Open Access Review

Article DOI: 10.7759/cureus.30238

Advancement in Partograph: WHO’s Labor Care

Guide
Received 08/04/2022
Yash Ghulaxe 1 , Surekha Tayade 2 , Shreyash Huse 1 , Jay Chavada 1
Review began 08/10/2022
Review ended 09/30/2022 1. Medical Student, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, IND 2.
Published 10/12/2022
Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical
© Copyright 2022 Sciences, Wardha, IND
Ghulaxe et al. This is an open access
article distributed under the terms of the
Corresponding author: Yash Ghulaxe, [email protected]
Creative Commons Attribution License CC-
BY 4.0., which permits unrestricted use,
distribution, and reproduction in any
medium, provided the original author and
source are credited. Abstract
Worldwide, the partograph, also known as a partogram, is used as a labor monitoring tool to detect
difficulties early, allowing for referral, intervention, or closer observations to follow. Despite widespread
support from health experts, there are worries that the partograph has not yet fully realized its potential for
enhancing therapeutic results. As a result, the instrument has undergone several changes, and numerous
studies have been conducted to examine the obstacles and enablers to its use. Nevertheless, the partograph
was widely embraced and has been a component of evaluating labor progress. Earlier it was also used as a
standard method for monitoring labor progress. Even though it is widely used, there have been reports of
usage and accurate execution rates. The WHO Labor Care Guide (LCG) was created so that medical
professionals could keep an eye on the health of pregnant women and their unborn children during labor by
conducting routine evaluations to spot any abnormalities. The tool intends to enhance women-centered care
and encourage collaborative decision-making between women and healthcare professionals. The LCG is
designed to be a tool for ensuring high-quality research centered on health, reducing pointless measures,
and offering comfort measures.

Categories: Obstetrics/Gynecology
Keywords: women-centered care, labour, world health organisation, labour care guide, partograph

Introduction And Background

Worldwide, more than 14 crore females have childbirth per year, and the percentage of deliveries by trained
medical workers is rising gradually [1]. Complications during labor and delivery cause maternal deaths
(>1/3rd), stillbirths (1/2), and newborn deaths (1/4th) [2,3]. Most of these fatalities occur in low-resource
environments and might be largely avoided with prompt interventions [4].

Over the past 20 years, widespread support for skilled birth attendance has been made in an effort to reduce
unnecessary maternal and perinatal death and morbidity [5]. Worldwide, this has resulted in significant
increases in facility-based deliveries and the coverage of births attended by trained medical staff (up from
62% in 2000 to 80% in 2017) [6]. Although the range has increased, this has not necessarily resulted in the
anticipated decline in mortality and morbidity during delivery, indicating that subpar treatment grade is still
a problem in hospitals [7-11]. Regularly overused interventions include early amniotomy, oxytocin for
augmentation, and continuous fetal monitoring [12]. Rising Caesarean section (CS) rates and poorer birth
experiences for women have been attributed to this over-medicalized and frequently disrespectful treatment
[13-15]. Therefore, it is critical to regularly monitor labor and delivery to spot dangers or difficulties and
stop bad birth results. The most popular labor monitoring device is the partograph, and trained healthcare
professionals have been using it to provide care during labor for more than 40 years.

However, the partograph needed to be revised to facilitate care following new research and international
priorities in light of the WHO recommendations (2018) on intrapartum supervision for pleasant birth [16].
To promote the health and wellbeing of women and their unborn children, the guidelines build up recent
development of definitions of the length of the first and second stages of labor. In addition, they offer advice
on time and usage of labor interference [17, 18]. The WHO guidelines included in this list are: care during
labor and delivery includes considerate maternal care, effective communication, labor amity, and continuity
of care. The first stage includes clinical pelvimetry upon admission, the definition of latent and active first
stages, the length and advancement of the first stage, the labor ward admission policy, pubic shaving, access
enema, and vaginal examination. The second stage of labor includes: what it is, how long it lasts, how to give
birth (with or without epidural anesthesia), how to push, how to avoid perineal injuries, and how to do an
episiotomy. Prophylactic uterotonics, delayed cord clamping, controlled cord traction, and uterine massage
are done during the third stage of labor. Regular nasal or oral suction during resuscitation, skin-to-skin
contact, nursing, vitamin K prophylaxis for hemorrhagic sickness, bathing, and other early postnatal care of
the infant are all included in the newborn's care. Following an uneventful vaginal birth, the lady will get
postpartum care that includes monitoring her uterine tonus, taking antibiotics, standard postpartum
maternal assessments, and discharge.

How to cite this article

Ghulaxe Y, Tayade S, Huse S, et al. (October 12, 2022) Advancement in Partograph: WHO’s Labor Care Guide. Cureus 14(10): e30238. DOI
10.7759/cureus.30238
 As a result, in 2018, WHO began work on a "next-generation" partograph, the WHO Labor Care Guide (LCG),
with the following objectives: frequently refreshing professionals to provide reassuring treatment during
delivery and to refresh for regular inspection that should be done at work to spot any developing
complications, in the mother and the fetus; offer benchmarks for aberrant labor observations that should
prompt particular responses; reduce needless interventional use and over- and under-diagnosis of
problematic labor episodes; assist with audits and raising the standard of labor care. The old WHO
partogram failed to demonstrate any meaningful clinical effect; hence this is an urgent requirement [19]. It
is crucial that the LCG can accommodate maternity care and professionals' needs and that it contains the
proper criteria for labor monitoring. The LCG was designed to care for mothers and their newborns
throughout labor and delivery. Although there was no risk status, it comprises evaluations and
examinations, which are crucial for treating all child-bearing females.

However, the LCG was primarily intended to be utilized to care for pregnant people who appeared to be in
good health and their unborn children (i.e., low-risk pregnancies). Women at a greater risk of having
difficulties during delivery might need more specific monitoring and care [20]. Even though LCG was
primarily developed to be used for the surveillance of child-bearing females who appeared to be in good
health, high-risk females who were having labor problems could also benefit from it as an observing tool [21].
Regardless of the woman's parity or the condition of her membranes, documentation on the LCG of the
mother's and the baby's health and the labor's progression should begin when she enters the first stage's
active phase of labor (five centimeters or greater cervical dilatation). Women and their babies are expected
to be observed and provided care and support during the latent stage of labor, even though LCG should not
be started at that time. Pregnancy, delivery, postpartum, and infant care: a guide for essential practice
provides comprehensive instructions on how to treat patients during the latent period of labor [22]. The LCG
was developed after extensive research, information synthesis, consultation, field testing, and improvement
[23,24].

Review
The LCG differs from earlier partograph designs in addressing the length of labor, identifying when clinical
interventions are necessary, and focusing on keeping the mother safe. It is expected that a change from
common partograph makeup may make medical professionals uneasy or even hostile. However, change
should not be implemented merely for the sake of change because it is difficult. Therefore, the seven
portions of LCG were modified from the original partograph layout. As shown in Figure 1, the sections are:
identifying information and labor characteristics at admission, supportive care, care of the baby, care of the
woman, labor progress, medication, and shared decision-making.

2022 Ghulaxe et al. Cureus 14(10): e30238. DOI 10.7759/cureus.30238 2 of 7

 FIGURE 1: WHO's Labor Care Guide.
Source: [25]

The woman's name, parity, method of labor onset, date of active labor diagnosis, date and time of
membrane rupture, and risk factors should all be recorded in Section 1 of the labor admission record. This
part should be finished with the knowledge acquired after a confirmed diagnosis of active labor. There is a
list of labor observations in Sections 2-7. As soon as the lady is admitted to the labor unit, the healthcare
provider should start recording observations for all parts. The remaining LCG is then finished after
additional labor-related evaluations. Each compliance has two axes, a perpendicular line data axis for
noticing any departure from the typical remarks and a horizontal time axis for tracking the length of the
inquiry. The woman's name and other crucial details necessary to comprehend her baseline features and risk
status at the time of labor admission are written in Section 1 as well. The woman's medical file should also
have information on other crucial demographic and labor features, like her age, period of gestational,
serological outcomes, hematocrit, blood group, Rh factor, status, referral reason, and symphysis-fundal
length. Supportive care is discussed in Section 2. The WHO's recommendations for intrapartum care
strongly emphasize respectful maternity care as a fundamental human right of expectant mothers [26]. At
each stage of labor care, the WHO advises clear interaction between health professionals and women in

2022 Ghulaxe et al. Cureus 14(10): e30238. DOI 10.7759/cureus.30238 3 of 7

 labor, including using easy, appropriate terminology. All women should receive a thorough explanation of
the techniques being used and why. The woman and her companion should be informed of the results of the
physical examinations. Baby care is included under Section 3. The fetal heart rate (FHR), amniotic fluid, the
position of the fetus, the shape of the fetal head, and the development of the caput succedaneum are all
regularly observed to determine the baby's health. Section 4 adds maternal care. This section attempts to
make it simpler to make decisions on sporadic, ongoing monitoring of women's wellness. On the LCG, the
pulse, blood pressure, temperature, and urine are regularly observed to keep track of the woman's health
and well-being. Work progress is shown in Section 5. This part promotes the routine practice of periodic
observation of labor development markers. The labor process is tracked on LCG by regularly observing the
frequency and length of contractions, cervical dilatation, and fetal descent. By indicating the patient is
getting oxytocin, its dosage and whether other drugs or IV fluids are given. Section 6 intends to allow
constant observation of all forms of drugs used during labor. Section 7 makes it easier for the lady and her
companion to communicate continuously and for all assessments and agreed-upon plans to be consistently
recorded.

The partograph and the LCG are tools used to enhance women-centered care, but they also have some points
in common and distinctions. The fundamental and revolutionary aspect of the original "Philpott chart" was
its graphical display of labor development in relation to women's cervical dilation and fall of presenting part
of the fetus against time [27,28]. The LCG and modified WHO partograph share some of these characteristics.
Despite cosmetic changes, this idea still holds a prominent place in the LCG. Additionally, regular formal
monitoring of significant clinical parameters reflecting the frequency and duration of uterine activity and
the health of the mother and the unborn child continues. The LCG mainly focuses on clinical parameters
rather than parameters obtained from USG [25]. The LCG has the following improvements among the two
uncommon features: the initial moment of the first stage's active phase of labor is dilatation of the cervix of
five centimeters (in spite of four centimeters or less); it adds up a division for observing second labor stage;
it consists of a division to evaluate and advance the use of understanding interruptions to enhance child
health, and every cm of cervical dilatation during the first stage of labor resulted in a shift in the hourly
"alarm" line and its corresponding "action" line with corroboration-based time constraints. Table 1 below
provides information on the frequent and rare characteristics of LCG and modified partograph [29].
Specialists distinguished a few difficulties in utilizing LCG that are normal to the utilization of any
partograph. A 2014 deliberate survey on partograph use in low-pay and center-pay nations found that while
the partograph was largely seen as a valuable device for observing work, its utilization was frequently seen as
tedious [30].

Modified Partograph Labor Care Guide

The active phase begins to start at cervix dilation from

The active phase begins to start at cervix dilation from 4cm
5 cm

Proof-based time restrictions on cervical dilations at

Alert and action line fixed at 1 cm/hr
each centimetre

Keeps track of the intensity, frequency, and length of uterine contractions Keeps track of span and repetition of uterine shrinking

There is no second stage Enhanced surveillance in the second stage

Companionship during labour, pain alleviation, oral

No documentation of interventions for reassuring help
fluid intake, and posture are all explicitly recorded

Besides cervical dilatation warning and action lines, there is no clear necessity to Requires that observation be noted, along with the
act in response to observation that differ from predictions of any labour provider recording the appropriate response

TABLE 1: Difference in features between modified partograph and LCG.

LCG: Labor Care Guide.

Common features are animated timelines showing the progression of labor as measured by cervical
dilatation and the head descent and formal and consistent documentation of crucial clinical indicators
indicating the mother's and child's health. However, there were some restrictions on how typical labor
progressed. Since labor's active first stage is supposed to be indicated by a line drawn at one centimeter per
hour from the initial assessment of the cervix, the original partograph uses this technique (three or four cm)
to identify prolonged labor (when the action line is crossed), and a parallel line two hours (commonly four
hours) later, as the alert or projected normal progress line [31]. This style was developed using Friedman and
Kroll's landmark research, suggesting the average cervical dilatation rate in primigravida was diphasic,
slower before three-centimeter dilatation, and roughly one centimeter per hour after three centimeters [31].
The primary problem with converting this statistical overview of several labors into a template for specific

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 women is that it ignores the variation in women's progression rates.

Additionally, because the action line criterion for protracted labor is set in advance for full delivery, it does
not consider the non-linear progression of each woman's labor. For instance, it might take longer than four
hours to get to the action line if labor had advanced quickly and was suddenly stopped. However, suppose
labor has been prolonged due to insufficient uterine movement and has traversed the action line. In that
case, it might continue to advance usually but cause anxiety as it is on the action line's wrong side. This
anxiety is then useless for directing the course of the rest of the labor. Because guiding factors for labor
advancement are dynamic rather than static in the new table for recording labor advancement in LCG, there
are significant differences. Instead of setting constant rate boundaries for overall labor's active first stage,
contemplation for interruption is governed by a proof-based limit of time for every inch of dilatation of the
cervix, which is acquired from 95th percentiles of labor span at various cm stage in a female with ordinary
perinatal results [32]. Even if it takes an unusually short amount of time to reach a dilation of 9 cm, the
projected upper limit of 10 cm stays the same. The appropriate cervical assessment (designated by an x)
would be highlighted. Actions for responding will be recorded in the plan division, just as in different
metrics in the alert division, such as moving from nine to ten centimeters and exceeding two hours. LCG and
the partograph vary most noticeably in not presence of the limit lines (diagonal labor progress). An obvious
need for recorded feedback when certain parameters have crossed, even though lines are discarded, and the
parameters are now presented in a modern, proof-based fashion. The definition of the active phase depends
upon the point of inflection on the Friedman curve, original partograph during the first stage of labor
identified the beginning of the active phase as 3 cm cervical dilation. The WHO shifted this threshold to 4
cm due to changes to the partograph [33]. It is compelling that Friedman lately pointed out a
misinterpretation of his project and admitted that point of inflection does, in fact, vary from woman to
woman. The three or four-centimeter threshold was frequently elaborated as explaining Friedman's actual
project. The median cervical dilation rate in normal women without unfavorable perinatal results was
observed to pass one centimeter/hour at five centimeters, which marks the fast start of the cervical
dilatation process and is the milestone used by the LCG [34]. This reduces the premature classification of
labor's active phase, a significant elicited reason for ostensibly slow labor advancement and needless
interruptions [35]. Because it can only be accurately identified in hindsight, the latent phase of the initial
labor stage is challenging to identify, according to the LCG. Its timing is frequently ambiguous, and the
length of time it lasts varies greatly across women. Innate in the real plan of the partograph, which set aside
the latent phase for eight hours, is a potential source of unnecessary intervention known as premature
charting of the latent phase. By starting to chronicle the progress of the labor process after the active phase
has been identified, this is neglected in the updated partograph style and LCG.

At a later stage of labor, the fact that the second stage of work is excluded from the original partograph
design and its revisions is a significant drawback. During the labor's second stage, there is no obligation to
explicitly continue keeping an eye on the mother's and the baby's health or the labor's progress. The second
stage of work is particularly crucial because of increased uterine activity and the mother's efforts to expel
the baby; if caution is not exercised during this time, disastrous results may result. The LCG addresses this
gap by emphasizing the importance of paying near awareness to the development and the welfare of both
mother and child during the second stage. The LCG is intended for the significance of the exploratory aspect
of labor by demanding graphic noting of proof-based applications that are important for better clinical
results for mothers and their children and women's good birth experiences. The LCG contains assessments
of the labor partner, mouth hydration, mother motility and attitude, and pain management to promote
intrapartum care and encourage using these evidence-based, but sometimes underutilized interventions.
The LCG is beyond just a scientific instrument for keeping track of a woman's health and that of her unborn
child throughout labor. The tool also offers testimonial values for the mother and fetal scrutiny and
stimulates detailed documentation of the mother's vital signs, fetal welfare, and labor advancement. The
plain necessity to circle any statement that conflicts with care, comfort, or labor advancement and to
document clinical or reassuring care feedback in conferences with women serves to reinforce the tool's care
purpose by encouraging early recognition and improvement of the support that mother and offspring
experienced. The caregiver enters the overall evaluation, any new information not before recorded but
crucial for labor observation is entered in the "Assessment" part, and the care scheme developed in
consultation with the mother is entered in the "Plan" section. This makes LCG more than just labor
documentation that could have been finished in the past; it makes it a contemporary monitoring and
response tool.

Conclusions
In the past few years, a lot has shifted in the way we provide proof-based, compassionate care during
delivery. Future studies will be needed to count women's experiences with care to completely comprehend
the applicability and implications of labor care and results. Nevertheless, medical practitioners will be
convinced that the fundamental principles that informed the construction of the modified partograph in
utilizing the new instrument would not compromise but rather advance the objectives of the earlier
partograph. LCG has evolved to reflect these changes and will motivate best practices, which add
advancement of excellent, considerate care for all women, new mothers, and their families.

Additional Information

2022 Ghulaxe et al. Cureus 14(10): e30238. DOI 10.7759/cureus.30238 5 of 7

 Disclosures
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.

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