Maternal health continues to be a central issue in public health, especially in low- and middle-income nations like India. Notwithstanding significant improvements, such as a major decline in the maternal mortality ratio (MMR) from 398 per 100,000 live births in 1997 to around 97 in 2020, India still accounts for a high percentage of global maternal deaths [1]. A significant percentage of these deaths are due to preventable reasons like obstetric haemorrhage, infection, and hypertensive disorders [1]. One of the cornerstones of reducing maternal mortality has been encouraging institutional deliveries, which guarantee exposure to skilled care providers and basic obstetric interventions. National initiatives such as the Janani Suraksha Yojana (JSY) have played a key role in this transition, with institutional births increasing from around 40% in 2005 to more than 88% in 2021 [1].

Increased institutional births have not always equated to high-quality intrapartum care. In most resource-poor environments, women still face systemic gaps in respectful and supportive childbirth experiences. Common deficits include the absence of labour companionship, restricted access to pain relief, and impaired maternal mobility in labour [2,3]. Furthermore, excessive medicalization through routine interventions like early amniotomy, oxytocin augmentation, and continuous foetal monitoring is still the norm, which often leads to unnecessary CS and adverse maternal outcomes [3–5].

A central component of quality intrapartum care is good labour monitoring. This has traditionally been done using the Friedman-based WHO partograph. Nonetheless, emerging evidence has pointed to the shortcomings of the traditional partograph, especially its use of fixed values such as 1 cm/hour cervical dilation and the application of alert and action lines, which are now outdated and scientifically unreliable [6–9]. In answer to these constraints, the World Health Organization published a new guidelines system of intrapartum care in 2018. These placed prominence on individualized labour progress, respectful care for mothers, and evidence-based care that sustains positive birth experiences [7–9].

For operationalization of these guidelines, the WHO created the Labour Care Guide (LCG), the next-generation clinical tool to better enhance labour monitoring and decision-making. The LCG includes key clinical parameters as well as supportive care features like companionship, maternal movement, birth positions, and analgesia measures [10]. Developed in a collaborative, multi-country development process, the LCG focuses on woman-centered care, promotes critical thinking for managing labour, and minimizes unnecessary interventions while enhancing both clinical results and maternal satisfaction [10–13].

Initial assessments of the LCG have indicated its feasibility, acceptability, and potential to decrease over- and under-diagnosis of abnormal labour events. It also promotes decreasing practices frowned upon by WHO, including routine episiotomy, unnecessary amniotomy, and indiscriminate oxytocin use [11–13]. Nevertheless, despite its encouraging design and congruence with WHO's revised intrapartum care framework, the effectiveness of the LCG in enhancing feto-maternal outcomes has yet to be extensively evaluated using randomized controlled trials.

Keeping the above background in mind, the current study was conducted to assess the efficacy of the WHO Labour Care Guide vis-à-vis the WHO Modified Partograph for monitoring spontaneous labor. The study was done to analyze and compare maternal and infant outcomes through a set of formal clinical and support parameters in the setting of tertiary care in India.

Study Design and Setting

This study was a hospital-based, open-label, randomized controlled trial carried out in the Department of Obstetrics and Gynecology, Chhattisgarh Institute of Medical Sciences (CIMS), Bilaspur, Chhattisgarh. The study was performed for a one-year duration between 2023 and 2024. The study was aimed at comparing feto-maternal outcomes with two dissimilar labour monitoring instruments: the WHO Labour Care Guide (LCG) and the WHO Modified Partograph.

Study Sample and Population Size

The study population comprised pregnant women who appeared in spontaneous labour with term gestation. A minimum total sample size of 100 patients was calculated using the assumption of equal allocation across groups and conventional statistical formulae for randomized controlled trials measuring categorical outcomes. The calculation included an assumed prevalence of 50%, a significance level (α) of 0.05, and power (1-β) of 80%, with an expected effect size of 20%. The participants were randomly divided into two groups—Group A (study group) followed up with the WHO Labour Care Guide, and Group B (control group) followed up with the WHO Modified Partograph—with 50 patients in each group.

Figure 1: WHO Modified Partograph

Figure 2: WHO Labour Care Guide

Sampling Method and Participant Recruitment

Recruitment was done by convenience sampling from among women eligible for delivery at the hospital. Women were included if aged 18-35 years, with a singleton pregnancy with cephalic presentation, and 37-40 weeks of gestation. Only those presenting with spontaneous labour without medical or surgical induction were recruited. Women with preterm or post-dated pregnancies, history of caesarean sections, medical comorbidities, malpresentations, or those who needed surgery in the latent period of labour were excluded. Informed written consent was obtained from all participants prior to enrolment.

Methodology and Study Procedure

Following ethical clearance and informed consent, all participants who were eligible went through a standardized clinical assessment. Baseline demographic and clinical details were recorded with a pre-tested standardized proforma. Women were then allocated at random to either of the two study arms. Group A was monitored starting from ≥5 cm cervical dilation with the use of the WHO Labour Care Guide, which entailed monitoring maternal and fetal parameters, labour progress, and reaction to any interventions that may be needed. Lag times for cervical dilation at each phase were recorded as per LCG guidelines, and alerts were triggered when progress was outside anticipated margins.

Group B participants were monitored starting at ≥4 cm of cervical dilation using the WHO Modified Partograph. Labour progress was checked against deviations to the right side of the alert or action lines. Decisions regarding management were made accordingly. Definitions of arrest of labour and uterine contraction strength were standardized across groups, and institutional oxytocin protocol was used similarly when augmentation was indicated. Both groups were continuously observed from the active phase of labour to delivery and to six weeks postpartum. Each monitoring chart was assessed on how well it facilitated clinical decision-making.

Operational Definitions

Spontaneous labour was operationally defined as labour beginning without medical or surgical induction. Labour stages were categorized according to standard obstetric definitions, from the beginning of regular contractions (first stage) to delivery of the infant (second stage), expulsion of the placenta (third stage), and the immediate postpartum period (fourth stage). Uterine contractions were considered adequate when three to five contractions were experienced every ten minutes, each lasting more than 40 seconds with increasing strength.

 Figure 3: Flow diagram showing algorithm for Operation theatre

Statistical Analysis

Data obtained during the research were entered and analyzed using Microsoft Excel, while statistical analysis was performed using SPSS version 25. Quantitative data were reported as means with standard deviations or medians with interquartile ranges, whereas qualitative data were reported as frequencies and percentages. Statistical significance was established using appropriate tests, where a p-value of less than 0.05 was regarded as statistically significant.

Ethical Considerations

The research protocol was vetted and approved by the ethical committee of the institution. Informed written consent was provided by all the patients or their legally acceptable representatives. Confidentiality of every patient's data was ensured strictly, and all information was utilized only for research. There was no extra risk involved with participation, and the patients were allowed to withdraw at any point of the study.

Study Population and Baseline Characteristics
100 singleton pregnant women were randomly divided into two groups: Group A (managed with WHO Labour Care Guide, n = 50) and Group B (managed with WHO Modified Partograph, n = 50). Demographic and clinical data at baseline, such as age, education, occupation, BMI, gravida status, gestational age, and laboratory parameters (hemoglobin, leukocyte count), were similar between groups (all p > 0.05, Tables 1–8, 20).

Maternal Outcomes

Table 1: Maternal Outcomes

Significant results: Group A experienced a shorter active phase (2.52 vs. 3.85 hrs, p = 0.001) and second stage (48.1 vs. 65.5 min, p = 0.003) of labor than Group B (Tables 10–11, Figures 1–2).

Non-significant results: Group A also experienced fewer caesarean deliveries (4% compared with 16%) and fewer PPHs (2% compared with 6%).

Fetal/Neonatal Outcomes

Table 2: Neonatal Outcomes

There were no stillbirths in either group.

Trends not significant: Group A recorded fewer NICU admissions (22% vs. 10%) and no complications at birth (vs. 4% Group B) (Tables 15–19, Figure 3).

Figures

(Active Phase)

(Second Stage)

Figure 4: Duration of Active Phase and Second Stage of Labor

Figure 5: Mode of Delivery Distribution

Figure 6: NICU Admission

Key conclusions
The WHO Labour Care Guide was linked to substantially shorter active labor and second stage durations than the Modified Partograph. Although maternal and neonatal outcomes (e.g., caesarean section rates, NICU admissions) in Group A were favorable, the differences were not statistically significant. Both interventions had similar safety profiles with no stillbirths and minimal adverse event rates.

The present study compared the effectiveness of the WHO Labour Care Guide (LCG) and the WHO Modified Partograph in the assessment of labour in 100 singleton pregnancies. The two groups were comparable at baseline with no statistically significant socio-demographic and clinical differences, thus minimizing potential confounders and increasing the robustness of the findings.

Group A (LCG) reported significantly shorter intervals during the active phase (2.52 vs. 3.85 hours, p = 0.001) and second stage of labor (48.1 vs. 65.5 minutes, p = 0.003) compared to Group B (Modified Partograph). These findings are in agreement with the results set by Pandey D et al., also finding a significantly shorter active phase duration in the LCG group (2.27 ± 1.44 vs. 4.12 ± 1.6 hours) [16]. Similarly, Srividya N et al. documented that in prolonged labour cases as well, the total duration remained within 8 hours as verified by the LCG [15]. These results highlight the LCG's capacity to enhance labour efficiency with more sensitive and customized monitoring.

Caesarean section (CS) rates were reduced in the LCG group (4%) versus the Modified Partograph group (16%), though this was not statistically significant (p = 0.12). Pandey D et al. saw the same trend, where CS rates were significantly lower in the LCG group (1.5% compared to 17.8%) [16], suggesting that the LCG can help reduce unnecessary surgery. Srividya N et al. [15] and Vogel J et al. [14] reported comparable CS rates between study groups, with emphasis on variability in implementation and outcomes across settings.

Postpartum hemorrhage (PPH) incidence was low in both groups and lower in Group A (2% compared with 6%), although this was not statistically significant. This was in agreement with results by Pandey D et al. and Srividya N et al., where PPH incidence was low and similar across groups [16][15].

While oxytocin consumption was lower in Group A (10 patients) compared to Group B (18 patients), the difference was not statistically significant (p = 0.20). Contrary to this, Pandey D et al. found significantly lower oxytocin utilization in the LCG group (18.4% vs. 51.8%) [16], which could be suggestive of variations in local practice style or levels of decision.

While not statistically significant, trends favored the LCG group with fewer NICU admissions (10% vs. 22%) and no bad neonatal outcomes (0% vs. 4%). The mean APGAR scores at 1 and 5 minutes were marginally higher in Group A, which is in line with findings by Pandey D et al., who also demonstrated improved neonatal outcomes, including lower NICU admission rates in the LCG group [16]. Conversely, Srividya N et al. found no neonatal advantages of note with the use of LCG [15], and urged more extensive multi-centric studies to verify these trends.

Key maternal parameters such as age, BMI, parity, gestational age, haemoglobin, and leukocyte count were statistically similar in the two groups in our study. This is in line with previous research that had determined equal baseline characteristics in intervention and control groups, e.g., by Pandey D et al. [16], Srividya N et al. [15], and Ranjan M et al. [17].

Strengths of the study are its prospective design, baseline comparability of participants, and adherence to WHO monitoring tools, which add reliability and internal validity to the findings. The study also adds to the existing body of literature which suggests advantages of the LCG in enhancing labour efficiency and possibly reducing unnecessary interventions.

Limitations do exist, however. The comparatively small sample size (n=100) could restrict the generalizability of the results and diminish statistical power in identifying differences in secondary outcomes like CS rates, NICU admissions, and PPH incidence. The study also took place at a single institution, and qualitative areas like healthcare provider satisfaction, user acceptability, and logistical feasibility of the LCG implementation were not assessed.

Implications for future research include the requirement of larger, multi-center randomized controlled trials to validate these findings and to examine outcome variability across various healthcare settings. Future studies need to include qualitative metrics to measure the practicality and sustainability of LCG implementation, as well as on provider behavior, clinical workflows, and maternal satisfaction. Examination of long-term maternal and neonatal outcomes may further elucidate the LCG's clinical value and inform policy and guideline development.

In conclusion, this randomized controlled trial between the WHO Labour Care Guide (LCG) and the WHO Modified Partograph for the management of spontaneous labour indicates both instruments are efficient in directing intrapartum care but can provide more benefits. Although maternal and neonatal baseline characteristics were similar between the two groups, the LCG group had significantly shorter active and second stages of labour. Although statistically significant differences were not observed between intervention needs, mode of delivery, postpartum complications, NICU admissions, and neonatal outcomes, trends in all instances benefited the LCG. These results imply that the LCG enables more woman-centered, timely, and individualized care, consistent with revised WHO guidelines. The implications are sufficient to support larger scale implementation and studies to examine long-term effects of the LCG in varied clinical environments.

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