Aggressive or expectant management of labour: a randomised clinical trial. [Trial of labor. A comparative study between Friedman's partogram and the conventional descriptive partogram]. Partogram action line study: a randomised trial. A randomized controlled trial of a bedside partogram in the active management of primiparous labour. Effect of different partogram action lines on birth outcomes: a randomized controlled trial.
To compare labour outcomes using aggressive or expectant management protocols.
                Randomised trial.
                Pretoria Academic Complex, South Africa. It serves an indigent urban population.
                Healthy nulliparous women in active labour, at term, with a health singleton pregnancy and cephalic presentation.
                The women were randomised to either aggressive (n = 344) or expectant (n = 350) management protocols. Aggressive management entailed using a single line partogram, a vaginal examination every two hours and use of an oxytocin infusion if the line was crossed. Expectant management entailed using a two line partogram, with the alert line and a parallel action line four hours to the right, with a vaginal examination every four hours. If the action line was reached, oxytocin was started. The women were reassessed every two hours thereafter. Analgesia was prescribed on request.
                Mode of birth, use of oxytocin and analgesia and neonatal outcome.
                The groups were similar with respect to maternal age, cervical dilation at trial entry, number crossing the alert line and birthweight of the infants. Significantly fewer women managed aggressively had caesarean sections (16.0%) than those managed expectantly (23.4%) (relative risk [RR] 0.68, 95% confidence intervals [CI] 0.50, 0.93). Significantly more oxytocin was used in the aggressive management group, but there was no difference with respect to the use of analgesia or episiotomy or in neonatal outcome with respect to the Apgar score at 1 or 10 minutes. There were three perinatal deaths. One woman was found to have an intrauterine death before trial entry and the other two were in the aggressive management group but did not receive oxytocin. Compliance by staff was poor in the aggressive management group.
                Aggressive management of labour reduces the caesarean section rate in nulliparous women but requires more intensive nursing. nan To assess the effect of three different partograms on caesarean section and maternal satisfaction.
                Prospective randomised clinical trial.
                Regional teaching hospital in North West of England.
                Nine hundred and twenty-eight primigravid women with uncomplicated pregnancies who presented in spontaneous labour at term.
                The 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. If the progress reached the action line, a diagnosis of prolonged labour was made. Prolonged labour was managed according to the standard ward protocol.
                Primary: Caesarean section rate and maternal satisfaction; secondary: need for augmentation, duration of labour, analgesia, cord blood gas analysis, postpartum haemorrhage, number of vaginal examinations, Apgar score and admission to special care baby unit.
                Caesarean section rate was lowest when labour was managed using a partogram with a 4-hour action line. The difference between the 3- and 4-hour partograms was statistically significant (OR 1 8, 95% CI 1.1-3.2), but the difference between 2 and 4 hours was not (OR 1.4, 95% CI 0.8-2.4). The women in the 2-hour arm were more satisfied with their labour when compared to the women in the 3-hour (P < 00001) and 4-hour (P <00001) arm.
                Our data suggest that women prefer active management of labour. It is possible that partograms which favour earlier intervention are associated with higher caesarean section rate. As the evidence on which to base the choice of partograms remains inconclusive further research is required. The partogram is a pictorial representation of the progress of labour, used in an effort to enhance early recognition of dystocia and help avoid Caesarean section (CS). The objective of this study was to evaluate the effect of partogram use on the CS and obstetric intervention rates.
                We conducted a randomized controlled trial of use of the partogram in 1932 primiparous women with uncomplicated pregnancies at term. Patients were randomly assigned to one of two groups: the standard group, who had the progress of labour charted in written notes, or the partogram group, whose progress in labour was recorded using a bedside graphical partogram as well as in written notes. Outcomes were stratified according to whether labour was spontaneous or induced and whether membranes were initially intact or ruptured. The primary outcome was the rate of CS; secondary outcome measures were rates of obstetric intervention for dystocia.
                There was no significant difference between the groups in rates of CS (partogram 24%, standard notes 25%), rates of other interventions, amniotomy, oxytocin use, or the mean cervical dilatation in labour.
                In this study, the use of a partogram without a mandatory management of labour protocol had no effect on rates of CS or other intrapartum interventions in healthy primiparous women at term. The World Health Organization recommends partograms with a 4-hour action line, denoting the timing of intervention for prolonged labor; others recommend earlier intervention. We assessed the effect of different action line positioning on birth outcomes.
                A randomized trial of primigravid women with uncomplicated pregnancies, in spontaneous labor at term, was conducted in the northwest of England. Women were assigned to have their labors recorded on a partogram with an action line 2 or 4 hours to the right of the alert line. If progress crossed the action line, diagnosis of prolonged labor was made and managed according to standard protocol. Primary outcomes were rate of cesarean delivery and maternal satisfaction.
                A total of 3,000 women were randomly assigned to groups; 2,975 (99.2%) were available for analysis. Questionnaires were completed by 1,929 (65%) women. There were no differences in cesarean delivery rate (136/1,490 compared with 135/1,485; relative risk [RR] 1, 95% confidence interval [CI] 0.80-1.26) or women dissatisfied with labor experience (72/962 compared with 81/967; RR 0.89, 95% CI 0.66-1.21). More women assigned to the 2-hour arm had labors that crossed the action line (854/1,490 compared with 673/1,485; RR 1.27, 95% CI 1.18-1.37); received more intervention (772/1,490 compared with 624/1,485; RR 1.23, 95% CI 1.14-1.33); and, if admitted to the midwife-led unit, were transferred for consultant-led care (366/674 compared with 285/666; RR 1.26, 95% CI 1.13-1.42).
                In this birth setting, for primigravid women selecting low intervention care, the 2-hour partogram increases the need for intervention without improving maternal or neonatal outcomes, compared with the 4-hour partogram, advocated by the World Health Organization.
                Current Controlled Trials, http://www.controlled-trials.com/isrctn/trial/|/0/78346801.html, ISRCTN78346801.
On the basis of the findings of this review, we cannot recommend routine use of the partogram as part of standard labour management and care. Given the fact that the partogram is currently in widespread use and generally accepted, it appears reasonable, until stronger evidence is available, that partogram use should be locally determined. Further trial evidence is required to establish the efficacy of partogram use.