research findings and interpret existing evidence-based

clinical practice guidelines.

EBP implications for nurses:

Nurses serve instrumental roles in ensuring and providing

evidence-based practice.

They must continually ask the questions, “What is the

evidence for this intervention?” or “How do we provide best
practice?” and “Are these the highest achievable outcomes
for the patient, family, and nurse?”

Nurses are also well positioned to work with other members

of the healthcare team to identify clinical problems and use
existing evidence to improve practice.

Nurses throughout the country also have been involved in

multidisciplinary efforts to reduce the number and severity of
falls and pressure ulcers/injuries. Such projects can help save
money and improve care processes and outcomes.

Why is EBP important to nursing practice?

• It results in better patient outcomes.

• It contributes to the science of nursing.

• It keeps practice current and relevant.

• It increases confidence in decision-making.

• Policies and procedures are current and include the latest

research
  Evidence-based practice helps nurses provide high-
quality patient care based on research and knowledge
 . Evidence-based practice provides a critical strategy to
ensure that care is up to date and that it reflects the
latest research evidence.

Evidence-based practice can be easier for nurses to use if

they refer to already-developed evidence based or clinical
practice guidelines. Numerous expert groups have already
undertaken systematic efforts to develop guidelines to help
both healthcare providers and patients make informed
decisions about care interventions.

Guideline developers use a systematic approach to critique

the existing research, rate the strength of the evidence, and
establish practice guidelines. The overall goal of these types
of efforts focuses on guiding practice and minimizing the
variability in care.

What are the barriers to implementing evidence-based

practice?

The barriers that prevent nurses from using research in

everyday practice have been cited in numerous studies, and
some common findings have emerged.

Nurses often report the following:

• Lack of value for research in practice

• Difficulty in changing practice

• Lack of administrative support

• Lack of knowledgeable mentors

• Insufficient time to conduct research

• Lack of education about the research process

• Lack of awareness about research or evidence-based

practice

• Research reports/articles not readily available

• Difficulty accessing research reports and articles

• No time on the job to read research

• Complexity of research reports

• Feeling overwhelmed by the process

Despite these barriers, nurses are engaging in EBP and

making a difference in patient outcomes.

Furthermore, barriers can be overcome through

organizational efforts focused on integrating research in
practice and using strategies such as journal clubs, nursing
grand rounds, and having research articles available for
review.

Evidence-based practice takes resources, work, time, and

effort, but the outcomes make them worthwhile. Every
patient deserves care that is based on the best scientific
knowledge and that ensures high-quality, cost-effective care.
WHO recommendation on the use of active phase
partograph with a four-hour action line for
monitoring the progress of labour :
PUBLISHED ON : 21 May 2014
Recommendation:
Active phase partograph with a four-hour action line is
recommended for monitoring the progress of labour.
(Strong recommendation, very low-quality evidence)
 
Background:
Difficult labour (or dystocia) is characterized by abnormally
slow labour progress arising from inefficient uterine
contractions, abnormal fetal presentation or position,
inadequate bony pelvis or abnormalities of the pelvic soft
tissues of the mother.
Evidence suggests that up to one third of first-time mothers
experience delay in the first stage of labour.
Augmentation of labour is the process of stimulating the
uterus to increase the frequency, duration and intensity of
contractions after the onset of spontaneous labour.
It has commonly been used to treat delayed labour when
uterine contractions are assessed to be insufficiently strong
or inappropriately coordinated to dilate the cervix.
Labour augmentation has traditionally been performed with
the use of intravenous oxytocin infusion and/or artificial
rupture of amniotic membranes (amniotomy).
The procedure aims to shorten labour in order to prevent
complications relating to undue prolongation, and to avert
caesarean section.
There is evidence that a significant proportion of women
with uncomplicated pregnancies are subjected to routine
augmentation of labour with oxytocin.
While augmentation of labour may be beneficial in
preventing prolonged labour, its inappropriate use may cause
harm. Augmentation with synthetic oxytocin may result in
uterine hyperstimulation, with adverse effects such as fetal
asphyxia and uterine rupture, and thus increase the risk of a
cascade of interventions during labour and delivery.
 Methods:
The recommendation was developed using standardized
operating procedures in accordance with the process
described in the "WHO handbook for guideline
development", guided by the GRADE approach.
Outcomes used for this recommendation were aligned with
the prioritized outcomes from the WHO recommendations
on augmentation of labour (2014).
A Cochrane systematic review was conducted, on use of the
partograph as a monitoring tool to identify when
intervention becomes indicated during labour.
In the review, randomized controlled trials relevant to the
key question were screened by review authors, and data on
relevant outcomes and comparisons were extracted.
Evidence profiles (in the form of GRADE tables) were
prepared for comparisons of interest, including the
assessment and judgments for each outcome, and the
estimated risks.
WHO convened a Guideline Development Group (GDG)
meeting on recommendations on augmentation of labour in
September 2013, where this recommendation was
developed. The GDG comprised of a group of independent
experts, who used the evidence profiles to assess evidence
on effects on the pre-specified outcomes.
GDG members discussed the balance between desirable and
undesirable effects, overall quality of supporting evidence,
values and preferences of stakeholders, resource
requirements, cost-effectiveness, acceptability, feasibility and
equity, to formulate the recommendation. Remarks were
added to clarify the recommendation, and aid
implementation.
 Evidence Summary:
Evidence on the use of a partograph as a monitoring tool to
identify when intervention becomes indicated during labour
was extracted from a Cochrane systematic review of six RCTs
(> 7000 women).
The review examined seven different comparisons:
Partograph versus no partograph:

 Two trials conducted in Canada and Mexico involving a

total of 1590 women compared partograph with no
partograph.

 In one trial, there were no significant differences in the

mean duration (MD) of the first or second stages of
labour.
  Overall, there was no significant difference in the
frequency of caesarean section although findings in the
two trials were not consistent.

 In the Canadian trial, there was no significant difference

between groups, whereas significantly fewer women in
the partograph group had caesarean section in the
Mexican trial .

 The Mexican trial, however, was at high risk of bias due

to poor allocation concealment.

 There were no significant differences between groups

for the other critical or important maternal and infant
outcomes reported: use of epidural , oxytocin
augmentation; instrumental vaginal birth ; artificial
rupture of the membranes ;low Apgar score at five
minutes ; and admission to special care nursery .

Partograph with an alert line only versus one with both

alert and action lines:

 A trial involving 694 women in South Africa compared a

partograph with an alert line only with one with both
alert and action lines.

 Women in the alert line only group received what was

described as "aggressive" labour management with two-
hourly vaginal examinations and oxytocin augmentation
once the alert line was crossed.

 Women in the other group received expectant

management with four-hourly vaginal examinations and
 oxytocin augmentation when the action line (four hrs to
the right of the alert line) was crossed.

 It was unclear whether the findings reflected the use of

different types of partograph or other features of labour
management.

 Women in the alert line only group were significantly

less likely to have caesarean section , Rates of oxytocin
augmentation and instrumental vaginal birth were similar
between the groups.

 There were insufficient events to detect differences in

terms of the infant outcomes reported.

Partograph with two-hour versus four-hour action lines:

 Two trials conducted in the United Kingdom compared

partographs with two-hour versus four-hour action lines.

 There were no significant differences between the

comparison groups for reported critical or important
maternal outcomes.

 There was a modest increase in the number of women

receiving oxytocin augmentation in the two-hour
partograph group .

 There were no significant differences in infant outcomes

reported.

Partograph with two-hour versus three-hour action lines:

 One trial in the United Kingdom compared partograph

with two-hour versus three-hour action lines
  . There were no statistically significant differences
between these partograph designs for any of the
maternal or infant outcomes reported.

Partograph with three-hour versus four-hour action lines

 One trial in the United Kingdom compared partographs

with three-hour versus four-hour action lines.

 There were no statistically significant differences

between these partograph designs for most of the
maternal and infant outcomes reported.

 The rates of caesarean section for fetal distress or for

delay in labour in the two groups were not significantly
different .

 However, in the trial (613 women), overall rate of

caesarean section was higher in the three-hour compared
with the four-hour action line group.

 Results for other maternal outcomes did not identify

statistically significant differences between women cared
for using the two partograph designs.

 There were no significant differences between any of

the infant outcomes reported: low Apgar score at five
cord pH < 7.1; and admission to special care nursery .

Partograph prompting early versus later intervention:

 The trial conducted in South Africa was pooled with the

two trials from the United Kingdom trials in a comparison
examining partograph designs prompting earlier versus
later intervention.
  Overall, there were no significant differences between
earlier and later intervention for the outcomes reported:
caesarean section and instrumental birth.

Partograph with latent phase versus partograph without

latent phase:

 One trial conducted in India with data for 743 women

compared a partograph design with a latent phase with
one without a latent phase.

 Women cared for using a partograph with a latent phase

were more likely to have caesarean section for all
indications and specifically for fetal distress.

 The difference between the groups in rates of caesarean

section for delay was not statistically significant .

 The partograph with a latent phase was also associated

with increased use of oxytocin augmentation .

 There was no difference between the groups in the

frequencies of instrumental vaginal birth.

 No significant difference was observed for low Apgar

scores at five minutes but infants in the latent phase
partograph group were more likely to be admitted to
special care nursery .

 Other maternal and neonatal outcomes were not

reported.

Implementation considerations:
 The successful introduction of this recommendation into
national programmes and health-care services depends
on well-planned and participatory consensus-driven
processes of adaptation and implementation.

 The adaptation and implementation processes may

include the development or revision of existing national
guidelines or protocols based on this recommendation.

 The recommendation should be adapted into a locally

appropriate document that can meet the specific needs
of each country and health service.

 Any changes should be made in an explicit and

transparent manner.

 A set of interventions should be established to ensure

that an enabling environment is created for the use of the
recommendations (including, for example, the availability
of augmentation agents and monitoring capacity), and
that the behaviour of the healthcare practitioner changes
towards the use of this evidence-based practice.

 In this process, the role of local professional societies is

important and an all-inclusive and participatory process
should be encouraged.

Remarks:

 The GDG acknowledged the low quality of the

supporting evidence but noted that many units in both
high- and low-income settings currently use the
partograph and, although no clinical benefits in health
outcomes were reported in the RCTs, it is a useful tool for
 providing a pictorial overview of progress, clinical audit,
training of health workers and facilitating the transfer of
care. These considerations, in addition to the low
resource implication of the intervention led the GDG to
make a strong recommendation in favour of the
partograph.

 The potential benefits of introducing the use of a

partograph may be more apparent in under-resourced
clinical settings where a standard protocol for labour
management is either not used or is inconsistently used.
However, the benefits of using the partograph can only
be maximized when accompanied by adherence to a
standard labour management protocol.

 Considering the variability among women with regard to

rates of progress during labour, the GDG placed its
emphasis on reducing the likelihood of unnecessary
interventions and therefore chose to recommend the
four-hour action line partograph rather than those with
earlier action lines.