***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE 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 . METHODS We conducted a r and omized controlled trial of use of the partogram in 1932 primiparous women with uncomplicated pregnancies at term . Patients were r and omly assigned to one of two groups : the st and ard 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 . RESULTS There was no significant difference between the groups in rates of CS ( partogram 24 % , st and ard notes 25 % ) , rates of other interventions , amniotomy , oxytocin use , or the mean cervical dilatation in labour . CONCLUSION In this study , the use of a partogram without a m and atory management of labour protocol had no effect on rates of CS or other intrapartum interventions in healthy primiparous women at term OBJECTIVE To explore the aspects of a woman 's childbirth experience which she perceived as being important . DESIGN As part of a large r and omised trial , which assessed the timing of intervention in prolonged labour , women 's views were explored using a specifically- design ed question naire . The question naire , which was administered on the second postnatal day , incorporated a rating scale followed by an open question . The responses to the open question are presented in this paper . SETTING Regional teaching hospital in the north west of Engl and . SAMPLE 615 primigravid women received a copy of the question naire . Of the 519 women who returned the question naire , 412 women answered the relevant section , the findings of which are presented in this paper . ANALYSIS The responses to the open-ended question were analysed by the generation of themes from the most frequently occurring responses . MAIN FINDINGS The main themes which emerged were support , information , intervention , decision making , control , pain relief and trial participation . KEY CONCLUSIONS AND IMPLICATION S FOR PRACTICE Most women are able to identify important contributors to a positive intrapartum experience . Midwives have an important role in identifying these contributors and supporting women to fulfil their individual needs Introduction : The partogram has been heralded as one of the most important advances in modern obstetric care . However , some healthcare practitioners , especially in high-income countries , have question ed its effectiveness . The purpose of this study is to evaluate prospect ively the use of a paperless partogram as a bedside tool in the management of labor . Material s and Methods : Women were invited to participate in the trial if they were at 36 to 42 weeks of gestation , and carrying a singleton pregnancy , with a cephalic presentation . All women who met the criteria and gave informed consent were included in the study till the required sample size of 91 was obtained .  Progress of labor was monitored on the basis of Alert estimated time of delivery ( ETD ) and Action ETD .  At the time of the Action ETD , if woman had not yet delivered , a diagnosis of abnormal labor was made and arrangements were made for emergency obstetric care . Results : Out of 91 women who participated in the study 55 ( 60 % ) were primigravida and 36 ( 40 % ) were multipara . The mean age of the participants was 25.36 years and the mean duration gestation was 281.9 days . The mean duration for delivery after Alert ETD was 4.3 hours . In our study , out of 91 participants , labor was induced only in 13 % of the cases . The mean duration for delivery after Alert ETD was 4.7 ± 1.9 hours in the primigravida and 3.7 ± 1.8 hours in multipara , but these differences were not statistically significant . Conclusion : In our study , the paperless partogram was found to be convenient and effective in the management of labor . The mean duration for delivery after Alert ETD was 4.3 hours in our study , which was similar to the World Health Organization 's ( WHO ) recommendation for partograms , with a four-hour action line , denoting the timing of intervention for prolonged labor Objective To compare labour outcomes using aggressive or expectant management protocol OBJECTIVE : 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 . METHODS : A r and omized trial of primigravid women with uncomplicated pregnancies , in spontaneous labor at term , was conducted in the northwest of Engl and . 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 st and ard protocol . Primary outcomes were rate of cesarean delivery and maternal satisfaction . RESULTS : A total of 3,000 women were r and omly assigned to groups ; 2,975 ( 99.2 % ) were available for analysis . Question naires 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 ) . CONCLUSION : 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 . CLINICAL TRIAL REGISTRATION : Current Controlled Trials , http://www.controlled-trials.com/is rct n/trial/|/0/78346801.html , IS RCT N78346801 . LEVEL OF EVIDENCE : OBJECTIVE to assess the effectiveness of promoting the use of the World Health Organization ( WHO ) partograph by midwives for labour in a maternity home by comparing outcomes after birth . SETTING Medan city , North Sumatera Province , Indonesia . PARTICIPANTS 20 midwives who regularly conducted births in maternity homes , r and omly allocated into two equal groups . DESIGN cluster r and omised-control trial . INTERVENTION under supervision from a team of obstetricians , midwives in the intervention group were introduced to the WHO partograph , trained in its use and instructed to use it in subsequent labours . MEASUREMENTS AND FINDINGS there were 304 eligible women with vertex presentations among 358 labouring women in the intervention group and 322 among 363 in the control group . Among the intervention group , 304 ( 92.4 % ) partographs were correctly completed . From 71 women with the graph beyond the alert line , 42 ( 65 % ) were referred to hospital . Introducing the partograph significantly increased referral rate , and reduced the number of vaginal examinations , oxytocin use and obstructed labour . The proportions of caesarean sections and prolonged labour were not significantly reduced . Apgar scores of less than 7 at 1min was reduced significantly , whereas Apgar scores at 5mins and requirement for neonatal resuscitation were not significantly different . Fetal death and early neonatal death rates were too low to compare . IMPLICATION S FOR PRACTICE a training programme with follow-up supervision and monitoring may be of use when introducing the WHO partograph in other similar setting s , and the findings of this study suggest that the appropriate time of referral needs more emphasis in continuing education . CONCLUSION the WHO partograph should be promoted for use by midwives who care for labouring women in a maternity home Summary : A prospect i ve study of 3 partogram design s was performed in 990 women in labour with singleton pregnancy . Partogram A , B and C showed a progressively flatter steepness of the curve of labour progression . Oxytocin was administered in 35.1 % of partogram‐A users , 45.9 % of partogram‐B users ( p = 0.001 ) and 44.1 % of partogram‐C users ( p = 0.035 ) . Significantly fewer patients among the partogram‐A users ( 10.2 % ) were administered  oxytocin  too early compared to 18.6 % of partogram‐B users and 20.5 % of partogram‐C users . Of those with spontaneous onset of labour , a significantly smaller total dose of oxytocin  was administered to the partogram‐A users compared to the other 2 groups . Ominous electrocardioto‐cographic fetal heart rate patterns were detected less frequently during the first stage of labour in partogram A users ( 0.4 % ) compared to partogram‐B users ( 1.1 % ) and partogram‐C users ( 3.0 % ) . Significantly fewer infants born to partogram‐A users had depressed Apgar scores at 1 and 5 minutes . Partograms displaying a flat graph , compared to a steep graph , were more often considered to have a slow progress of labour . Adoption of partograms showing a steep graph of progress of cervical dilatation is recommended BACKGROUND The precise timing of medical intervention for women in prolonged labor is the subject of considerable debate . The partogram action line is a tool to assist practitioners in the correct diagnosis of prolonged labor . Despite its widespread use , the precise timing of the action line has not been rigorously studied , and women 's views have rarely been sought . The aim of this study was to assess the effect on maternal satisfaction of managing labor using partograms with action lines drawn at 2 , 3 , or 4 hours to the right of the alert line . METHODS As part of a large pilot r and omized controlled trial , women 's views were explored using a specifically design ed question naire that was completed by 615 primiparas 2 days after giving birth . The quantifiable data were analyzed by comparing means using ANOVA followed by the Scheffe test . RESULTS Women in the 2-hour arm were significantly more satisfied than those in the other two arms ( p < 0.001 ) , despite having the most obstetric intervention . CONCLUSIONS For women in prolonged labor , obstetric intervention can be an acceptable or even favorable option . Midwives and obstetricians need to provide labor management that takes into account the preferences of the women to whom they give care & NA ; Dystocia , or slow labor , is the leading cause of first‐time cesarean sections . Current diagnostic guidelines for dystocia are vague , and there is no clear postoperative confirmatory evidence to assess the correctness of this diagnosis . For several decades , various professional organizations have indicated that cesarean rates could be lowered safely and have recommended levels that are far below national averages . The three major factors , of roughly equal importance , associated with cesarean for slow labor are the baby 's weight , the mother 's height , and the threshold at which the physician believes it is reasonable to intervene . The last is the only modifiable factor , and quality programs are a major part of changing medical behavior . By using two study design s , the effect of a mathematical method for evaluating labor progress on the rate of cesarean section  was measured . In the prospect i ve r and omized clinical trial , the relative risk of cesarean in the experimental group was unchanged at 1.04 . In the pretest‐posttest analysis , the rates fell from 19.54 % to 17.04 % at 6 months and 16.62 % at 12 months OBJECTIVE To compare two World Health Organization ( WHO ) partographs - a composite partograph including the latent phase with a simplified one without the latent phase in women with uncomplicated pregnancy . MATERIAL AND METHODS This was a r and omized controlled trial conducted at a tertiary hospital at Belgaum , India . 743 women with term , singleton , vertex gestation , in spontaneous labor were included in the study over a period of one year . Either of the partographs was used on laboring women . The following outcomes were compared : labor crossing the alert and action line , augmentation of labor , rate of cesarean section , perinatal outcome , user friendliness and maternal complications . Statistical analysis was done using Chi-square test . RESULTS Labor values crossed the alert and action lines significantly more often when composite partograph was used ( p<0.001 ) in each , with increased number of augmentations ( p<0.001 ) . The number of vaginal deliveries were high ( p<0.005 ) in the simplified group . There was no significant difference in the rate of cesarean deliveries due to non progress of labor in both groups ( p=0.68 ) . NICU admissions were higher in the composite group ( p=0.035 ) . Most resident doctors ( 9 
    Output:
    
There were no clear differences between groups for oxytocin augmentation , low Apgar score , instrumental vaginal birth and perinatal death .
On the basis of the findings of this review , we can not be certain of the effects of routine use of the partograph as part of st and ard labour management and care , or which design , if any , are most effective .