8 Antibiotic use 1 1156 Risk Ratio (M-H, Fixed, 95% CI) 1.23 [0.88, 1.73]
8.1 High-resource setting 1 1156 Risk Ratio (M-H, Fixed, 95% CI) 1.23 [0.88, 1.73]
9 Duration of second stage of 1 1156 Mean Difference (IV, Fixed, 95% CI) 0.0 [-0.21, 0.21]
labour (hours)
9.1 High-resource setting 1 1156 Mean Difference (IV, Fixed, 95% CI) 0.0 [-0.21, 0.21]
10 Number of vaginal 1 1156 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
examinations
10.1 High-resource setting 1 1156 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
11 Admission to special care 1 1156 Risk Ratio (M-H, Fixed, 95% CI) 0.94 [0.51, 1.75]
nursery
11.1 High-resource setting 1 1156 Risk Ratio (M-H, Fixed, 95% CI) 0.94 [0.51, 1.75]

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 54
Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Comparison 2. Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried out
in a high- and low-resource settings)

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Caesarean section (overall) 4 4749 Risk Ratio (M-H, Fixed, 95% CI) 1.06 [0.88, 1.28]
1.1 Low-resource setting 2 1148 Risk Ratio (M-H, Fixed, 95% CI) 1.09 [0.71, 1.68]
1.2 High-resource setting 2 3601 Risk Ratio (M-H, Fixed, 95% CI) 1.06 [0.86, 1.30]
2 Oxytocin augmentation 4 4749 Risk Ratio (M-H, Random, 95% CI) 2.44 [1.36, 4.35]
2.1 Low-resource setting 2 1148 Risk Ratio (M-H, Random, 95% CI) 7.22 [2.49, 20.91]
2.2 High-resource setting 2 3601 Risk Ratio (M-H, Random, 95% CI) 1.14 [1.05, 1.22]
3 Duration of first stage of labour 1 948 Risk Ratio (M-H, Fixed, 95% CI) 0.81 [0.32, 2.04]
(length of labour greater than
18 hours, length of labour
greater than 12 hours)
4 Maternal experience of 2 2269 Risk Ratio (M-H, Random, 95% CI) 0.61 [0.28, 1.35]
childbirth - negative childbirth
experience
5 Low Apgar score (less than 7 at 5 4 4749 Risk Ratio (M-H, Fixed, 95% CI) 0.93 [0.61, 1.42]
minutes)
5.1 Low-resource setting 2 1148 Risk Ratio (M-H, Fixed, 95% CI) 1.31 [0.58, 2.96]
5.2 High-resource setting 2 3601 Risk Ratio (M-H, Fixed, 95% CI) 0.82 [0.50, 1.35]
6 Serious maternal morbidity or 2 3601 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
death
7 Caesarean section (distress) 2 3601 Risk Ratio (M-H, Fixed, 95% CI) 1.30 [0.86, 1.96]
8 Caesarean section (delay) 2 3601 Risk Ratio (M-H, Fixed, 95% CI) 0.98 [0.77, 1.25]
9 Instrumental vaginal delivery 3 3801 Risk Ratio (M-H, Fixed, 95% CI) 0.92 [0.81, 1.04]
10 Postpartum haemorrhage - 3 4549 Risk Ratio (M-H, Fixed, 95% CI) 1.06 [0.90, 1.25]
blood loss > 500 mL
10.1 Low-resource setting 1 948 Risk Ratio (M-H, Fixed, 95% CI) 0.85 [0.26, 2.76]
10.2 High-resource setting 2 3601 Risk Ratio (M-H, Fixed, 95% CI) 1.07 [0.90, 1.26]
11 Regional analgesia - epidural 2 3601 Risk Ratio (M-H, Random, 95% CI) 1.06 [0.92, 1.21]
12 Performance of artificial 3 3801 Risk Ratio (M-H, Random, 95% CI) 1.00 [0.84, 1.18]
rupture of the membranes
during labour
13 Number of vaginal 2 3601 Mean Difference (IV, Random, 95% CI) -0.08 [-0.37, 0.21]
examinations in labour
14 Serious neonatal morbidity or 2 3601 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
perinatal death
15 Admission to special care 3 3801 Risk Ratio (M-H, Fixed, 95% CI) 0.83 [0.51, 1.34]
nursery
15.1 Low-resource setting 1 200 Risk Ratio (M-H, Fixed, 95% CI) 1.33 [0.31, 5.81]
15.2 High-resource setting 2 3601 Risk Ratio (M-H, Fixed, 95% CI) 0.78 [0.46, 1.31]
16 Cord blood arterial pH less 2 3601 Risk Ratio (M-H, Fixed, 95% CI) 0.73 [0.44, 1.22]
than 7.1

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Comparison 3. Partograph with 2-hour action line versus partograph with 3-hour action line (study carried out
in a high-resource setting)

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Caesarean section (overall) 1 617 Risk Ratio (M-H, Fixed, 95% CI) 0.78 [0.51, 1.18]
2 Oxytocin augmentation 1 617 Risk Ratio (M-H, Fixed, 95% CI) 1.02 [0.85, 1.21]
3 Maternal experience of 1 348 Risk Ratio (M-H, Fixed, 95% CI) 0.49 [0.27, 0.90]
childbirth - negative childbirth
experience
4 Low Apgar score (less than 7 at 5 1 617 Risk Ratio (M-H, Fixed, 95% CI) 1.44 [0.41, 5.05]
minutes)
5 Serious maternal morbidity or 1 617 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
death
6 Caesarean section (distress) 1 617 Risk Ratio (M-H, Fixed, 95% CI) 0.96 [0.44, 2.10]
7 Caesarean section (delay) 1 617 Risk Ratio (M-H, Fixed, 95% CI) 0.71 [0.42, 1.19]
8 Instrumental vaginal delivery 1 617 Risk Ratio (M-H, Fixed, 95% CI) 0.93 [0.69, 1.26]
9 Postpartum haemorrhage - blood 1 617 Risk Ratio (M-H, Fixed, 95% CI) 0.96 [0.63, 1.45]
loss > 500 mL
10 Regional analgesia - epidural 1 617 Risk Ratio (M-H, Fixed, 95% CI) 1.16 [0.94, 1.44]
11 Performance of artificial 1 617 Risk Ratio (M-H, Fixed, 95% CI) 0.94 [0.77, 1.15]
rupture of membranes during
labour
12 Vaginal examinations 1 617 Mean Difference (IV, Fixed, 95% CI) 0.0 [-0.29, 0.29]
13 Serious neonatal morbidity or 1 617 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
perinatal death
14 Admission to special care 1 617 Risk Ratio (M-H, Fixed, 95% CI) 3.83 [0.43, 34.12]
nursery
15 Cord blood arterial pH less 1 617 Risk Ratio (M-H, Fixed, 95% CI) 0.38 [0.07, 1.96]
than 7.1

Comparison 4. Partograph with 3-hour action line versus partograph with 4-hour action line (study carried out
in a high-resource setting)

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Caesarean section (overall) 1 613 Risk Ratio (M-H, Fixed, 95% CI) 1.70 [1.07, 2.70]
2 Oxytocin augmentation 1 613 Risk Ratio (M-H, Fixed, 95% CI) 1.09 [0.91, 1.30]
3 Maternal experience of 1 340 Risk Ratio (M-H, Fixed, 95% CI) 0.80 [0.51, 1.27]
childbirth - negative childbirth
experience
4 Low Apgar score (less than 7 at 5 1 613 Risk Ratio (M-H, Fixed, 95% CI) 0.82 [0.22, 3.04]
minutes)
5 Serious maternal morbidity or 1 613 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
death
6 Caesarean section (distress) 1 613 Risk Ratio (M-H, Fixed, 95% CI) 1.77 [0.70, 4.42]
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7 Caesarean section (delay) 1 613 Risk Ratio (M-H, Fixed, 95% CI) 1.68 [0.97, 2.91]
8 Instrumental vaginal delivery 1 613 Risk Ratio (M-H, Fixed, 95% CI) 0.96 [0.72, 1.28]
9 Postpartum haemorrhage - blood 1 613 Risk Ratio (M-H, Fixed, 95% CI) 1.03 [0.68, 1.56]
loss > 500 mL
10 Regional analgesia - epidural 1 613 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.80, 1.27]
11 Performance of artificial 1 613 Risk Ratio (M-H, Fixed, 95% CI) 1.04 [0.85, 1.26]
rupture of membranes during
labour
12 Number of vaginal 1 613 Mean Difference (IV, Fixed, 95% CI) 0.10 [-0.19, 0.39]
examinations in labour
13 Serious neonatal morbidity or 1 613 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
perinatal death
14 Admission to special care 1 613 Risk Ratio (M-H, Fixed, 95% CI) 0.51 [0.05, 5.65]
nursery
15 Cord blood arterial pH less 1 613 Risk Ratio (M-H, Fixed, 95% CI) 2.57 [0.50, 13.17]
than 7.1

Comparison 5. Partograph with alert line only versus partograph with alert and action line (study carried out in
a low-resource setting)

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Caesarean section (overall) 1 694 Risk Ratio (M-H, Fixed, 95% CI) 0.68 [0.50, 0.93]
2 Oxytocin augmentation 1 694 Risk Ratio (M-H, Fixed, 95% CI) 0.81 [0.62, 1.05]
3 Low Apgar score (less than 7 at 5 1 694 Risk Ratio (M-H, Fixed, 95% CI) 7.12 [0.37, 137.36]
minutes)
4 Instrumental vaginal delivery 1 694 Risk Ratio (M-H, Fixed, 95% CI) 0.87 [0.66, 1.15]
5 Serious neonatal morbidity or 1 694 Risk Ratio (M-H, Fixed, 95% CI) 7.12 [0.37, 137.36]
perinatal death

Comparison 6. Partograph with latent phase versus partograph without latent phase (study carried out in a low-
resource setting)

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Caesarean section (overall) 1 743 Risk Ratio (M-H, Fixed, 95% CI) 2.45 [1.72, 3.50]
2 Oxytocin augmentation 1 743 Risk Ratio (M-H, Fixed, 95% CI) 2.18 [1.67, 2.83]
3 Low Apgar score (less than 7 at 5 1 743 Risk Ratio (M-H, Fixed, 95% CI) 0.75 [0.21, 2.63]
minutes)
4 Caesarean section (distress) 1 743 Risk Ratio (M-H, Fixed, 95% CI) 4.87 [2.83, 8.37]
5 Caesarean section (delay) 1 743 Risk Ratio (M-H, Fixed, 95% CI) 1.35 [0.59, 3.08]
6 Instrumental vaginal delivery 1 743 Risk Ratio (M-H, Fixed, 95% CI) 1.04 [0.61, 1.77]
7 Admission to special care nursery 1 743 Risk Ratio (M-H, Fixed, 95% CI) 1.84 [1.29, 2.63]
8 Usability: user-friendliness score 1 743 Mean Difference (IV, Fixed, 95% CI) -7.89 [-8.14, -7.64]

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Comparison 7. Partograph with 2-hour action line versus partograph with stepped dystocia line

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Caesarean section 1 99 Risk Ratio (M-H, Fixed, 95% CI) 1.10 [0.46, 2.62]
2 Oxytocin augmentation 1 99 Risk Ratio (M-H, Fixed, 95% CI) 0.62 [0.39, 0.98]
3 Duration of first stage of labour 1 99 Risk Ratio (M-H, Fixed, 95% CI) 0.76 [0.31, 1.89]
(labour longer than 12 hours)
4 Maternal experience of 1 90 Mean Difference (IV, Fixed, 95% CI) 0.0 [-3.58, 3.58]
childbirth (BSS-R score)
5 Low Apgar score (less than 4 at 4 1 99 Risk Ratio (M-H, Fixed, 95% CI) 0.98 [0.06, 15.23]
min)
6 Instrumental vaginal birth 1 99 Risk Ratio (M-H, Fixed, 95% CI) 0.75 [0.37, 1.56]
7 Postpartum haemorrhage (> 500 1 99 Risk Ratio (M-H, Fixed, 95% CI) 1.57 [0.55, 4.46]
mL)
8 Regional analgesia 1 99 Risk Ratio (M-H, Fixed, 95% CI) 0.86 [0.56, 1.32]
9 Opioid use 1 99 Risk Ratio (M-H, Fixed, 95% CI) 0.98 [0.45, 2.14]
10 Need for intubation at birth 1 99 Risk Ratio (M-H, Fixed, 95% CI) 0.44 [0.14, 1.32]

Comparison 8. Partograph versus labour scale (study carried out in a low-resource setting)

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Caesarean section (overall) 1 122 Risk Ratio (M-H, Fixed, 95% CI) 0.42 [0.16, 1.11]
2 Oxytocin augmentation 1 122 Risk Ratio (M-H, Fixed, 95% CI) 0.32 [0.18, 0.54]
3 Duration of first stage of labour 1 110 Mean Difference (IV, Fixed, 95% CI) 0.44 [-0.40, 1.28]
4 Low Apgar score (less than 7 at 5 1 110 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
minutes)
5 Caesarean section (delay) 1 122 Risk Ratio (M-H, Fixed, 95% CI) 0.2 [0.05, 0.88]
6 Stillbirth, neonatal death or 1 110 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
neonatal morbidity
7 Birth injuries and PPH 1 122 Risk Ratio (M-H, Fixed, 95% CI) 3.0 [0.32, 28.04]
(non-prespecified outcome)

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 Analysis 1.1. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource
settings), Outcome 1 Caesarean section (overall).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 1 Partograph versus no partograph (studies carried out in high- and low-resource settings)

Outcome: 1 Caesarean section (overall)

Study or subgroup Partograph No partograph Risk Ratio Weight Risk Ratio

M- M-
H,Random,95% H,Random,95%
n/N n/N CI CI

1 Low-resource setting
Rani 2015 21/110 19/113 30.2 % 1.14 [ 0.65, 1.99 ]

Walss Rodriguez 1987 21/224 52/210 32.4 % 0.38 [ 0.24, 0.61 ]

Subtotal (95% CI) 334 323 62.6 % 0.65 [ 0.22, 1.91 ]

Total events: 42 (Partograph), 71 (No partograph)
Heterogeneity: Tau2 = 0.54; Chi2 = 8.66, df = 1 (P = 0.003); I2 =88%
Test for overall effect: Z = 0.79 (P = 0.43)
2 High-resource setting
Windrim 2006 125/580 121/576 37.4 % 1.03 [ 0.82, 1.28 ]

Subtotal (95% CI) 580 576 37.4 % 1.03 [ 0.82, 1.28 ]

Total events: 125 (Partograph), 121 (No partograph)
Heterogeneity: not applicable
Test for overall effect: Z = 0.23 (P = 0.82)
Total (95% CI) 914 899 100.0 % 0.77 [ 0.40, 1.46 ]
Total events: 167 (Partograph), 192 (No partograph)
Heterogeneity: Tau2 = 0.28; Chi2 = 15.07, df = 2 (P = 0.00053); I2 =87%
Test for overall effect: Z = 0.81 (P = 0.42)
Test for subgroup differences: Chi2 = 0.67, df = 1 (P = 0.41), I2 =0.0%

0.1 0.2 0.5 1 2 5 10

Favours partograph Favours no partograph

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 Analysis 1.2. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource
settings), Outcome 2 Oxytocin augmentation.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 1 Partograph versus no partograph (studies carried out in high- and low-resource settings)

Outcome: 2 Oxytocin augmentation

Study or subgroup Partograph No partograph Risk Ratio Weight Risk Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

1 High-resource setting
Windrim 2006 423/580 412/576 100.0 % 1.02 [ 0.95, 1.10 ]

Total (95% CI) 580 576 100.0 % 1.02 [ 0.95, 1.10 ]

Total events: 423 (Partograph), 412 (No partograph)
Heterogeneity: not applicable
Test for overall effect: Z = 0.53 (P = 0.59)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours partograph Favours no partograph

Analysis 1.3. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource
settings), Outcome 3 Duration of first stage of labour.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 1 Partograph versus no partograph (studies carried out in high- and low-resource settings)

Outcome: 3 Duration of first stage of labour

Mean Mean
Study or subgroup Partograph No partograph Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 High-resource setting
Windrim 2006 (1) 580 16.8 (7.3) 576 16 (7.6) 100.0 % 0.80 [ -0.06, 1.66 ]

Total (95% CI) 580 576 100.0 % 0.80 [ -0.06, 1.66 ]

Heterogeneity: not applicable
Test for overall effect: Z = 1.82 (P = 0.068)
Test for subgroup differences: Not applicable

-10 -5 0 5 10
Favours partograph Favours no partograph

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 (1) Duration in hours

Analysis 1.4. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource
settings), Outcome 4 Low Apgar score (less than 7 at 5 minutes).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 1 Partograph versus no partograph (studies carried out in high- and low-resource settings)

Outcome: 4 Low Apgar score (less than 7 at 5 minutes)

Study or subgroup Partograph No partograph Risk Ratio Weight Risk Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

1 Low-resource setting
Walss Rodriguez 1987 1/230 2/210 22.9 % 0.46 [ 0.04, 5.00 ]

Subtotal (95% CI) 230 210 22.9 % 0.46 [ 0.04, 5.00 ]

Total events: 1 (Partograph), 2 (No partograph)
Heterogeneity: not applicable
Test for overall effect: Z = 0.64 (P = 0.52)
2 High-resource setting
Windrim 2006 6/580 7/576 77.1 % 0.85 [ 0.29, 2.52 ]

Subtotal (95% CI) 580 576 77.1 % 0.85 [ 0.29, 2.52 ]

Total events: 6 (Partograph), 7 (No partograph)
Heterogeneity: not applicable
Test for overall effect: Z = 0.29 (P = 0.77)
Total (95% CI) 810 786 100.0 % 0.76 [ 0.29, 2.03 ]
Total events: 7 (Partograph), 9 (No partograph)
Heterogeneity: Chi2 = 0.22, df = 1 (P = 0.64); I2 =0.0%
Test for overall effect: Z = 0.55 (P = 0.58)
Test for subgroup differences: Chi2 = 0.22, df = 1 (P = 0.64), I2 =0.0%

0.05 0.2 1 5 20
Favours partograph Favours no partograph

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 Analysis 1.5. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource
settings), Outcome 5 Instrumental vaginal birth.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 1 Partograph versus no partograph (studies carried out in high- and low-resource settings)

Outcome: 5 Instrumental vaginal birth

Study or subgroup Partograph No partograph Risk Ratio Weight Risk Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

1 Low-resource setting
Rani 2015 12/110 16/113 6.8 % 0.77 [ 0.38, 1.55 ]

Walss Rodriguez 1987 45/224 36/210 16.0 % 1.17 [ 0.79, 1.74 ]

Subtotal (95% CI) 334 323 22.9 % 1.05 [ 0.75, 1.48 ]

Total events: 57 (Partograph), 52 (No partograph)
Heterogeneity: Chi2 = 1.04, df = 1 (P = 0.31); I2 =4%
Test for overall effect: Z = 0.29 (P = 0.77)
2 High-resource setting
Windrim 2006 173/580 178/576 77.1 % 0.97 [ 0.81, 1.15 ]

Subtotal (95% CI) 580 576 77.1 % 0.97 [ 0.81, 1.15 ]

Total events: 173 (Partograph), 178 (No partograph)
Heterogeneity: not applicable
Test for overall effect: Z = 0.40 (P = 0.69)
Total (95% CI) 914 899 100.0 % 0.99 [ 0.84, 1.15 ]
Total events: 230 (Partograph), 230 (No partograph)
Heterogeneity: Chi2 = 1.26, df = 2 (P = 0.53); I2 =0.0%
Test for overall effect: Z = 0.19 (P = 0.85)
Test for subgroup differences: Chi2 = 0.19, df = 1 (P = 0.66), I2 =0.0%

0.1 0.2 0.5 1 2 5 10

Favours partograph Favours no partograph

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 Analysis 1.6. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource
settings), Outcome 6 Regional analgesia - epidural.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 1 Partograph versus no partograph (studies carried out in high- and low-resource settings)

Outcome: 6 Regional analgesia - epidural

Study or subgroup Partograph No partograph Risk Ratio Weight Risk Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

1 High-resource setting
Windrim 2006 532/580 521/576 100.0 % 1.01 [ 0.98, 1.05 ]

Total (95% CI) 580 576 100.0 % 1.01 [ 0.98, 1.05 ]

Total events: 532 (Partograph), 521 (No partograph)
Heterogeneity: not applicable
Test for overall effect: Z = 0.76 (P = 0.45)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours partograph Favours no partograph

Analysis 1.7. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource
settings), Outcome 7 Performance of artificial rupture of membranes during labour.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 1 Partograph versus no partograph (studies carried out in high- and low-resource settings)

Outcome: 7 Performance of artificial rupture of membranes during labour

Study or subgroup Partograph No partograph Risk Ratio Weight Risk Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

1 High-resource setting
Windrim 2006 283/580 284/576 100.0 % 0.99 [ 0.88, 1.11 ]

Total (95% CI) 580 576 100.0 % 0.99 [ 0.88, 1.11 ]

Total events: 283 (Partograph), 284 (No partograph)
Heterogeneity: not applicable
Test for overall effect: Z = 0.17 (P = 0.86)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours partograph Favours no partograph

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 Analysis 1.8. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource
settings), Outcome 8 Antibiotic use.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 1 Partograph versus no partograph (studies carried out in high- and low-resource settings)

Outcome: 8 Antibiotic use

Study or subgroup Partograph No partograph Risk Ratio Weight Risk Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

1 High-resource setting
Windrim 2006 67/580 54/576 100.0 % 1.23 [ 0.88, 1.73 ]

Total (95% CI) 580 576 100.0 % 1.23 [ 0.88, 1.73 ]

Total events: 67 (Partograph), 54 (No partograph)
Heterogeneity: not applicable
Test for overall effect: Z = 1.21 (P = 0.23)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours partograph Favours no partograph

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 Analysis 1.9. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-resource
settings), Outcome 9 Duration of second stage of labour (hours).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 1 Partograph versus no partograph (studies carried out in high- and low-resource settings)

Outcome: 9 Duration of second stage of labour (hours)

Mean Mean
Study or subgroup Partograph No partograph Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 High-resource setting
Windrim 2006 580 2.4 (1.8) 576 2.4 (1.9) 100.0 % 0.0 [ -0.21, 0.21 ]

Total (95% CI) 580 576 100.0 % 0.0 [ -0.21, 0.21 ]

Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P = 1.0)
Test for subgroup differences: Not applicable

-10 -5 0 5 10
Favours partograph Favours no partograph

Analysis 1.10. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-
resource settings), Outcome 10 Number of vaginal examinations.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 1 Partograph versus no partograph (studies carried out in high- and low-resource settings)

Outcome: 10 Number of vaginal examinations

Mean Mean
Study or subgroup Partograph No partograph Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 High-resource setting
Windrim 2006 580 4 (0) 576 4 (0) Not estimable

Total (95% CI) 580 576 Not estimable

Heterogeneity: not applicable
Test for overall effect: not applicable
Test for subgroup differences: Chi2 = 0.0, df = -1 (P = 0.0), I2 =0.0%

-10 -5 0 5 10
Favours partograph Favours no partograph

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 Analysis 1.11. Comparison 1 Partograph versus no partograph (studies carried out in high- and low-
resource settings), Outcome 11 Admission to special care nursery.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 1 Partograph versus no partograph (studies carried out in high- and low-resource settings)

Outcome: 11 Admission to special care nursery

Study or subgroup Partograph No partograph Risk Ratio Weight Risk Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

1 High-resource setting
Windrim 2006 19/580 20/576 100.0 % 0.94 [ 0.51, 1.75 ]

Total (95% CI) 580 576 100.0 % 0.94 [ 0.51, 1.75 ]

Total events: 19 (Partograph), 20 (No partograph)
Heterogeneity: not applicable
Test for overall effect: Z = 0.18 (P = 0.85)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours partograph Favours no partograph

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 Analysis 2.1. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line
(studies carried out in a high- and low-resource settings), Outcome 1 Caesarean section (overall).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried out in a high- and low-resource settings)

Outcome: 1 Caesarean section (overall)

Study or subgroup 2-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

1 Low-resource setting
Orhue 2013 29/470 28/478 14.0 % 1.05 [ 0.64, 1.74 ]

Sinha 2017 11/100 9/100 4.5 % 1.22 [ 0.53, 2.82 ]

Subtotal (95% CI) 570 578 18.6 % 1.09 [ 0.71, 1.68 ]

Total events: 40 (2-hour action line), 37 (4-hour action line)
Heterogeneity: Chi2 = 0.09, df = 1 (P = 0.77); I2 =0.0%
Test for overall effect: Z = 0.41 (P = 0.68)
2 High-resource setting
Lavender 1998a 35/315 26/311 13.2 % 1.33 [ 0.82, 2.15 ]

Lavender 2006 136/1490 135/1485 68.2 % 1.00 [ 0.80, 1.26 ]

Subtotal (95% CI) 1805 1796 81.4 % 1.06 [ 0.86, 1.30 ]

Total events: 171 (2-hour action line), 161 (4-hour action line)
Heterogeneity: Chi2 = 1.06, df = 1 (P = 0.30); I2 =6%
Test for overall effect: Z = 0.53 (P = 0.60)
Total (95% CI) 2375 2374 100.0 % 1.06 [ 0.88, 1.28 ]
Total events: 211 (2-hour action line), 198 (4-hour action line)
Heterogeneity: Chi2 = 1.17, df = 3 (P = 0.76); I2 =0.0%
Test for overall effect: Z = 0.65 (P = 0.51)
Test for subgroup differences: Chi2 = 0.02, df = 1 (P = 0.88), I2 =0.0%

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 4-hour

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 Analysis 2.2. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line
(studies carried out in a high- and low-resource settings), Outcome 2 Oxytocin augmentation.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried out in a high- and low-resource settings)

Outcome: 2 Oxytocin augmentation

Study or subgroup 2-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
M- M-
H,Random,95% H,Random,95%
n/N n/N CI CI

1 Low-resource setting
Orhue 2013 118/470 10/478 22.0 % 12.00 [ 6.37, 22.60 ]

Sinha 2017 29/100 7/100 19.4 % 4.14 [ 1.90, 9.01 ]

Subtotal (95% CI) 570 578 41.4 % 7.22 [ 2.49, 20.91 ]

Total events: 147 (2-hour action line), 17 (4-hour action line)
Heterogeneity: Tau2 = 0.46; Chi2 = 4.51, df = 1 (P = 0.03); I2 =78%
Test for overall effect: Z = 3.64 (P = 0.00027)
2 High-resource setting
Lavender 1998a 144/315 129/311 29.0 % 1.10 [ 0.92, 1.32 ]

Lavender 2006 696/1490 607/1485 29.6 % 1.14 [ 1.05, 1.24 ]

Subtotal (95% CI) 1805 1796 58.6 % 1.14 [ 1.05, 1.22 ]

Total events: 840 (2-hour action line), 736 (4-hour action line)
Heterogeneity: Tau2 = 0.0; Chi2 = 0.13, df = 1 (P = 0.72); I2 =0.0%
Test for overall effect: Z = 3.35 (P = 0.00080)
Total (95% CI) 2375 2374 100.0 % 2.44 [ 1.36, 4.35 ]
Total events: 987 (2-hour action line), 753 (4-hour action line)
Heterogeneity: Tau2 = 0.29; Chi2 = 69.40, df = 3 (P<0.00001); I2 =96%
Test for overall effect: Z = 3.01 (P = 0.0026)
Test for subgroup differences: Chi2 = 11.57, df = 1 (P = 0.00), I2 =91%

0.02 0.1 1 10 50
Favours 2-hour Favours 4-hour

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 Analysis 2.3. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line
(studies carried out in a high- and low-resource settings), Outcome 3 Duration of first stage of labour (length
of labour greater than 18 hours, length of labour greater than 12 hours).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried out in a high- and low-resource settings)

Outcome: 3 Duration of first stage of labour (length of labour greater than 18 hours, length of labour greater than 12 hours)

Study or subgroup 2-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Orhue 2013 (1) 8/470 10/478 100.0 % 0.81 [ 0.32, 2.04 ]

Total (95% CI) 470 478 100.0 % 0.81 [ 0.32, 2.04 ]

Total events: 8 (2-hour action line), 10 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.44 (P = 0.66)
Test for subgroup differences: Not applicable

0.02 0.1 1 10 50
Favours 2-hour Favours 4-hour

(1) Described as ”prolonged labour”.

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 Analysis 2.4. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line
(studies carried out in a high- and low-resource settings), Outcome 4 Maternal experience of childbirth -
negative childbirth experience.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried out in a high- and low-resource settings)

Outcome: 4 Maternal experience of childbirth - negative childbirth experience

Study or subgroup 2-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
M- M-
H,Random,95% H,Random,95%
n/N n/N CI CI
Lavender 1998a 14/179 34/171 45.0 % 0.39 [ 0.22, 0.71 ]

Lavender 2006 72/962 81/957 55.0 % 0.88 [ 0.65, 1.20 ]

Total (95% CI) 1141 1128 100.0 % 0.61 [ 0.28, 1.35 ]

Total events: 86 (2-hour action line), 115 (4-hour action line)
Heterogeneity: Tau2 = 0.27; Chi2 = 5.78, df = 1 (P = 0.02); I2 =83%
Test for overall effect: Z = 1.21 (P = 0.23)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 4-hour

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 Analysis 2.5. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line
(studies carried out in a high- and low-resource settings), Outcome 5 Low Apgar score (less than 7 at 5
minutes).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried out in a high- and low-resource settings)

Outcome: 5 Low Apgar score (less than 7 at 5 minutes)

Study or subgroup 2-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

1 Low-resource setting
Orhue 2013 (1) 7/470 6/478 13.5 % 1.19 [ 0.40, 3.50 ]

Sinha 2017 6/100 4/100 9.1 % 1.50 [ 0.44, 5.15 ]

Subtotal (95% CI) 570 578 22.6 % 1.31 [ 0.58, 2.96 ]

Total events: 13 (2-hour action line), 10 (4-hour action line)
Heterogeneity: Chi2 = 0.08, df = 1 (P = 0.78); I2 =0.0%
Test for overall effect: Z = 0.66 (P = 0.51)
2 High-resource setting
Lavender 1998a 6/315 5/311 11.4 % 1.18 [ 0.37, 3.84 ]

Lavender 2006 22/1490 29/1485 66.0 % 0.76 [ 0.44, 1.31 ]

Subtotal (95% CI) 1805 1796 77.4 % 0.82 [ 0.50, 1.35 ]

Total events: 28 (2-hour action line), 34 (4-hour action line)
Heterogeneity: Chi2 = 0.46, df = 1 (P = 0.50); I2 =0.0%
Test for overall effect: Z = 0.79 (P = 0.43)
Total (95% CI) 2375 2374 100.0 % 0.93 [ 0.61, 1.42 ]
Total events: 41 (2-hour action line), 44 (4-hour action line)
Heterogeneity: Chi2 = 1.48, df = 3 (P = 0.69); I2 =0.0%
Test for overall effect: Z = 0.33 (P = 0.74)
Test for subgroup differences: Chi2 = 0.94, df = 1 (P = 0.33), I2 =0.0%

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 4-hour

(1) Described as ”neonatal asphyxia at 5 minutes”.

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 Analysis 2.6. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line
(studies carried out in a high- and low-resource settings), Outcome 6 Serious maternal morbidity or death.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried out in a high- and low-resource settings)

Outcome: 6 Serious maternal morbidity or death

Study or subgroup 2-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 0/315 0/311 Not estimable

Lavender 2006 0/1490 0/1485 Not estimable

Total (95% CI) 1805 1796 Not estimable

Total events: 0 (2-hour action line), 0 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: not applicable
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 4-hour

Analysis 2.7. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line
(studies carried out in a high- and low-resource settings), Outcome 7 Caesarean section (distress).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried out in a high- and low-resource settings)

Outcome: 7 Caesarean section (distress)

Study or subgroup 2-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 12/315 7/311 18.0 % 1.69 [ 0.68, 4.24 ]

Lavender 2006 39/1490 32/1485 82.0 % 1.21 [ 0.77, 1.93 ]

Total (95% CI) 1805 1796 100.0 % 1.30 [ 0.86, 1.96 ]

Total events: 51 (2-hour action line), 39 (4-hour action line)
Heterogeneity: Chi2 = 0.40, df = 1 (P = 0.53); I2 =0.0%
Test for overall effect: Z = 1.25 (P = 0.21)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 4-hour

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 Analysis 2.8. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line
(studies carried out in a high- and low-resource settings), Outcome 8 Caesarean section (delay).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried out in a high- and low-resource settings)

Outcome: 8 Caesarean section (delay)

Study or subgroup 2-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 23/315 19/311 15.6 % 1.20 [ 0.66, 2.15 ]

Lavender 2006 97/1490 103/1485 84.4 % 0.94 [ 0.72, 1.23 ]

Total (95% CI) 1805 1796 100.0 % 0.98 [ 0.77, 1.25 ]

Total events: 120 (2-hour action line), 122 (4-hour action line)
Heterogeneity: Chi2 = 0.54, df = 1 (P = 0.46); I2 =0.0%
Test for overall effect: Z = 0.17 (P = 0.86)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 4-hour

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 Analysis 2.9. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line
(studies carried out in a high- and low-resource settings), Outcome 9 Instrumental vaginal delivery.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried out in a high- and low-resource settings)

Outcome: 9 Instrumental vaginal delivery

Study or subgroup 2-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 66/315 73/311 18.3 % 0.89 [ 0.67, 1.20 ]

Lavender 2006 294/1490 320/1485 79.7 % 0.92 [ 0.80, 1.05 ]

Sinha 2017 9/100 8/100 2.0 % 1.13 [ 0.45, 2.80 ]

Total (95% CI) 1905 1896 100.0 % 0.92 [ 0.81, 1.04 ]

Total events: 369 (2-hour action line), 401 (4-hour action line)
Heterogeneity: Chi2 = 0.23, df = 2 (P = 0.89); I2 =0.0%
Test for overall effect: Z = 1.37 (P = 0.17)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 4-hour

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 Analysis 2.10. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line
(studies carried out in a high- and low-resource settings), Outcome 10 Postpartum haemorrhage - blood loss >
500 mL.
Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried out in a high- and low-resource settings)

Outcome: 10 Postpartum haemorrhage - blood loss > 500 mL

Study or subgroup 2-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

1 Low-resource setting
Orhue 2013 5/470 6/478 2.6 % 0.85 [ 0.26, 2.76 ]

Subtotal (95% CI) 470 478 2.6 % 0.85 [ 0.26, 2.76 ]

Total events: 5 (2-hour action line), 6 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.27 (P = 0.78)
2 High-resource setting
Lavender 1998a 39/315 39/311 17.0 % 0.99 [ 0.65, 1.50 ]

Lavender 2006 201/1490 185/1485 80.4 % 1.08 [ 0.90, 1.30 ]

Subtotal (95% CI) 1805 1796 97.4 % 1.07 [ 0.90, 1.26 ]

Total events: 240 (2-hour action line), 224 (4-hour action line)
Heterogeneity: Chi2 = 0.16, df = 1 (P = 0.69); I2 =0.0%
Test for overall effect: Z = 0.74 (P = 0.46)
Total (95% CI) 2275 2274 100.0 % 1.06 [ 0.90, 1.25 ]
Total events: 245 (2-hour action line), 230 (4-hour action line)
Heterogeneity: Chi2 = 0.30, df = 2 (P = 0.86); I2 =0.0%
Test for overall effect: Z = 0.68 (P = 0.49)
Test for subgroup differences: Chi2 = 0.14, df = 1 (P = 0.71), I2 =0.0%

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 4-hour

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 Analysis 2.11. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line
(studies carried out in a high- and low-resource settings), Outcome 11 Regional analgesia - epidural.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried out in a high- and low-resource settings)

Outcome: 11 Regional analgesia - epidural

Study or subgroup 2-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
M- M-
H,Random,95% H,Random,95%
n/N n/N CI CI
Lavender 1998a 120/315 101/311 30.1 % 1.17 [ 0.95, 1.45 ]

Lavender 2006 479/1490 473/1485 69.9 % 1.01 [ 0.91, 1.12 ]

Total (95% CI) 1805 1796 100.0 % 1.06 [ 0.92, 1.21 ]

Total events: 599 (2-hour action line), 574 (4-hour action line)
Heterogeneity: Tau2 = 0.00; Chi2 = 1.54, df = 1 (P = 0.21); I2 =35%
Test for overall effect: Z = 0.79 (P = 0.43)
Test for subgroup differences: Not applicable

0.5 0.7 1 1.5 2

Favours 2-hour Favours 4-hour

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 Analysis 2.12. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line
(studies carried out in a high- and low-resource settings), Outcome 12 Performance of artificial rupture of the
membranes during labour.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried out in a high- and low-resource settings)

Outcome: 12 Performance of artificial rupture of the membranes during labour

Study or subgroup 2-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
M- M-
H,Random,95% H,Random,95%
n/N n/N CI CI
Lavender 1998a 120/315 121/311 34.5 % 0.98 [ 0.80, 1.19 ]

Lavender 2006 715/1490 657/1485 55.7 % 1.08 [ 1.00, 1.17 ]

Sinha 2017 19/100 29/100 9.8 % 0.66 [ 0.39, 1.09 ]

Total (95% CI) 1905 1896 100.0 % 1.00 [ 0.84, 1.18 ]

Total events: 854 (2-hour action line), 807 (4-hour action line)
Heterogeneity: Tau2 = 0.01; Chi2 = 4.43, df = 2 (P = 0.11); I2 =55%
Test for overall effect: Z = 0.04 (P = 0.97)
Test for subgroup differences: Not applicable

0.5 0.7 1 1.5 2

Favours 2-hour Favours 4-hour

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 Analysis 2.13. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line
(studies carried out in a high- and low-resource settings), Outcome 13 Number of vaginal examinations in
labour.
Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried out in a high- and low-resource settings)

Outcome: 13 Number of vaginal examinations in labour

Mean Mean
Study or subgroup 2-hour action line 4-hour action line Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

Lavender 1998a 315 4 (1.9) 311 3.9 (1.8) 40.7 % 0.10 [ -0.19, 0.39 ]

Lavender 2006 1490 3.2 (1.9) 1485 3.4 (2) 59.3 % -0.20 [ -0.34, -0.06 ]

Total (95% CI) 1805 1796 100.0 % -0.08 [ -0.37, 0.21 ]

Heterogeneity: Tau2 = 0.03; Chi2 = 3.33, df = 1 (P = 0.07); I2 =70%
Test for overall effect: Z = 0.53 (P = 0.60)
Test for subgroup differences: Not applicable

-0.5 -0.25 0 0.25 0.5

Favours 2-hour Favours 4-hour

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 Analysis 2.14. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line
(studies carried out in a high- and low-resource settings), Outcome 14 Serious neonatal morbidity or perinatal
death.
Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried out in a high- and low-resource settings)

Outcome: 14 Serious neonatal morbidity or perinatal death

Study or subgroup 2-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 0/315 0/311 Not estimable

Lavender 2006 0/1490 0/1485 Not estimable

Total (95% CI) 1805 1796 Not estimable

Total events: 0 (2-hour action line), 0 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: not applicable
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 4-hour

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 Analysis 2.15. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line
(studies carried out in a high- and low-resource settings), Outcome 15 Admission to special care nursery.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried out in a high- and low-resource settings)

Outcome: 15 Admission to special care nursery

Study or subgroup 2-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

1 Low-resource setting
Sinha 2017 4/100 3/100 8.6 % 1.33 [ 0.31, 5.81 ]

Subtotal (95% CI) 100 100 8.6 % 1.33 [ 0.31, 5.81 ]

Total events: 4 (2-hour action line), 3 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.38 (P = 0.70)
2 High-resource setting
Lavender 1998a 4/315 2/311 5.7 % 1.97 [ 0.36, 10.70 ]

Lavender 2006 21/1490 30/1485 85.7 % 0.70 [ 0.40, 1.21 ]

Subtotal (95% CI) 1805 1796 91.4 % 0.78 [ 0.46, 1.31 ]

Total events: 25 (2-hour action line), 32 (4-hour action line)
Heterogeneity: Chi2 = 1.32, df = 1 (P = 0.25); I2 =24%
Test for overall effect: Z = 0.95 (P = 0.34)
Total (95% CI) 1905 1896 100.0 % 0.83 [ 0.51, 1.34 ]
Total events: 29 (2-hour action line), 35 (4-hour action line)
Heterogeneity: Chi2 = 1.79, df = 2 (P = 0.41); I2 =0.0%
Test for overall effect: Z = 0.77 (P = 0.44)
Test for subgroup differences: Chi2 = 0.46, df = 1 (P = 0.50), I2 =0.0%

0.05 0.2 1 5 20
Favours 2-hour Favours 4-hour

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 Analysis 2.16. Comparison 2 Partograph with 2-hour action line versus partograph with 4-hour action line
(studies carried out in a high- and low-resource settings), Outcome 16 Cord blood arterial pH less than 7.1.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 2 Partograph with 2-hour action line versus partograph with 4-hour action line (studies carried out in a high- and low-resource settings)

Outcome: 16 Cord blood arterial pH less than 7.1

Study or subgroup 2-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 2/315 2/311 5.9 % 0.99 [ 0.14, 6.97 ]

Lavender 2006 23/1490 32/1485 94.1 % 0.72 [ 0.42, 1.22 ]

Total (95% CI) 1805 1796 100.0 % 0.73 [ 0.44, 1.22 ]

Total events: 25 (2-hour action line), 34 (4-hour action line)
Heterogeneity: Chi2 = 0.10, df = 1 (P = 0.76); I2 =0.0%
Test for overall effect: Z = 1.19 (P = 0.23)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 4-hour

Analysis 3.1. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line
(study carried out in a high-resource setting), Outcome 1 Caesarean section (overall).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried out in a high-resource setting)

Outcome: 1 Caesarean section (overall)

Study or subgroup 2-hour action line 3-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 35/315 43/302 100.0 % 0.78 [ 0.51, 1.18 ]

Total (95% CI) 315 302 100.0 % 0.78 [ 0.51, 1.18 ]

Total events: 35 (2-hour action line), 43 (3-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 1.16 (P = 0.24)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 3-hour

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 Analysis 3.2. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line
(study carried out in a high-resource setting), Outcome 2 Oxytocin augmentation.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried out in a high-resource setting)

Outcome: 2 Oxytocin augmentation

Study or subgroup 2-hour action line 3-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 144/315 136/302 100.0 % 1.02 [ 0.85, 1.21 ]

Total (95% CI) 315 302 100.0 % 1.02 [ 0.85, 1.21 ]

Total events: 144 (2-hour action line), 136 (3-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.17 (P = 0.87)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 3-hour

Analysis 3.3. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line
(study carried out in a high-resource setting), Outcome 3 Maternal experience of childbirth - negative
childbirth experience.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried out in a high-resource setting)

Outcome: 3 Maternal experience of childbirth - negative childbirth experience

Study or subgroup 2-hour action line 3-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 14/179 27/169 100.0 % 0.49 [ 0.27, 0.90 ]

Total (95% CI) 179 169 100.0 % 0.49 [ 0.27, 0.90 ]

Total events: 14 (2-hour action line), 27 (3-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 2.29 (P = 0.022)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 3-hour

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 Analysis 3.4. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line
(study carried out in a high-resource setting), Outcome 4 Low Apgar score (less than 7 at 5 minutes).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried out in a high-resource setting)

Outcome: 4 Low Apgar score (less than 7 at 5 minutes)

Study or subgroup 2-hour action line 3-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 6/315 4/302 100.0 % 1.44 [ 0.41, 5.05 ]

Total (95% CI) 315 302 100.0 % 1.44 [ 0.41, 5.05 ]

Total events: 6 (2-hour action line), 4 (3-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.57 (P = 0.57)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 3-hour

Analysis 3.5. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line
(study carried out in a high-resource setting), Outcome 5 Serious maternal morbidity or death.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried out in a high-resource setting)

Outcome: 5 Serious maternal morbidity or death

Study or subgroup 2-hour action line 3-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 0/315 0/302 Not estimable

Total (95% CI) 315 302 Not estimable

Total events: 0 (2-hour action line), 0 (3-hour action line)
Heterogeneity: not applicable
Test for overall effect: not applicable
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 3-hour

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 Analysis 3.6. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line
(study carried out in a high-resource setting), Outcome 6 Caesarean section (distress).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried out in a high-resource setting)

Outcome: 6 Caesarean section (distress)

Study or subgroup 2-hour action line 3-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 12/315 12/302 100.0 % 0.96 [ 0.44, 2.10 ]

Total (95% CI) 315 302 100.0 % 0.96 [ 0.44, 2.10 ]

Total events: 12 (2-hour action line), 12 (3-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.11 (P = 0.92)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 3-hour

Analysis 3.7. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line
(study carried out in a high-resource setting), Outcome 7 Caesarean section (delay).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried out in a high-resource setting)

Outcome: 7 Caesarean section (delay)

Study or subgroup 2-hour action line 3-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 23/315 31/302 100.0 % 0.71 [ 0.42, 1.19 ]

Total (95% CI) 315 302 100.0 % 0.71 [ 0.42, 1.19 ]

Total events: 23 (2-hour action line), 31 (3-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 1.29 (P = 0.20)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 3-hour

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 Analysis 3.8. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line
(study carried out in a high-resource setting), Outcome 8 Instrumental vaginal delivery.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried out in a high-resource setting)

Outcome: 8 Instrumental vaginal delivery

Study or subgroup 2-hour action line 3-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 66/315 68/302 100.0 % 0.93 [ 0.69, 1.26 ]

Total (95% CI) 315 302 100.0 % 0.93 [ 0.69, 1.26 ]

Total events: 66 (2-hour action line), 68 (3-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.47 (P = 0.64)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 3-hour

Analysis 3.9. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line
(study carried out in a high-resource setting), Outcome 9 Postpartum haemorrhage - blood loss > 500 mL.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried out in a high-resource setting)

Outcome: 9 Postpartum haemorrhage - blood loss > 500 mL

Study or subgroup 2-hour action line 3-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 39/315 39/302 100.0 % 0.96 [ 0.63, 1.45 ]

Total (95% CI) 315 302 100.0 % 0.96 [ 0.63, 1.45 ]

Total events: 39 (2-hour action line), 39 (3-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.20 (P = 0.84)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 3-hour

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 Analysis 3.10. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line
(study carried out in a high-resource setting), Outcome 10 Regional analgesia - epidural.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried out in a high-resource setting)

Outcome: 10 Regional analgesia - epidural

Study or subgroup 2-hour action line 3-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 120/315 99/302 100.0 % 1.16 [ 0.94, 1.44 ]

Total (95% CI) 315 302 100.0 % 1.16 [ 0.94, 1.44 ]

Total events: 120 (2-hour action line), 99 (3-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 1.37 (P = 0.17)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 3-hour

Analysis 3.11. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line
(study carried out in a high-resource setting), Outcome 11 Performance of artificial rupture of membranes
during labour.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried out in a high-resource setting)

Outcome: 11 Performance of artificial rupture of membranes during labour

Study or subgroup 2-hour action line 3-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 120/315 122/302 100.0 % 0.94 [ 0.77, 1.15 ]

Total (95% CI) 315 302 100.0 % 0.94 [ 0.77, 1.15 ]

Total events: 120 (2-hour action line), 122 (3-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.59 (P = 0.56)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 3-hour

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 Analysis 3.12. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line
(study carried out in a high-resource setting), Outcome 12 Vaginal examinations.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried out in a high-resource setting)

Outcome: 12 Vaginal examinations

Mean Mean
Study or subgroup 2-hour action line 3-hour action line Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Lavender 1998a 315 4 (1.9) 302 4 (1.8) 100.0 % 0.0 [ -0.29, 0.29 ]

Total (95% CI) 315 302 100.0 % 0.0 [ -0.29, 0.29 ]

Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P = 1.0)
Test for subgroup differences: Not applicable

-10 -5 0 5 10
Favours 2-hour Favours 3-hour

Analysis 3.13. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line
(study carried out in a high-resource setting), Outcome 13 Serious neonatal morbidity or perinatal death.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried out in a high-resource setting)

Outcome: 13 Serious neonatal morbidity or perinatal death

Study or subgroup 2-hour action line 3-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 0/315 0/302 Not estimable

Total (95% CI) 315 302 Not estimable

Total events: 0 (2-hour action line), 0 (3-hour action line)
Heterogeneity: not applicable
Test for overall effect: not applicable
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 2-hour Favours 3-hour

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 Analysis 3.14. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line
(study carried out in a high-resource setting), Outcome 14 Admission to special care nursery.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried out in a high-resource setting)

Outcome: 14 Admission to special care nursery

Study or subgroup 2-hour action line 3-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 4/315 1/302 100.0 % 3.83 [ 0.43, 34.12 ]

Total (95% CI) 315 302 100.0 % 3.83 [ 0.43, 34.12 ]

Total events: 4 (2-hour action line), 1 (3-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 1.21 (P = 0.23)
Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours 2-hour Favours 3-hour

Analysis 3.15. Comparison 3 Partograph with 2-hour action line versus partograph with 3-hour action line
(study carried out in a high-resource setting), Outcome 15 Cord blood arterial pH less than 7.1.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 3 Partograph with 2-hour action line versus partograph with 3-hour action line (study carried out in a high-resource setting)

Outcome: 15 Cord blood arterial pH less than 7.1

Study or subgroup 2-hour action line 3-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 2/315 5/302 100.0 % 0.38 [ 0.07, 1.96 ]

Total (95% CI) 315 302 100.0 % 0.38 [ 0.07, 1.96 ]

Total events: 2 (2-hour action line), 5 (3-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 1.15 (P = 0.25)
Test for subgroup differences: Not applicable

0.05 0.2 1 5 20
Favours 2-hour Favours 3-hour

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 Analysis 4.1. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line
(study carried out in a high-resource setting), Outcome 1 Caesarean section (overall).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried out in a high-resource setting)

Outcome: 1 Caesarean section (overall)

Study or subgroup 3-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 43/302 26/311 100.0 % 1.70 [ 1.07, 2.70 ]

Total (95% CI) 302 311 100.0 % 1.70 [ 1.07, 2.70 ]

Total events: 43 (3-hour action line), 26 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 2.27 (P = 0.023)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 3-hour Favours 4-hour

Analysis 4.2. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line
(study carried out in a high-resource setting), Outcome 2 Oxytocin augmentation.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried out in a high-resource setting)

Outcome: 2 Oxytocin augmentation

Study or subgroup 3-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 136/302 129/311 100.0 % 1.09 [ 0.91, 1.30 ]

Total (95% CI) 302 311 100.0 % 1.09 [ 0.91, 1.30 ]

Total events: 136 (3-hour action line), 129 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.89 (P = 0.37)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 3-hour Favours 4-hour

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 Analysis 4.3. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line
(study carried out in a high-resource setting), Outcome 3 Maternal experience of childbirth - negative
childbirth experience.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried out in a high-resource setting)

Outcome: 3 Maternal experience of childbirth - negative childbirth experience

Study or subgroup 3-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 27/169 34/171 100.0 % 0.80 [ 0.51, 1.27 ]

Total (95% CI) 169 171 100.0 % 0.80 [ 0.51, 1.27 ]

Total events: 27 (3-hour action line), 34 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.94 (P = 0.35)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 3-hour Favours 4-hour

Analysis 4.4. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line
(study carried out in a high-resource setting), Outcome 4 Low Apgar score (less than 7 at 5 minutes).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried out in a high-resource setting)

Outcome: 4 Low Apgar score (less than 7 at 5 minutes)

Study or subgroup 3-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 4/302 5/311 100.0 % 0.82 [ 0.22, 3.04 ]

Total (95% CI) 302 311 100.0 % 0.82 [ 0.22, 3.04 ]

Total events: 4 (3-hour action line), 5 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.29 (P = 0.77)
Test for subgroup differences: Not applicable

0.05 0.2 1 5 20
Favours 3-hour Favours 4-hour

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 Analysis 4.5. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line
(study carried out in a high-resource setting), Outcome 5 Serious maternal morbidity or death.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried out in a high-resource setting)

Outcome: 5 Serious maternal morbidity or death

Study or subgroup 3-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 0/302 0/311 Not estimable

Total (95% CI) 302 311 Not estimable

Total events: 0 (3-hour action line), 0 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: not applicable
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 3-hour Favours 4-hour

Analysis 4.6. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line
(study carried out in a high-resource setting), Outcome 6 Caesarean section (distress).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried out in a high-resource setting)

Outcome: 6 Caesarean section (distress)

Study or subgroup 3-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 12/302 7/311 100.0 % 1.77 [ 0.70, 4.42 ]

Total (95% CI) 302 311 100.0 % 1.77 [ 0.70, 4.42 ]

Total events: 12 (3-hour action line), 7 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 1.21 (P = 0.23)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 3-hour Favours 4-hour

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 Analysis 4.7. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line
(study carried out in a high-resource setting), Outcome 7 Caesarean section (delay).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried out in a high-resource setting)

Outcome: 7 Caesarean section (delay)

Study or subgroup 3-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 31/302 19/311 100.0 % 1.68 [ 0.97, 2.91 ]

Total (95% CI) 302 311 100.0 % 1.68 [ 0.97, 2.91 ]

Total events: 31 (3-hour action line), 19 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 1.85 (P = 0.064)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 3-hour Favours 4-hour

Analysis 4.8. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line
(study carried out in a high-resource setting), Outcome 8 Instrumental vaginal delivery.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried out in a high-resource setting)

Outcome: 8 Instrumental vaginal delivery

Study or subgroup 3-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 68/302 73/311 100.0 % 0.96 [ 0.72, 1.28 ]

Total (95% CI) 302 311 100.0 % 0.96 [ 0.72, 1.28 ]

Total events: 68 (3-hour action line), 73 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.28 (P = 0.78)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 3-hour Favours 4-hour

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 Analysis 4.9. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line
(study carried out in a high-resource setting), Outcome 9 Postpartum haemorrhage - blood loss > 500 mL.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried out in a high-resource setting)

Outcome: 9 Postpartum haemorrhage - blood loss > 500 mL

Study or subgroup 3-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 39/302 39/311 100.0 % 1.03 [ 0.68, 1.56 ]

Total (95% CI) 302 311 100.0 % 1.03 [ 0.68, 1.56 ]

Total events: 39 (3-hour action line), 39 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.14 (P = 0.89)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 3-hour Favours 4-hour

Analysis 4.10. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line
(study carried out in a high-resource setting), Outcome 10 Regional analgesia - epidural.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried out in a high-resource setting)

Outcome: 10 Regional analgesia - epidural

Study or subgroup 3-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 99/302 101/311 100.0 % 1.01 [ 0.80, 1.27 ]

Total (95% CI) 302 311 100.0 % 1.01 [ 0.80, 1.27 ]

Total events: 99 (3-hour action line), 101 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.08 (P = 0.94)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 3-hour Favours 4-hour

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 Analysis 4.11. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line
(study carried out in a high-resource setting), Outcome 11 Performance of artificial rupture of membranes
during labour.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried out in a high-resource setting)

Outcome: 11 Performance of artificial rupture of membranes during labour

Study or subgroup 3-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 122/302 121/311 100.0 % 1.04 [ 0.85, 1.26 ]

Total (95% CI) 302 311 100.0 % 1.04 [ 0.85, 1.26 ]

Total events: 122 (3-hour action line), 121 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.38 (P = 0.71)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 3-hour Favours 4-hour

Analysis 4.12. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line
(study carried out in a high-resource setting), Outcome 12 Number of vaginal examinations in labour.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried out in a high-resource setting)

Outcome: 12 Number of vaginal examinations in labour

Mean Mean
Study or subgroup 3-hour action line 4-hour action line Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Lavender 1998a 302 4 (1.8) 311 3.9 (1.8) 100.0 % 0.10 [ -0.19, 0.39 ]

Total (95% CI) 302 311 100.0 % 0.10 [ -0.19, 0.39 ]

Heterogeneity: not applicable
Test for overall effect: Z = 0.69 (P = 0.49)
Test for subgroup differences: Not applicable

-10 -5 0 5 10
Favours 3-hour Favours 4-hour

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 Analysis 4.13. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line
(study carried out in a high-resource setting), Outcome 13 Serious neonatal morbidity or perinatal death.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried out in a high-resource setting)

Outcome: 13 Serious neonatal morbidity or perinatal death

Study or subgroup 3-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 0/302 0/311 Not estimable

Total (95% CI) 302 311 Not estimable

Total events: 0 (3-hour action line), 0 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: not applicable
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours 3-hour Favours 4-hour

Analysis 4.14. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line
(study carried out in a high-resource setting), Outcome 14 Admission to special care nursery.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried out in a high-resource setting)

Outcome: 14 Admission to special care nursery

Study or subgroup 3-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 1/302 2/311 100.0 % 0.51 [ 0.05, 5.65 ]

Total (95% CI) 302 311 100.0 % 0.51 [ 0.05, 5.65 ]

Total events: 1 (3-hour action line), 2 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.54 (P = 0.59)
Test for subgroup differences: Not applicable

0.005 0.1 1 10 200

Favours 3-hour Favours 4-hour

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 Analysis 4.15. Comparison 4 Partograph with 3-hour action line versus partograph with 4-hour action line
(study carried out in a high-resource setting), Outcome 15 Cord blood arterial pH less than 7.1.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 4 Partograph with 3-hour action line versus partograph with 4-hour action line (study carried out in a high-resource setting)

Outcome: 15 Cord blood arterial pH less than 7.1

Study or subgroup 3-hour action line 4-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lavender 1998a 5/302 2/311 100.0 % 2.57 [ 0.50, 13.17 ]

Total (95% CI) 302 311 100.0 % 2.57 [ 0.50, 13.17 ]

Total events: 5 (3-hour action line), 2 (4-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 1.14 (P = 0.26)
Test for subgroup differences: Not applicable

0.02 0.1 1 10 50
Favours 3-hour Favours 4-hour

Analysis 5.1. Comparison 5 Partograph with alert line only versus partograph with alert and action line
(study carried out in a low-resource setting), Outcome 1 Caesarean section (overall).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 5 Partograph with alert line only versus partograph with alert and action line (study carried out in a low-resource setting)

Outcome: 1 Caesarean section (overall)

Study or subgroup alert line only alert and action Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Pattinson 2003 (1) 55/344 82/350 100.0 % 0.68 [ 0.50, 0.93 ]

Total (95% CI) 344 350 100.0 % 0.68 [ 0.50, 0.93 ]

Total events: 55 (alert line only), 82 (alert and action)
Heterogeneity: not applicable
Test for overall effect: Z = 2.44 (P = 0.015)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours alert line only Favours alert and action

(1) ’alert line only’ describes aggressive management at two hours

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 Analysis 5.2. Comparison 5 Partograph with alert line only versus partograph with alert and action line
(study carried out in a low-resource setting), Outcome 2 Oxytocin augmentation.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 5 Partograph with alert line only versus partograph with alert and action line (study carried out in a low-resource setting)

Outcome: 2 Oxytocin augmentation

Study or subgroup Alert line only Alert and action Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Pattinson 2003 (1) 77/344 97/350 100.0 % 0.81 [ 0.62, 1.05 ]

Total (95% CI) 344 350 100.0 % 0.81 [ 0.62, 1.05 ]

Total events: 77 (Alert line only), 97 (Alert and action)
Heterogeneity: not applicable
Test for overall effect: Z = 1.61 (P = 0.11)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours alert line only Favours alert and action

(1) ’alert line only’ describes aggressive management at two hours

Analysis 5.3. Comparison 5 Partograph with alert line only versus partograph with alert and action line
(study carried out in a low-resource setting), Outcome 3 Low Apgar score (less than 7 at 5 minutes).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 5 Partograph with alert line only versus partograph with alert and action line (study carried out in a low-resource setting)

Outcome: 3 Low Apgar score (less than 7 at 5 minutes)

Study or subgroup Alert line only Alert and action Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Pattinson 2003 (1) 3/344 0/350 100.0 % 7.12 [ 0.37, 137.36 ]

Total (95% CI) 344 350 100.0 % 7.12 [ 0.37, 137.36 ]

Total events: 3 (Alert line only), 0 (Alert and action)
Heterogeneity: not applicable
Test for overall effect: Z = 1.30 (P = 0.19)
Test for subgroup differences: Not applicable

0.001 0.01 0.1 1 10 100 1000

Favours alert line only Favours alert and action

(1) ’alert line only’ describes aggressive management at two hours

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 Analysis 5.4. Comparison 5 Partograph with alert line only versus partograph with alert and action line
(study carried out in a low-resource setting), Outcome 4 Instrumental vaginal delivery.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 5 Partograph with alert line only versus partograph with alert and action line (study carried out in a low-resource setting)

Outcome: 4 Instrumental vaginal delivery

Study or subgroup Alert line only Alert and action Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Pattinson 2003 (1) 70/344 82/350 100.0 % 0.87 [ 0.66, 1.15 ]

Total (95% CI) 344 350 100.0 % 0.87 [ 0.66, 1.15 ]

Total events: 70 (Alert line only), 82 (Alert and action)
Heterogeneity: not applicable
Test for overall effect: Z = 0.98 (P = 0.33)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours alert line only Favours alert and action

(1) ’alert line only’ describes aggressive management at two hours

Analysis 5.5. Comparison 5 Partograph with alert line only versus partograph with alert and action line
(study carried out in a low-resource setting), Outcome 5 Serious neonatal morbidity or perinatal death.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 5 Partograph with alert line only versus partograph with alert and action line (study carried out in a low-resource setting)

Outcome: 5 Serious neonatal morbidity or perinatal death

Study or subgroup Alert line only Alert and action Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Pattinson 2003 (1) 3/344 0/350 100.0 % 7.12 [ 0.37, 137.36 ]

Total (95% CI) 344 350 100.0 % 7.12 [ 0.37, 137.36 ]

Total events: 3 (Alert line only), 0 (Alert and action)
Heterogeneity: not applicable
Test for overall effect: Z = 1.30 (P = 0.19)
Test for subgroup differences: Not applicable

0.001 0.01 0.1 1 10 100 1000

Favours alert line only Favours alert and action

(1) ’alert line only’ describes aggressive management at two hours

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 Analysis 6.1. Comparison 6 Partograph with latent phase versus partograph without latent phase (study
carried out in a low-resource setting), Outcome 1 Caesarean section (overall).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low-resource setting)

Outcome: 1 Caesarean section (overall)

Partograph Partograph
with latent without latent
Study or subgroup phase phase Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Kenchaveeriah 2011 83/350 38/393 100.0 % 2.45 [ 1.72, 3.50 ]

Total (95% CI) 350 393 100.0 % 2.45 [ 1.72, 3.50 ]

Total events: 83 (Partograph with latent phase), 38 (Partograph without latent phase)
Heterogeneity: not applicable
Test for overall effect: Z = 4.94 (P < 0.00001)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Partograph with latent phase Partograph without latent phase

Analysis 6.2. Comparison 6 Partograph with latent phase versus partograph without latent phase (study
carried out in a low-resource setting), Outcome 2 Oxytocin augmentation.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low-resource setting)

Outcome: 2 Oxytocin augmentation

Partograph Partograph
with latent without latent
Study or subgroup phase phase Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Kenchaveeriah 2011 126/350 65/393 100.0 % 2.18 [ 1.67, 2.83 ]

Total (95% CI) 350 393 100.0 % 2.18 [ 1.67, 2.83 ]

Total events: 126 (Partograph with latent phase), 65 (Partograph without latent phase)
Heterogeneity: not applicable
Test for overall effect: Z = 5.81 (P < 0.00001)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Partograph with latent phase Partograph without latent phase

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 Analysis 6.3. Comparison 6 Partograph with latent phase versus partograph without latent phase (study
carried out in a low-resource setting), Outcome 3 Low Apgar score (less than 7 at 5 minutes).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low-resource setting)

Outcome: 3 Low Apgar score (less than 7 at 5 minutes)

Partograph Partograph
with latent without latent
Study or subgroup phase phase Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Kenchaveeriah 2011 4/350 6/393 100.0 % 0.75 [ 0.21, 2.63 ]

Total (95% CI) 350 393 100.0 % 0.75 [ 0.21, 2.63 ]

Total events: 4 (Partograph with latent phase), 6 (Partograph without latent phase)
Heterogeneity: not applicable
Test for overall effect: Z = 0.45 (P = 0.65)
Test for subgroup differences: Not applicable

0.02 0.1 1 10 50
Partograph with latent phase Partograph without latent phase

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 Analysis 6.4. Comparison 6 Partograph with latent phase versus partograph without latent phase (study
carried out in a low-resource setting), Outcome 4 Caesarean section (distress).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low-resource setting)

Outcome: 4 Caesarean section (distress)

Partograph Partograph
with latent without latent
Study or subgroup phase phase Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Kenchaveeriah 2011 65/350 15/393 100.0 % 4.87 [ 2.83, 8.37 ]

Total (95% CI) 350 393 100.0 % 4.87 [ 2.83, 8.37 ]

Total events: 65 (Partograph with latent phase), 15 (Partograph without latent phase)
Heterogeneity: not applicable
Test for overall effect: Z = 5.71 (P < 0.00001)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Partograph with latent phase Partograph without latent phase

Analysis 6.5. Comparison 6 Partograph with latent phase versus partograph without latent phase (study
carried out in a low-resource setting), Outcome 5 Caesarean section (delay).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low-resource setting)

Outcome: 5 Caesarean section (delay)

Partograph Partograph
with latent without latent
Study or subgroup phase phase Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Kenchaveeriah 2011 12/350 10/393 100.0 % 1.35 [ 0.59, 3.08 ]

Total (95% CI) 350 393 100.0 % 1.35 [ 0.59, 3.08 ]

Total events: 12 (Partograph with latent phase), 10 (Partograph without latent phase)
Heterogeneity: not applicable
Test for overall effect: Z = 0.71 (P = 0.48)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Partograph with latent phase Partograph without latent phase

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 Analysis 6.6. Comparison 6 Partograph with latent phase versus partograph without latent phase (study
carried out in a low-resource setting), Outcome 6 Instrumental vaginal delivery.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low-resource setting)

Outcome: 6 Instrumental vaginal delivery

Partograph Partograph
with latent without latent
Study or subgroup phase phase Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Kenchaveeriah 2011 24/350 26/393 100.0 % 1.04 [ 0.61, 1.77 ]

Total (95% CI) 350 393 100.0 % 1.04 [ 0.61, 1.77 ]

Total events: 24 (Partograph with latent phase), 26 (Partograph without latent phase)
Heterogeneity: not applicable
Test for overall effect: Z = 0.13 (P = 0.90)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Partograph with latent phase Partograph without latent phase

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 Analysis 6.7. Comparison 6 Partograph with latent phase versus partograph without latent phase (study
carried out in a low-resource setting), Outcome 7 Admission to special care nursery.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low-resource setting)

Outcome: 7 Admission to special care nursery

Partograph Partograph
with latent without latent
Study or subgroup phase phase Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Kenchaveeriah 2011 69/350 42/393 100.0 % 1.84 [ 1.29, 2.63 ]

Total (95% CI) 350 393 100.0 % 1.84 [ 1.29, 2.63 ]

Total events: 69 (Partograph with latent phase), 42 (Partograph without latent phase)
Heterogeneity: not applicable
Test for overall effect: Z = 3.38 (P = 0.00074)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Partograph with latent phase Partograph without latent phase

Analysis 6.8. Comparison 6 Partograph with latent phase versus partograph without latent phase (study
carried out in a low-resource setting), Outcome 8 Usability: user-friendliness score.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low-resource setting)

Outcome: 8 Usability: user-friendliness score

Partograph Partograph
with latent without latent Mean Mean
Study or subgroup phase phase Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Kenchaveeriah 2011 (1) 350 2.87 (1.86) 393 10.76 (1.61) 100.0 % -7.89 [ -8.14, -7.64 ]

Total (95% CI) 350 393 100.0 % -7.89 [ -8.14, -7.64 ]

Heterogeneity: not applicable
Test for overall effect: Z = 61.46 (P < 0.00001)
Test for subgroup differences: Not applicable

-10 -5 0 5 10
Partograph without latent Partograph with latent

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 (1) High score = positive

Analysis 7.1. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia
line, Outcome 1 Caesarean section.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 7 Partograph with 2-hour action line versus partograph with stepped dystocia line

Outcome: 1 Caesarean section

Study or subgroup Dystocia line 2-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lee 2015 9/50 8/49 100.0 % 1.10 [ 0.46, 2.62 ]

Total (95% CI) 50 49 100.0 % 1.10 [ 0.46, 2.62 ]

Total events: 9 (Dystocia line), 8 (2-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.22 (P = 0.83)
Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours dystocia line Favours 2-hour

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 Analysis 7.2. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia
line, Outcome 2 Oxytocin augmentation.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 7 Partograph with 2-hour action line versus partograph with stepped dystocia line

Outcome: 2 Oxytocin augmentation

Study or subgroup Dystocia line 2-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lee 2015 17/50 27/49 100.0 % 0.62 [ 0.39, 0.98 ]

Total (95% CI) 50 49 100.0 % 0.62 [ 0.39, 0.98 ]

Total events: 17 (Dystocia line), 27 (2-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 2.05 (P = 0.040)
Test for subgroup differences: Not applicable

0.5 0.7 1 1.5 2

Favours dystocia line Favours 2-hour

Analysis 7.3. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia
line, Outcome 3 Duration of first stage of labour (labour longer than 12 hours).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 7 Partograph with 2-hour action line versus partograph with stepped dystocia line

Outcome: 3 Duration of first stage of labour (labour longer than 12 hours)

Study or subgroup Dystocia line 2-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lee 2015 7/50 9/49 100.0 % 0.76 [ 0.31, 1.89 ]

Total (95% CI) 50 49 100.0 % 0.76 [ 0.31, 1.89 ]

Total events: 7 (Dystocia line), 9 (2-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.59 (P = 0.56)
Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours dystocia line Favours 2-hour

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 Analysis 7.4. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia
line, Outcome 4 Maternal experience of childbirth (BSS-R score).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 7 Partograph with 2-hour action line versus partograph with stepped dystocia line

Outcome: 4 Maternal experience of childbirth (BSS-R score)

Mean Mean
Study or subgroup Dystocia line 2-hour action line Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Lee 2015 46 24.3 (8.67) 44 24.3 (8.66) 100.0 % 0.0 [ -3.58, 3.58 ]

Total (95% CI) 46 44 100.0 % 0.0 [ -3.58, 3.58 ]

Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P = 1.0)
Test for subgroup differences: Not applicable

-10 -5 0 5 10
Favours 2-hour Favours dystocia line

Analysis 7.5. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia
line, Outcome 5 Low Apgar score (less than 4 at 4 min).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 7 Partograph with 2-hour action line versus partograph with stepped dystocia line

Outcome: 5 Low Apgar score (less than 4 at 4 min)

Study or subgroup Dystocia line 2-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lee 2015 1/50 1/49 100.0 % 0.98 [ 0.06, 15.23 ]

Total (95% CI) 50 49 100.0 % 0.98 [ 0.06, 15.23 ]

Total events: 1 (Dystocia line), 1 (2-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.01 (P = 0.99)
Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours dystocia line Favours 2-hour

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 Analysis 7.6. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia
line, Outcome 6 Instrumental vaginal birth.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 7 Partograph with 2-hour action line versus partograph with stepped dystocia line

Outcome: 6 Instrumental vaginal birth

Study or subgroup Dystocia line 2-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lee 2015 10/50 13/49 100.0 % 0.75 [ 0.37, 1.56 ]

Total (95% CI) 50 49 100.0 % 0.75 [ 0.37, 1.56 ]

Total events: 10 (Dystocia line), 13 (2-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.76 (P = 0.44)
Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours dystocia line Favours 2-hour

Analysis 7.7. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia
line, Outcome 7 Postpartum haemorrhage (> 500 mL).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 7 Partograph with 2-hour action line versus partograph with stepped dystocia line

Outcome: 7 Postpartum haemorrhage (> 500 mL)

Study or subgroup Dystocia line 2-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lee 2015 8/50 5/49 100.0 % 1.57 [ 0.55, 4.46 ]

Total (95% CI) 50 49 100.0 % 1.57 [ 0.55, 4.46 ]

Total events: 8 (Dystocia line), 5 (2-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.84 (P = 0.40)
Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours dystocia line Favours 2-hour

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 Analysis 7.8. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia
line, Outcome 8 Regional analgesia.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 7 Partograph with 2-hour action line versus partograph with stepped dystocia line

Outcome: 8 Regional analgesia

Study or subgroup Dystocia line 2-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lee 2015 21/50 24/49 100.0 % 0.86 [ 0.56, 1.32 ]

Total (95% CI) 50 49 100.0 % 0.86 [ 0.56, 1.32 ]

Total events: 21 (Dystocia line), 24 (2-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.70 (P = 0.49)
Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours dystocia line Favours 2-hour

Analysis 7.9. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia
line, Outcome 9 Opioid use.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 7 Partograph with 2-hour action line versus partograph with stepped dystocia line

Outcome: 9 Opioid use

Study or subgroup Dystocia line 2-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lee 2015 10/50 10/49 100.0 % 0.98 [ 0.45, 2.14 ]

Total (95% CI) 50 49 100.0 % 0.98 [ 0.45, 2.14 ]

Total events: 10 (Dystocia line), 10 (2-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 0.05 (P = 0.96)
Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours dystocia use Favours 2-hour

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 Analysis 7.10. Comparison 7 Partograph with 2-hour action line versus partograph with stepped dystocia
line, Outcome 10 Need for intubation at birth.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 7 Partograph with 2-hour action line versus partograph with stepped dystocia line

Outcome: 10 Need for intubation at birth

Study or subgroup Dystocia line 2-hour action line Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Lee 2015 (1) 4/50 9/49 100.0 % 0.44 [ 0.14, 1.32 ]

Total (95% CI) 50 49 100.0 % 0.44 [ 0.14, 1.32 ]

Total events: 4 (Dystocia line), 9 (2-hour action line)
Heterogeneity: not applicable
Test for overall effect: Z = 1.47 (P = 0.14)
Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours dystocia line Favours 2-hour

(1) Active resuscitation

Analysis 8.1. Comparison 8 Partograph versus labour scale (study carried out in a low-resource setting),
Outcome 1 Caesarean section (overall).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 8 Partograph versus labour scale (study carried out in a low-resource setting)

Outcome: 1 Caesarean section (overall)

Study or subgroup Labour scale WHO partograph Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Shazly 2017 5/61 12/61 100.0 % 0.42 [ 0.16, 1.11 ]

Total (95% CI) 61 61 100.0 % 0.42 [ 0.16, 1.11 ]

Total events: 5 (Labour scale), 12 (WHO partograph)
Heterogeneity: not applicable
Test for overall effect: Z = 1.75 (P = 0.080)
Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours labour scale Favours partograph

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 Analysis 8.2. Comparison 8 Partograph versus labour scale (study carried out in a low-resource setting),
Outcome 2 Oxytocin augmentation.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 8 Partograph versus labour scale (study carried out in a low-resource setting)

Outcome: 2 Oxytocin augmentation

Study or subgroup Labour scale WHO partograph Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Shazly 2017 12/61 38/61 100.0 % 0.32 [ 0.18, 0.54 ]

Total (95% CI) 61 61 100.0 % 0.32 [ 0.18, 0.54 ]

Total events: 12 (Labour scale), 38 (WHO partograph)
Heterogeneity: not applicable
Test for overall effect: Z = 4.16 (P = 0.000032)
Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours labour scale Favours partograph

Analysis 8.3. Comparison 8 Partograph versus labour scale (study carried out in a low-resource setting),
Outcome 3 Duration of first stage of labour.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 8 Partograph versus labour scale (study carried out in a low-resource setting)

Outcome: 3 Duration of first stage of labour

Mean Mean
Study or subgroup Labour scale WHO partograph Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Shazly 2017 (1) 55 4.84 (2.51) 55 4.4 (1.96) 100.0 % 0.44 [ -0.40, 1.28 ]

Total (95% CI) 55 55 100.0 % 0.44 [ -0.40, 1.28 ]

Heterogeneity: not applicable
Test for overall effect: Z = 1.02 (P = 0.31)
Test for subgroup differences: Not applicable

-2 -1 0 1 2
Favours labour scale Favours partograph

(1) Duration of ’active stage’ (hours)

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 Analysis 8.4. Comparison 8 Partograph versus labour scale (study carried out in a low-resource setting),
Outcome 4 Low Apgar score (less than 7 at 5 minutes).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 8 Partograph versus labour scale (study carried out in a low-resource setting)

Outcome: 4 Low Apgar score (less than 7 at 5 minutes)

Study or subgroup Labour scale WHO partograph Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Shazly 2017 0/55 0/55 Not estimable

Total (95% CI) 55 55 Not estimable

Total events: 0 (Labour scale), 0 (WHO partograph)
Heterogeneity: not applicable
Test for overall effect: not applicable
Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours labour scale Favours partograph

Analysis 8.5. Comparison 8 Partograph versus labour scale (study carried out in a low-resource setting),
Outcome 5 Caesarean section (delay).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 8 Partograph versus labour scale (study carried out in a low-resource setting)

Outcome: 5 Caesarean section (delay)

Study or subgroup Labour scale WHO partograph Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Shazly 2017 (1) 2/61 10/61 100.0 % 0.20 [ 0.05, 0.88 ]

Total (95% CI) 61 61 100.0 % 0.20 [ 0.05, 0.88 ]

Total events: 2 (Labour scale), 10 (WHO partograph)
Heterogeneity: not applicable
Test for overall effect: Z = 2.14 (P = 0.033)
Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours labour scale Favours partograph

(1) Described as ’labour dystocia’

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 Analysis 8.6. Comparison 8 Partograph versus labour scale (study carried out in a low-resource setting),
Outcome 6 Stillbirth, neonatal death or neonatal morbidity.

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 8 Partograph versus labour scale (study carried out in a low-resource setting)

Outcome: 6 Stillbirth, neonatal death or neonatal morbidity

Study or subgroup Labour scale WHO partograph Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Shazly 2017 0/55 0/55 Not estimable

Total (95% CI) 55 55 Not estimable

Total events: 0 (Labour scale), 0 (WHO partograph)
Heterogeneity: not applicable
Test for overall effect: not applicable
Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours labour scale Favours partograph

Analysis 8.7. Comparison 8 Partograph versus labour scale (study carried out in a low-resource setting),
Outcome 7 Birth injuries and PPH (non-prespecified outcome).

Review: Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Comparison: 8 Partograph versus labour scale (study carried out in a low-resource setting)

Outcome: 7 Birth injuries and PPH (non-prespecified outcome)

Study or subgroup Labour scale WHO partograph Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Shazly 2017 3/61 1/61 100.0 % 3.00 [ 0.32, 28.04 ]

Total (95% CI) 61 61 100.0 % 3.00 [ 0.32, 28.04 ]

Total events: 3 (Labour scale), 1 (WHO partograph)
Heterogeneity: not applicable
Test for overall effect: Z = 0.96 (P = 0.34)
Test for subgroup differences: Not applicable

0.002 0.1 1 10 500

Favours labour scale Favours partograph

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WHAT’S NEW
Last assessed as up-to-date: 31 August 2017.

Date Event Description

31 August 2017 New search has been performed We updated the search and added five new trials (Lee
2015; Orhue 2013; Rani 2015; Shazly 2017; Sinha 2017)
. We updated the Background and Discussion. We incor-
porated a ’Summary of findings’ table for this update

31 August 2017 New citation required and conclusions have changed We slightly amended the Conclusion, to reflect the fact
that other ’partograph’ designs are being explored

HISTORY
Protocol first published: Issue 3, 2005
Review first published: Issue 4, 2008

Date Event Description

17 June 2013 New citation required and conclusions have changed Review updated and corrections made to errors in data
for outcomes 1.5 and 5.4 in previous publication (
Lavender 2012). The corrections do not change the
conclusions.

17 June 2013 New search has been performed Search updated in May 2013. No new trials iden-
tified. Ajoodani 2011a remains in Studies awaiting
classification, awaiting translation.

14 June 2012 New citation required but conclusions have not Review updated.
changed

14 June 2012 New search has been performed Search updated in May 2012. Three new trials iden-
tified. One has been included (Kenchaveeriah 2011)
, one has been excluded (Hamilton 2004), and one is
awaiting classification (Ajoodani 2011a).
This review is now comprised of six included studies
(involving 7706 women)

12 May 2009 Amended Corrected typographical error in results section.

10 November 2008 Amended Contact details edited.

29 April 2008 Amended Converted to new review format.

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies (Review) 113
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CONTRIBUTIONS OF AUTHORS
Tina Lavender, Anna Cuthbert and Rebecca Smyth assessed studies for inclusion independently and extracted all the data. All review
authors interpreted the results individually. Tina Lavender drafted and finalised the text of the review. Anna Cuthbert and Rebecca
Smyth contributed to the content.
All authors contributed to the 2017 update.

DECLARATIONS OF INTEREST
Tina Lavender: was investigator of two trials included in this review (Lavender 1998a; Lavender 2006); therefore, she was not involved
with evaluating these studies. No other relevant conflicts of interest.
Anna Cuthbert: is employed by the University of Liverpool as a Research Associate with Cochrane Pregnancy and Childbirth. Her
employment is supported by the National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to Cochrane
Pregnancy and Childbirth. She had no involvement with the editorial processes for this review update.
Rebecca Smyth: none known.

SOURCES OF SUPPORT

Internal sources
• University of Liverpool, UK.

External sources
• (2012 update) National Institute for Health Research, UK.
NIHR Programme of centrally-managed pregnancy and childbirth systematic reviews of priority to the National Health Service
(NHS) and users of the NHS: 10/4001/02
• (2017 update) UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research
Training in Human Reproduction (HRP), Department of Reproductive Health and Research (RHR), World Health Organization,
Switzerland.

DIFFERENCES BETWEEN PROTOCOL AND REVIEW

For this update, we assessed trial quality for seven selected outcomes using the GRADE approach (see Summary of findings for the
main comparison).
In a previous version of this review (Lavender 2013), we recorded caesarean section for fetal distress and caesarean section for delay in
labour. We have therefore added these to the outcomes in this update.
We changed the title from ’Effect of partogram use on outcomes for women in spontaneous labour at term’ to ’Effect of partograph
use on outcomes for women in spontaneous labour at term’. We felt that this terminology is more widely used.

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INDEX TERMS

Medical Subject Headings (MeSH)

∗ Pregnancy Outcome; Cesarean Section [utilization]; Delivery, Obstetric [methods]; Labor, Obstetric [∗ physiology]; Randomized

Controlled Trials as Topic; Term Birth [∗ physiology]; Time Factors; Uterine Inertia [diagnosis]; Uterine Monitoring [∗ methods]

MeSH check words

Female; Humans; Pregnancy

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