Labor & Delivery: Monitoring Labor with the Partograph and Labor Care Guide
Monitoring Mother and Baby Throughout the Delivery Process
Monitoring of labor and childbirth is the single most effective strategy for preventing poor birth outcomes such as stillbirths, obstructed labor, obstetric fistula, nerve injury (e.g., footdrop,) and maternal and neonatal mortality.
The partograph is a tool for monitoring labor and childbirth with the aim of timely detection of complications and action to ensure maternal and fetal well-being. The partograph primarily monitors cervical dilation and fetal descent, and it is designed to be used at any level of care.
WHO Labor Care Guide (LGC) is an evolution of labor monitoring tools, replacing the traditional partograph. It emphasizes a more holistic, evidence-based, and woman-centered approach to intrapartum care. It integrates continuous monitoring of maternal and fetal well-being with principles of respectful maternity care, shared decision-making, and comfort measures.
It is designed to empower healthcare providers to deliver high-quality care for all women in labor, particularly those at low risk of complications. However, women at elevated risk for labor complications might need extra specialized monitoring and care. Upon arrival at the labor unit, an initial assessment should be performed to confirm the onset of labor. Women who are in labor will then need ongoing monitoring of their progress using the LCG. The LCG can be used across all levels of healthcare facilities; however, the plan of action will differ based on the level of care.
WHO’s Labor Care Guide (LGC).
How to Use the Labor Care Guide
The LCG establishes a positive feedback and decision-making cycle by guiding healthcare providers to:
- Assess the well-being of both the woman and her baby, along with the progression of labor.
- Record and document all labor observations.
- Review established reference thresholds, comparing current labor observations with the values in the "Alert" column.
- Collaborate with the woman to plan and determine if any interventions are necessary, and document these decisions.
This process of recording and reviewing observations against benchmarks encourages healthcare providers to engage in thinking critically, reduce unnecessary interventions, and respond promptly to danger/warning signs. The LCG also features a dedicated section for documenting shared decisions made when deviations are observed. Primarily, the choice to intervene during labor is driven by observing a deviation from expected physiological parameters.
Section 1: Patient Identification and Labor History
This section captures key background details: the woman’s name, parity, onset of labor (spontaneous or induced), date and time of membrane rupture, date of active labor diagnosis, and any known risk factors.
If any information is unavailable at the time of entry, use the abbreviation “U” to indicate it is unknown.
Section 2. Supportive Care
This section promotes respectful maternity care – a fundamental human right. It focuses on ensuring every woman receives continuous, compassionate support throughout labor. Providers should document the presence of a labor companion, access to both pharmacological and non-pharmacological pain relief, encouragement to drink fluids, and the woman’s posture or mobility. These indicators should be recorded hourly.
Clear, culturally appropriate communication is essential at every stage. Providers should engage with the woman using language and gestures that are respectful and easy to understand.
The following table provides guidance for documenting Section 2 of the LCG:
| Section 2: Supportive Care | |
|---|---|
| Companionship | Y = Yes N = No D = Woman declines |
| Pain relief | Y = Yes N = No D = Woman declines to receive pharmacological or non-pharmacological pain relief |
| Oral fluid | Y = Ye N = No D = Woman declines |
| Posture | SP = Supine MO = Mobile |
Section 3. Baby
This section focuses on assessing fetal health during labor. It includes documentation of the baseline fetal heart rate (FHR) and any decelerations, the condition of the amniotic fluid, the fetal position, the presence of head moulding, and any signs of caput succedaneum. Regular monitoring of these indicators helps identify early signs of fetal distress and guides timely intervention to ensure a safe outcome.
The following table provides guidance for documenting section 3:
| Section 3: Baby | |
|---|---|
| FHR deceleration | N = No E = Early L = Late V = Variable |
| Amniotic fluid | I = Intact membranes C = Membranes ruptured, clear fluid M = Meconium-stained fluid: record +, ++ and +++ to represent non-significant, medium and thick meconium, respectively B = Blood-stained fluid |
| Fetal position | A = Any occiput anterior position P = Any occiput posterior position T = Any occiput transverse position |
| Caput | 0 = None + ++ +++ = Marked |
| Moulding | 0 = None + = Sutures apposed ++ = Sutures overlapped but reducible +++ = Sutures overlapped and not reducible |
Section 4: Woman
This section of the LCG focuses on monitoring the well-being of the woman during labor. It includes routine measurement and documentation of vital signs – pulse, blood pressure, and temperature – as well as assessment of urine output and characteristics. These indicators help detect early signs of maternal distress or complications and ensure timely clinical response.
The following table provides guidance for documenting this section:
| Section 4: Woman | |
|---|---|
| Urine | P − (No proteinuria) P Trace (Trace of proteinuria) P 1+ P 2+ P 3+ |
| Acetone | A − (No acetonuria) A 1+ A 2+ A 3+ A 4+ |
Section 5. Labor Progress
This section tracks labor progression by documenting the frequency and duration of uterine contractions, cervical dilatation, and descent of the fetal head.
During the active first stage of labor, cervical dilatation is marked with an “X” and fetal head descent with an “O”. An alert is triggered if the expected time for cervical progress is exceeded without advancement. In the second stage, use “P” to indicate when the woman begins pushing.
Section 6. Medication
This section is used to monitor and document all medications administered during labor and childbirth. This includes uterotonics (e.g., oxytocin), intravenous (IV) fluids, and any additional medications given to support the woman’s health and manage complications.
The following table provides guidance for documenting section 6:
| Section 6: Medication | |
|---|---|
| Oxytocin | N = No If “Yes”, U/L and drops/min |
| Medication | N = No If “Yes”, describe medication name, dose and route of administration |
| IV fluids | Y = Yes N = No |
Section 7. Shared Decision-Making
This section records all assessments and management plans made during labor and childbirth. It plays a key role in facilitating open, respectful communication and collaborative decision-making between healthcare providers and the woman and her birth companion. Documentation here ensures that care decisions are transparent, informed, and based on shared understanding and agreement.
The following table provides guidance for documenting section 7:
| Record | |
|---|---|
| Assessment |
|
| Plan |
|
Adaptation of the WHO Labor Care Guide (LCG)
The LCG is designed to be globally applicable and adaptable to local healthcare settings, ensuring it is practical, effective, and sustainable.
Key Areas for Adaptation:
- Use local, culturally appropriate language to ensure the LCG is understood by healthcare workers and women.
- The LCG emphasizes continuous care, which may require creative staffing solutions. It may require consideration of how observations can be optimally paced and prioritized while maintaining safety.
- Assessment of the availability of essential equipment like blood pressure cuffs, thermometers, and fetoscopes/Dopplers is paramount to integrating the LCG's requirements. Where essential equipment is unavailable, identify the safest alternatives without compromising patient safety.
- Adapt recommendations for mobility and companionship based on the physical layout and privacy afforded by the healthcare facility’s labor rooms by incorporating solutions like privacy screens and/or designated areas for history taking.
- Align the LCG with existing national or local maternal health guidelines to prevent conflicting instructions and ensure smooth integration into current practice.
- Identify culturally accepted birth companions (e.g., husband, mother, mother-in-law) and support their involvement while addressing any cultural sensitivities around male companions in the labor ward.
- Mainstream pain management options that are culturally acceptable and accessible, encompassing both pharmacological and non-pharmacological methods.
- Normalize and encourage women to adopt positions that are comfortable for them and culturally appropriate, aligning with the LCG's emphasis on freedom of movement.
- Tailor training materials to address specific challenges and contexts within your facility, using case studies and scenarios that are relevant to the local context and resources.
- Ensure the adapted LCG documentation feeds into local health information reporting, requirements monitoring, and evaluation.
- Clearly define referral criteria and pathways in conjunction with the LCG's alert signs, ensuring timely transfer to higher levels of care when needed.
Process for Adaptation
- Establish a Technical Working Group composed of key stakeholders, including obstetricians, midwives, nurses, facility managers, and representatives from communities or patient groups.
- Conduct a situational analysis to map current labor management practices, identify gaps, assess available resources, and understand cultural norms and barriers related to childbirth care.
- Pilot the adapted LCG in a small number of facilities to test its feasibility, identify potential challenges, and collect feedback from users.
- Revise and refine the LCG and its implementation strategy based on findings from the pilot, incorporating user input and local context.
- Monitor and evaluate implementation by assessing the LCG’s impact on service delivery and health outcomes, and make ongoing adjustments to ensure effectiveness and sustainability.
Key Indicators
- Number of healthcare workers trained and mentored on the LCG.
- Proportion of births monitored using the LCG.
- Proportion of health facilities that have implemented the use of the LCG.
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Tips
- Emphasize culture change: Present the LCG as more than a charting tool – it is a catalyst for improved, woman-centered care. Foster a positive and supportive environment for adoption.
- Empower clinical judgment: Encourage healthcare workers to use the LCG alongside their professional expertise, rather than following rigid thresholds or lines.
- Integrate into routine systems: Ensure that training, mentorship, and the supply of forms are embedded into routine operations to sustain LCG use over the long term.
Challenges
- Staff shortages and high workload can make it difficult for healthcare workers to complete the LCG accurately and on time.
- Perception of the LCG as administrative paperwork may lead some providers to undervalue its role as a clinical decision-making tool, reducing adherence.
- Limited availability of printed forms and essential equipment, such as fetal heart rate monitors, can hinder effective use of the tool.
- Resistance to change may occur when transitioning from the traditional partograph to the LCG due to unfamiliarity with the new format and principles.
- Some components of the LCG require subjective judgment, such as assessing contraction strength or moulding, which can lead to inconsistencies.
- Infrastructure constraints – such as a lack of private spaces for labor companions or limited room for mobility – may make it difficult to fully implement supportive care practices recommended in the LCG.
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The Challenge Initiative is led by the William H. Gates Sr. Institute for Population and Reproductive Health in the Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health.
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