Bernitz S, et al. - Authors comparatively studied the rate of intrapartum cesarean section (ICS) in reference to the WHO partograph and Zhang's guideline for labor progression. They found an overall drop in ICS due to close focus on valuing labor progress as compared to the use of the guidelines.

Methods

• In this multicentre, cluster-randomised controlled trial at obstetric units in Norway, each site was needed to deliver more than 500 babies per annum to be eligible for inclusion.
• Nulliparous females who had a singleton, full-term fetus with cephalic presentation, and who entered spontaneous active labor were involved.
• They treated the obstetric units as clusters, and women treated within the clusters were given the same treatment.
• These clusters were stratified by size and number of previous cesarean sections.
• The clusters containing the obstetric units were then randomly assigned in 1:1 ratio ie, to the control group (adhered to the WHO partograph) and to the intervention group (adhered to Zhang's guideline).
• The randomisation was computer-generated and was done in the Unit of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway, with no further involvement investigators in this unit.
• The researchers assessing the data were masked to group allocation but were unable to mask the candidates or health-care providers.
• They noted the use of ICS during active labour (cervical dilatation of 4–10 cm) in all participating females as the primary outcome.

Results

• From Aug 1, 2014 to Sept 1, 2014, they enrolled 14 clusters in the LaPS trial, and on Sept 11, 2014, a sum of 7 obstetric units were randomly assigned to the control group (adhering to the WHO partograph) and 7 obstetric units to the intervention group (adhering to Zhang's guideline).
• Between Dec 1, 2014, and Jan 31, 2017, they judged 11,615 eligible women for recruitment in the trial, which comprised 5421 (46·7%) females in the control group units and 6194 (53·3%) in the intervention group units.
• In the control group, 2100 (38·7%) of 5421 women were not agreed to participate and 16 (0·3%) were abstained from participation.
• In the intervention group, 2181 (35·2%) of 6194 women did not give signed consent to participate and 41 (0·7%) women abstained from participation.
• A total of 7277 (62·7%) females were hence involved in the analysis of the primary endpoint.
• A fraction of 3305 (45·4%) candidates were in an obstetric unit, randomly assigned to the control group (adhering to the WHO partograph) whereas 3972 (54·6%) participants were in an obstetric unit, randomly assigned to the intervention group (adhering to Zhang's guideline).
• No women dropped out during the trial.
• Before the initiation of the trial, ICS was implemented in 9·5% of parturition in the control group and in 9·3% of intervention group obstetric units.
• They observed no difference in the the frequency of ICS between the 2 groups (adjusted relative risk 1·17, 95% CI 0·98–1·40; p=0·08; adjusted risk difference 1·00%, 95% CI −0·1 to 2·1).
• Theyu recorded 196 (5·9%) ICS deliveries in women in the control group (WHO partograph) and 271 (6·8%) ICS deliveries in women in the intervention group (Zhang's guideline).
• No maternal or neonatal deaths were observed during the trial.