Systematic monitoring of labour is essential for identifying abnormal progression and facilitating timely obstetric intervention. The partogram provides a graphical representation of cervical dilatation, fetal condition, uterine activity and maternal parameters and is widely used to support clinical decision-making during labour. However, conventional paper partograms may be affected by delayed recording, incomplete documentation and errors in plotting. Electronic partograms have been developed to overcome some of these limitations through real-time data entry, automated plotting and clinical alerts.[1]

Comparative evidence has demonstrated that electronic partograms are feasible for routine intrapartum monitoring and may facilitate timely recognition of abnormal labour and appropriate intervention. Electronic systems have also been reported to be acceptable to healthcare providers and suitable for integration into routine maternity services.[2] Nevertheless, their effectiveness depends on consistent documentation, and quality-improvement measures have been shown to increase adherence to electronic partogram plotting.[3]

Simplified paperless approaches have similarly been evaluated as bedside tools for labour management and may assist in recognizing abnormal labour progression while reducing the burden of conventional graphical documentation.[4] Comparative evaluation of paperless and modified WHO partograms has demonstrated the potential usefulness of simplified monitoring systems in labour management.[5] Further evidence suggests that paperless monitoring can provide a practical approach for identifying deviations from normal labour and supporting decisions regarding obstetric intervention.[6]

One of the clinically important consequences of abnormal labour is the requirement for operative delivery, either instrumental vaginal delivery or caesarean section. Whether electronic monitoring influences the frequency, indications and pattern of operative intervention compared with conventional paper monitoring remains clinically relevant. Therefore, the present study was undertaken to compare operative delivery during labour monitored by electronic and paper partograms, with particular emphasis on the indications and outcomes of operative intervention.

Study design and setting This was a prospective comparative observational study conducted in the Department of Obstetrics and Gynaecology of a tertiary care teaching hospital. Women admitted in active labour who fulfilled the eligibility criteria were enrolled and followed until delivery. Sample size and study groups A total of 1,500 women were included in the study and categorized into two equal groups according to the method of intrapartum monitoring: Group E: 750 women monitored using an electronic partogram. Group P: 750 women monitored using the modified WHO paper partogram. The same overall study cohort was retained to permit comparison of operative delivery and its indications between the two monitoring approaches. Inclusion criteria Women aged 19–40 years with term singleton pregnancy, cephalic presentation and active labour were included. Partogram monitoring was initiated when cervical dilatation was ≥4 cm. Exclusion criteria Women with previous caesarean section, preterm pregnancy, multiple gestation, malpresentation or antepartum haemorrhage were excluded. Study procedure At enrolment, maternal age, parity, gestational age and relevant obstetric characteristics were recorded. Women in Group E were monitored using an electronic partogram, in which intrapartum observations were entered electronically. The system enabled structured documentation of labour progression and relevant maternal and fetal observations. Women in Group P were monitored using the modified WHO paper partogram, with labour parameters manually recorded at appropriate intervals. Cervical dilatation, descent of the fetal head, uterine contractions, fetal heart rate and maternal observations were monitored according to routine institutional practice. All women received standard intrapartum obstetric care. Decisions regarding operative delivery were made by the treating obstetric team based on labour progression and maternal or fetal indications. Outcome measures The principal outcome was operative delivery, categorized as instrumental vaginal delivery or caesarean section. Spontaneous vaginal delivery was recorded as the reference delivery outcome. The indications for caesarean section were classified as: 1. Protracted active phase; 2. Secondary arrest of cervical dilatation; 3. Arrest of descent; and 4. Pathological cardiotocography. The indications for instrumental vaginal delivery were classified as: 1. Poor maternal bearing-down effort; and 2. Prolonged fetal deceleration. The frequency and distribution of operative deliveries and their indications were compared between the electronic and paper partogram groups. Statistical analysis Data were entered into Microsoft Excel and analysed using SPSS version 23.0. Continuous variables were expressed as mean ± standard deviation, while categorical variables were presented as frequency and percentage. Baseline continuous variables were compared using the independent-samples t-test. The proportions of spontaneous vaginal, instrumental vaginal and caesarean deliveries and the distribution of indications for operative delivery were compared using the Chi-square test or Fisher's exact test, as appropriate. A p-value <0.05 was considered statistically significant.

A total of 1,500 women in active labour were evaluated, of whom 750 were monitored using an electronic partogram (Group E) and 750 using a modified WHO paper partogram (Group P). The analysis focused on the occurrence, type and indications of operative delivery in the two groups.

Table 1. Distribution of operative and non-operative deliveries

Spontaneous vaginal delivery was achieved in 82.93% of women monitored with the electronic partogram and 82.27% monitored with the paper partogram. Overall operative delivery was required in 128 (17.07%) women in Group E compared with 132 (17.60%) in Group P. Instrumental vaginal delivery rates were almost identical (12.53% vs 12.40%), whereas caesarean section was numerically less frequent in the electronic-partogram group (4.53% vs 5.20%). Overall, the distribution of mode of delivery was comparable between the groups.

Table 2. Indications for caesarean section

Among women requiring caesarean section, pathological cardiotocography was the most frequent indication in both groups, accounting for 12 cases in Group E and 13 cases in Group P. Secondary arrest of dilatation occurred in 8 and 10 women, respectively, while arrest of descent was observed in 6 women monitored electronically compared with 9 monitored using the paper partogram. Protracted active phase accounted for 8 and 7 caesarean sections, respectively. The overall pattern of indications was similar between the two groups.

Table 3. Indications for instrumental vaginal delivery

Poor maternal bearing-down effort was the predominant indication for instrumental vaginal delivery in both groups, accounting for 72 (9.60%) women in Group E and 69 (9.20%) in Group P. Prolonged fetal deceleration resulted in instrumental delivery in 22 (2.93%) and 24 (3.20%) women, respectively. Thus, both the frequency and pattern of instrumental delivery were comparable between the monitoring groups.

Table 4. Pattern of operative delivery among women requiring intervention

Among women who underwent operative delivery, instrumental vaginal delivery constituted 73.44% of operative interventions in the electronic-partogram group and 70.45% in the paper-partogram group. Caesarean sections accounted for 26.56% and 29.55% of operative deliveries, respectively.

Overall, operative delivery rates were comparable between electronic and paper partogram monitoring (17.07% vs 17.60%). Electronic monitoring showed a small numerical reduction in the proportion of caesarean sections, particularly for arrest of descent and secondary arrest of dilatation, but the available dataset does not establish a statistically significant difference in overall operative delivery. The findings therefore indicate a broadly similar pattern of operative intervention and indications with the two methods of intrapartum monitoring.

The present study compared operative delivery among 1,500 women in active labour monitored using electronic and paper partograms. The overall operative delivery rate was 17.07% in the electronic-partogram group and 17.60% in the paper-partogram group. Instrumental vaginal delivery rates were nearly identical (12.53% vs 12.40%), while caesarean section was numerically lower with electronic monitoring (4.53% vs 5.20%). Thus, the type of partogram used for intrapartum monitoring was not associated with an appreciable difference in the overall requirement for operative delivery. Previous evaluation of paperless partogram monitoring has demonstrated its usefulness as a simple clinical tool for identifying deviations from normal labour and facilitating appropriate intervention.[7] Comparative assessment of paperless and WHO partograms has similarly suggested that simplified monitoring can be incorporated into labour management without an apparent increase in operative intervention.[8] More recent comparative evidence has also reported broadly comparable modes of delivery between women monitored with paperless and modified WHO partographs.[9] These observations are consistent with the present findings. The slightly lower caesarean section rate observed with electronic monitoring may reflect differences in the recognition and management of labour abnormalities; however, this numerical difference should not be interpreted as a causal reduction in caesarean delivery. Contemporary reviews have emphasized that the effectiveness of a partogram depends not only on its design but also on accurate recording, interpretation of labour progress and timely clinical response.[10] Partogram use has been associated with structured labour surveillance and improved recognition of abnormal progression, potentially allowing obstetric intervention to be undertaken when clinically indicated.[11] At the same time, decisions regarding operative delivery are multifactorial, and appropriate intrapartum management remains important in avoiding unnecessary primary caesarean delivery.[12] Therefore, digitalization of labour monitoring should primarily be viewed as a means of supporting clinical decision-making rather than independently determining the mode of delivery. In the present study, pathological cardiotocography was the most frequent indication for caesarean section in both groups. Secondary arrest of dilatation and arrest of descent were slightly less frequent in the electronic-partogram group. For instrumental vaginal delivery, poor maternal bearing-down effort was the predominant indication in both groups, followed by prolonged fetal deceleration. The overall distribution of indications was broadly comparable. Recent digital labour-room initiatives have demonstrated increasing feasibility and acceptance of electronic partogram applications, supporting their integration into routine intrapartum care.[13] The major strength of the present study was its large sample size with equal numbers of women monitored by each method. However, the observational design limits causal interpretation, and factors influencing the clinical decision for operative delivery could not be completely accounted for. Further prospective multicentre studies may help determine whether electronic monitoring influences the timing and appropriateness of operative intervention.

Operative delivery rates were comparable among women monitored using electronic and paper partograms. Instrumental vaginal delivery occurred at similar rates in both groups, while caesarean section was numerically less frequent with electronic monitoring. The indications for operative intervention were also broadly similar. Electronic partograms therefore provide a feasible alternative to conventional paper partograms for intrapartum monitoring without evidence of increased operative delivery.