WHO next-generation partograph: revolutionary steps towards
individualised labour care?
Nanna Maaløe1,2, Jos van
Roosmalen3,4, Brenda Sequeira
Dmello1,5,7, Barbara Kwast6, Thomas
van den Akker3,4, Natasha
Housseine7, Monica Lauridsen
Kujabi1, Tarek Meguid8, Hussein
Kidanto7.
- Global Health Section, Department of Public Health, University of
Copenhagen, Denmark
- Department of Obstetrics and Gynaecology, Hvidovre University
Hospital, Hvidovre, Denmark
- Athena Institute, VU University, Amsterdam, the Netherlands
- Department of Obstetrics and Gynaecology, Leiden University Medical
Centre, Leiden, the Netherlands
- Maternal and Newborn Health, Comprehensive Community Based
Rehabilitation in Tanzania, Dar es salaam, United Republic of Tanzania
- International Consultant Maternal Health and Safe Motherhood, Leusden,
the Netherlands
- Medical College East Africa, Aga Khan University, Dar es Salaam,
United Republic of Tanzania
- Kivunge hospital, Zanzibar, United Republic of Tanzania
Corresponding author: Prof. Jos van Roosmalen,
j.j.m.van_roosmalen@lumc.nl
Word count: 1172
Hofmeyr et al. anticipate that departure from the familiar partograph
“may provoke anxiety and even antipathy among healthcare
professionals”.1 We do concur that change is urgently
needed to reach beyond the co-existence of too little, too late and too
much, too soon care during childbirth.2 In particular,
we applaud the World Health Organization (WHO) for their underlying
Better Outcomes in Labour Difficulty (BOLD) project, which has disclosed
the urgency of delaying the onset of the active phase of the first stage
of labour from 3-4 centimeters of cervical dilatation to at least
5.3 We do agree that the previously premature
designation was ”a major iatrogenic cause of apparent poor labour
progress and unnecessary interventions”, which has contributed to the
epidemic of caesarean sections in many countries
globally.1 For the Labour Care Guide (LCG), however,
to catalyse such change, we urge WHO to consider three major concerns
before further LCG implementation.
First, any early warning chart only becomes a “monitoring and
response tool” when applied in combination with clear guidance as to
how to respond.2,4 We once again draw attention to
WHO’s own multicentre cluster-randomized trial of 35.484 births in
South-East Asia, which indicated that failure to know what to do next
may be more central to suboptimal partograph use than failure to fill it
in. Combining the partograph with clear management guidelines was
associated with reductions in rates of prolonged labour (from 6·4% to
3·4%), oxytocin use for labour augmentation (from 20·7% to 9·1%),
emergency caesarean section (from 9·9% to 8·3%) and intrapartum
stillbirth (from 0·5% to 0·3%).5 Although the LCG
provides alert values for cervical dilatation, its user’s manual is
unclear and leads to confusion with regard to when and which action
should follow. The previous WHO
2018 guidelines were also unspecific in this respect, and even in
disagreement with the 2017
guidelines.6 Lack of specific guidance on prolonged
labour is particularly alarming in light of the high rates of oxytocin
augmentation in low-resource hospitals in Nigeria and Uganda, disclosed
in WHO’s BOLD project.3 Oxytocin augmentation, when
indicated, prevents the risks of prolonged labour, but introduces risks
of perinatal adverse outcomes in low-resource hospitals, if not combined
with appropriate surveillance.
Similar to the aforementioned WHO study of the partograph, the PartoMa
project has co-created clear and comprehensive intrapartum management
guidelines with frontline health providers in
Tanzania.6 In case of suboptimal labour progress, the
PartoMa guidelines suggest: 1. Consider underlying causes (power of
contractions, pelvis, position of the baby, urination and anxiety); 2.
Artificial rupture of membranes when these are still intact, caring
support, oral fluid, food and ambulation); 3. When the partographs’s
action line is crossed, consider careful augmentation with oxytocin; 4.
Assisted vaginal birth considered in second stage of labour. Only when
these action steps do not apply should the last option of performing
caesarean section be considered.6
Secondly, the LCG is not context-stratified to available resources.
Therefore, one may question the claim that it sets off “revolutionary
steps towards individualized labour care”.1 Maternity
units in low- and lower-middle income countries are increasingly
congested and the human resources crisis is
tremendous.7,8 As we have previously disclosed, it is
just impossible to follow the LCG’s surveillance regime if caring for
more than two women simultaneously.4 Checking fetal
heart rate and assessing contractions, blood pressure, pulse and vaginal
examination every four hours during active labour, would take 110
minutes per woman, excluding extra time for supportive
care.6
Although the different thresholds for every centimetre of dilatation may
provide accurate average progression curves, such complexity hampers
care provision in already overstretched clinical realities. Furthermore,
if a woman remains just below the LCG’s threshold at each centimeter of
dilatation, she can be in active labour for over 18 hours without
triggering cervical alerts. At the same time, the 95thcentile for cumulative time from 5 to 10cm in the WHO’s Bold study was
11 hours. This adds to the confusion of the LCG and causes concern for
how strong the LCG is informed by the underlying BOLD
evidence.3 For anyone who has worked in busy maternity
units amid cries of pain and fear of women labouring alone, such
extended “watchful waiting” seems to be a horrifying prospect.
Moreover, it may be good to remember that historically the first
partograph, as designed by Philpott in the 1970s, included the four-hour
time frame between the alert and action lines with the aim of arranging
timely referral from a basic to a comprehensive emergency obstetric care
facility for those women who crossed the alert line. Crossing the alert
line was not intended as an indication for oxytocin
augmentation.9 Many women may need earlier alertness
than the new LCG proposes to initiate the aforementioned steps 1 and 2,
and to arrange timely referrals for those giving birth in facilities
without comprehensive emergency obstetric and neonatal care functions.
As the LCG stands now, the new “partograph” may work in private
practice with one-to-one care, a birth companion present and pain-relief
available. The presence of a birth companion is an evidence-based
intervention, increasing spontaneous vaginal births and reducing the
need for pain relief.10 A birth companion, however, is
often not allowed in the busy labour wards in many countries in
sub-Saharan Africa whilst pain relief is only in place for
post-operative care.
Finally, adaptation and pilot testing of the LCG is paramount, including
assessments of less obvious direct and indirect (side-)effects. What is
included and how it is prioritized in a universal partograph might frame
priorities of what is done, and what might be
neglected.4 For instance, we applaud WHO for placing
additional focus on the second stage of labour. However, neglecting the
latent phase is worrisome as it may cause delay in recognizing
complications or onset of active labour.11 Many women
who enter facilities in the latent phase, are those with prolonged
labour in the active phase and need our support also during the latent
phase. Likewise, we applaud WHO for emphasizing compassionate and
supportive care during birth, including advocating for birth companions
and the option of pain relief.10 However, to include
for instance posture of the woman higher up on the partograph than the
well-being of her unborn baby, which used to be at the top, seems
disrespectful to women’s priorities. Monitoring the baby is an essential
part of caring support, but in many low-resource maternity units still
highly under-prioritized.12
To conclude, our “anxiety” is not caused by fear of change, but by
fear of history repeating itself. At global and local levels, we must
intensify the struggle to end root causes of unacceptable intrapartum
care, including the human resources for health crisis and women’s unmet
sexual and reproductive rights. Simultaneously, we must assist currently
overburdened and often less well trained midwives and doctors with
clear, realistically achievable and integrated monitoring and response
guidance.4 We sincerely hope that the LCG will be
adapted based on our worries. We feel that such adaptation is the only
way to reach “the right amount of care at the right time,
delivered in a manner that respects, protects and promotes human
rights”.
References:
- Hofmeyr GJ, Bernitz S, Bonet M, et al. WHO next-generation partograph:
revolutionary steps towards individualized labour care. BJOG 2021;
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- Miller S, Abalos E, Chamillard M, et al. Beyond too little, too late
and too much, too soon: a pathway towards evidence-based, respectful
maternity care worldwide. Lancet. 2016; 388: 2176-2192
- Oladapo OT, Souza JP, Fawole B, et al. Progression of the first stage
of spontaneous labour: a prospective cohort study in two sub-Saharan
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- Maaløe N, Ørtved AMR, Sørensen JB, et al. The unjustice of unfit
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- Kwast BE, Lennox CE, Farley TMM. World Health Organization partograph
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- Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous
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- Kwast BE, Poovan P, Vera E, Kohls E. The modified WHO partograph: do
we need a latent phase? Afr J Midwifery Women’s Health 2008; 2:
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- Housseine N, Punt MC, Browne J, et al. Strategies for intrapartum
foetal surveillance in low- and middle-income countries: A systematic
review. PLoS One 2018; 13: e0206295.