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Meta-Analysis
. 2018 Aug 6;8(8):CD005461.
doi: 10.1002/14651858.CD005461.pub5.

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Tina Lavender  1 , Anna Cuthbert, Rebecca Md Smyth
Affiliations
Meta-Analysis

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies

Tina Lavender et al. Cochrane Database Syst Rev. .

Abstract

Background: The partograph (sometimes known as partogram) is usually a pre-printed paper form on which labour observations are recorded. The aim of the partograph is to provide a pictorial overview of labour, and to alert midwives and obstetricians to deviations in maternal or fetal well-being and labour progress. Charts have traditionally contained pre-printed alert and action lines. An alert line, which is based on the slowest 10% of primigravid women's labours, signifies slow progress. An action line is placed a number of hours after the alert line (usually two or four hours) to prompt effective management of slow progress of labour.This review is an update of a review last published in 2013.

Objectives: The primary objective was to determine the effectiveness and safety of partograph use on perinatal and maternal morbidity and mortality. The secondary objective was to determine which partograph design is most effective for perinatal and maternal morbidity and mortality outcomes.

Search methods: We searched Cochrane Pregnancy and Childbirth's Trials Register (31 August 2017), ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (31 August 2017) and reference lists of retrieved studies.

Selection criteria: Randomised, cluster-randomised, and quasi-randomised controlled trials involving a comparison of partograph use with no partograph, or comparison between different partograph designs.

Data collection and analysis: Three review authors independently assessed eligibility, quality and extracted data. When one review author was also the trial author, the two remaining review authors assessed the studies independently. We assessed the evidence using the GRADE approach.

Main results: We have included 11 studies, involving 9475 women in this review; three studies assessed partograph use versus no partograph, seven assessed different partograph designs, and one assessed partograph use versus labour scale. Risk of bias varied in all studies. It was infeasible to blind staff or women to the intervention. Two studies did not adequately conceal allocation. Loss to follow-up was low in all studies. We assessed the evidence for partograph use versus no partograph using the GRADE approach; downgrading decisions were due to study design, inconsistency, indirectness, and imprecision of effect estimates.Most trials reported caesarean section rates and Apgar scores less than 7 at five minutes; all other outcomes were not consistently reported (e.g. duration of first stage of labour and maternal experience of childbirth).Partograph versus no partograph (3 trials, 1813 women)It is uncertain whether there is any clear difference between partograph use and no partograph in caesarean section rates (average risk ratio (RR) 0.77, 95% confidence interval (CI) 0.40 to 1.46; n = 1813; 3 trials; I² = 87%; very low-quality evidence); oxytocin augmentation (RR 1.02, 95% CI 0.95 to 1.10; n = 1156; 1 trial; moderate-quality evidence); duration of first stage of labour (mean difference (MD) 0.80 hours, 95% CI -0.06 to 1.66; n = 1156; 1 trial; low-quality evidence); or Apgar score less than 7 at five minutes (RR 0.76, 95% CI 0.29 to 2.03; n = 1596; 2 trials; I² = 87%; very low-quality evidence).Partograph with different placement of action lines (4 trials, 5051 women)When compared to a four-hour action line, women in the two-hour action line group were more likely to receive oxytocin augmentation (average RR 2.44, 95% CI 1.36 to 4.35; n = 4749; 4 trials; I² = 96%). There was no clear difference in caesarean section rates (RR 1.06, 95% CI 0.88 to 1.28; n = 4749; 4 trials); duration of first stage of labour (RR 0.81 hours, 95% CI 0.32 to 2.04; n = 948; 1 trial); maternal experience of childbirth (average RR 0.61, 95% CI 0.28 to 1.35; n = 2269; 2 trials; I² = 83%); or Apgar score less than 7 at five minutes (RR 0.93, 95% CI 0.61 to 1.42; n = 4749; 4 trials) between the two- and four-hour action line.The following comparisons only include data from single studies. Fewer women reported negative childbirth experiences in the two-hour action line group compared to the three-hour action line group (RR 0.49, 95% CI 0.27 to 0.90; n = 348; 1 trial). When we compared the three- and four-hour action line groups, the caesarean section rate was higher in the three-hour action line group (RR 1.70, 95% CI 1.07 to 2.70; n = 613; 1 trial). We did not observe any clear differences in any of the other outcomes in these comparisons.Partograph with alert line only versus partograph with alert and action line (1 trial, 694 women)The caesarean section rate was lower in the alert line only group (RR 0.68, 95% CI 0.50 to 0.93). There were no clear differences between groups for oxytocin augmentation, low Apgar score, instrumental vaginal birth and perinatal death.Partograph with latent phase (composite) versus partograph without latent phase (modified) (1 trial, 743 women)The caesarean section and oxytocin augmentation rates were higher in the partograph with a latent phase (RR 2.45, 95% CI 1.72 to 3.50; and RR 2.18, 95% CI 1.67 to 2.83, respectively). There were no clear differences between groups for oxytocin augmentation, and Apgar score less than 7 at five minutes.Partograph with two-hour action line versus partograph with stepped dystocia line (1 trial, 99 women)Fewer women received oxytocin augmentation in the dystocia line group (RR 0.62, 95% CI 0.39 to 0.98). We did not observe any clear differences in any of the other primary outcomes in this comparison.Partograph versus labour scale (1 trial, 122 women)The use of the partograph compared with the labour scale resulted in fewer women receiving oxytocin augmentation (RR 0.32, 95% CI 0.18 to 0.54), but did not produce any clear differences for any of the other primary outcomes.

Authors' conclusions: On the basis of the findings of this review, we cannot be certain of the effects of routine use of the partograph as part of standard labour management and care, or which design, if any, are most effective. Further trial evidence is required to establish the efficacy of partograph use per se and its optimum design.

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Conflict of interest statement

Tina Lavender: was investigator of two trials included in this review (Lavender 1998a; Lavender 2006); therefore, she was not involved with evaluating these studies. No other relevant conflicts of interest.

Anna Cuthbert: is employed by the University of Liverpool as a Research Associate with Cochrane Pregnancy and Childbirth. Her employment is supported by the National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to Cochrane Pregnancy and Childbirth. She had no involvement with the editorial processes for this review update.

Rebecca Smyth: none known.

Figures

1
1
Modified partograph
2
2
Study flow diagram.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 1 Caesarean section (overall).
1.2
1.2. Analysis
Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 2 Oxytocin augmentation.
1.3
1.3. Analysis
Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 3 Duration of first stage of labour.
1.4
1.4. Analysis
Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 4 Low Apgar score (less than 7 at 5 minutes).
1.5
1.5. Analysis
Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 5 Instrumental vaginal birth.
1.6
1.6. Analysis
Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 6 Regional analgesia ‐ epidural.
1.7
1.7. Analysis
Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 7 Performance of artificial rupture of membranes during labour.
1.8
1.8. Analysis
Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 8 Antibiotic use.
1.9
1.9. Analysis
Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 9 Duration of second stage of labour (hours).
1.10
1.10. Analysis
Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 10 Number of vaginal examinations.
1.11
1.11. Analysis
Comparison 1 Partograph versus no partograph (studies carried out in high‐ and low‐resource settings), Outcome 11 Admission to special care nursery.
2.1
2.1. Analysis
Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 1 Caesarean section (overall).
2.2
2.2. Analysis
Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 2 Oxytocin augmentation.
2.3
2.3. Analysis
Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 3 Duration of first stage of labour (length of labour greater than 18 hours, length of labour greater than 12 hours).
2.4
2.4. Analysis
Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 4 Maternal experience of childbirth ‐ negative childbirth experience.
2.5
2.5. Analysis
Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 5 Low Apgar score (less than 7 at 5 minutes).
2.6
2.6. Analysis
Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 6 Serious maternal morbidity or death.
2.7
2.7. Analysis
Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 7 Caesarean section (distress).
2.8
2.8. Analysis
Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 8 Caesarean section (delay).
2.9
2.9. Analysis
Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 9 Instrumental vaginal delivery.
2.10
2.10. Analysis
Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 10 Postpartum haemorrhage ‐ blood loss > 500 mL.
2.11
2.11. Analysis
Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 11 Regional analgesia ‐ epidural.
2.12
2.12. Analysis
Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 12 Performance of artificial rupture of the membranes during labour.
2.13
2.13. Analysis
Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 13 Number of vaginal examinations in labour.
2.14
2.14. Analysis
Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 14 Serious neonatal morbidity or perinatal death.
2.15
2.15. Analysis
Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 15 Admission to special care nursery.
2.16
2.16. Analysis
Comparison 2 Partograph with 2‐hour action line versus partograph with 4‐hour action line (studies carried out in a high‐ and low‐resource settings), Outcome 16 Cord blood arterial pH less than 7.1.
3.1
3.1. Analysis
Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 1 Caesarean section (overall).
3.2
3.2. Analysis
Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 2 Oxytocin augmentation.
3.3
3.3. Analysis
Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 3 Maternal experience of childbirth ‐ negative childbirth experience.
3.4
3.4. Analysis
Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 4 Low Apgar score (less than 7 at 5 minutes).
3.5
3.5. Analysis
Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 5 Serious maternal morbidity or death.
3.6
3.6. Analysis
Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 6 Caesarean section (distress).
3.7
3.7. Analysis
Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 7 Caesarean section (delay).
3.8
3.8. Analysis
Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 8 Instrumental vaginal delivery.
3.9
3.9. Analysis
Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 9 Postpartum haemorrhage ‐ blood loss > 500 mL.
3.10
3.10. Analysis
Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 10 Regional analgesia ‐ epidural.
3.11
3.11. Analysis
Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 11 Performance of artificial rupture of membranes during labour.
3.12
3.12. Analysis
Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 12 Vaginal examinations.
3.13
3.13. Analysis
Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 13 Serious neonatal morbidity or perinatal death.
3.14
3.14. Analysis
Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 14 Admission to special care nursery.
3.15
3.15. Analysis
Comparison 3 Partograph with 2‐hour action line versus partograph with 3‐hour action line (study carried out in a high‐resource setting), Outcome 15 Cord blood arterial pH less than 7.1.
4.1
4.1. Analysis
Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 1 Caesarean section (overall).
4.2
4.2. Analysis
Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 2 Oxytocin augmentation.
4.3
4.3. Analysis
Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 3 Maternal experience of childbirth ‐ negative childbirth experience.
4.4
4.4. Analysis
Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 4 Low Apgar score (less than 7 at 5 minutes).
4.5
4.5. Analysis
Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 5 Serious maternal morbidity or death.
4.6
4.6. Analysis
Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 6 Caesarean section (distress).
4.7
4.7. Analysis
Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 7 Caesarean section (delay).
4.8
4.8. Analysis
Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 8 Instrumental vaginal delivery.
4.9
4.9. Analysis
Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 9 Postpartum haemorrhage ‐ blood loss > 500 mL.
4.10
4.10. Analysis
Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 10 Regional analgesia ‐ epidural.
4.11
4.11. Analysis
Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 11 Performance of artificial rupture of membranes during labour.
4.12
4.12. Analysis
Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 12 Number of vaginal examinations in labour.
4.13
4.13. Analysis
Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 13 Serious neonatal morbidity or perinatal death.
4.14
4.14. Analysis
Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 14 Admission to special care nursery.
4.15
4.15. Analysis
Comparison 4 Partograph with 3‐hour action line versus partograph with 4‐hour action line (study carried out in a high‐resource setting), Outcome 15 Cord blood arterial pH less than 7.1.
5.1
5.1. Analysis
Comparison 5 Partograph with alert line only versus partograph with alert and action line (study carried out in a low‐resource setting), Outcome 1 Caesarean section (overall).
5.2
5.2. Analysis
Comparison 5 Partograph with alert line only versus partograph with alert and action line (study carried out in a low‐resource setting), Outcome 2 Oxytocin augmentation.
5.3
5.3. Analysis
Comparison 5 Partograph with alert line only versus partograph with alert and action line (study carried out in a low‐resource setting), Outcome 3 Low Apgar score (less than 7 at 5 minutes).
5.4
5.4. Analysis
Comparison 5 Partograph with alert line only versus partograph with alert and action line (study carried out in a low‐resource setting), Outcome 4 Instrumental vaginal delivery.
5.5
5.5. Analysis
Comparison 5 Partograph with alert line only versus partograph with alert and action line (study carried out in a low‐resource setting), Outcome 5 Serious neonatal morbidity or perinatal death.
6.1
6.1. Analysis
Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low‐resource setting), Outcome 1 Caesarean section (overall).
6.2
6.2. Analysis
Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low‐resource setting), Outcome 2 Oxytocin augmentation.
6.3
6.3. Analysis
Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low‐resource setting), Outcome 3 Low Apgar score (less than 7 at 5 minutes).
6.4
6.4. Analysis
Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low‐resource setting), Outcome 4 Caesarean section (distress).
6.5
6.5. Analysis
Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low‐resource setting), Outcome 5 Caesarean section (delay).
6.6
6.6. Analysis
Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low‐resource setting), Outcome 6 Instrumental vaginal delivery.
6.7
6.7. Analysis
Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low‐resource setting), Outcome 7 Admission to special care nursery.
6.8
6.8. Analysis
Comparison 6 Partograph with latent phase versus partograph without latent phase (study carried out in a low‐resource setting), Outcome 8 Usability: user‐friendliness score.
7.1
7.1. Analysis
Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 1 Caesarean section.
7.2
7.2. Analysis
Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 2 Oxytocin augmentation.
7.3
7.3. Analysis
Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 3 Duration of first stage of labour (labour longer than 12 hours).
7.4
7.4. Analysis
Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 4 Maternal experience of childbirth (BSS‐R score).
7.5
7.5. Analysis
Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 5 Low Apgar score (less than 4 at 4 min).
7.6
7.6. Analysis
Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 6 Instrumental vaginal birth.
7.7
7.7. Analysis
Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 7 Postpartum haemorrhage (> 500 mL).
7.8
7.8. Analysis
Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 8 Regional analgesia.
7.9
7.9. Analysis
Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 9 Opioid use.
7.10
7.10. Analysis
Comparison 7 Partograph with 2‐hour action line versus partograph with stepped dystocia line, Outcome 10 Need for intubation at birth.
8.1
8.1. Analysis
Comparison 8 Partograph versus labour scale (study carried out in a low‐resource setting), Outcome 1 Caesarean section (overall).
8.2
8.2. Analysis
Comparison 8 Partograph versus labour scale (study carried out in a low‐resource setting), Outcome 2 Oxytocin augmentation.
8.3
8.3. Analysis
Comparison 8 Partograph versus labour scale (study carried out in a low‐resource setting), Outcome 3 Duration of first stage of labour.
8.4
8.4. Analysis
Comparison 8 Partograph versus labour scale (study carried out in a low‐resource setting), Outcome 4 Low Apgar score (less than 7 at 5 minutes).
8.5
8.5. Analysis
Comparison 8 Partograph versus labour scale (study carried out in a low‐resource setting), Outcome 5 Caesarean section (delay).
8.6
8.6. Analysis
Comparison 8 Partograph versus labour scale (study carried out in a low‐resource setting), Outcome 6 Stillbirth, neonatal death or neonatal morbidity.
8.7
8.7. Analysis
Comparison 8 Partograph versus labour scale (study carried out in a low‐resource setting), Outcome 7 Birth injuries and PPH (non‐prespecified outcome).
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References

References to studies included in this review

Kenchaveeriah 2011 {published data only}
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Mathews 2007 {published data only}
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References to studies awaiting assessment

NCT02911272 {published data only}
    1. NCT02911272. Best partograph action line to prevent prolonged labour (partograph). clinicaltrials.gov/show/NCT02911272 (first received 14 September 2016).

References to ongoing studies

NCT02714270 {published data only}
    1. NCT02714270. A randomized clinical trial of paperless versus modified World Health Organization partograph in management of first stage of labour [Paperless partograph for management of low risk labour]. clinicaltrials.gov/ct2/show/NCT02714270 (first received 16 March 2016).
NCT02741141 {published data only}
    1. NCT02741141. A comparative study of the effect of two partographs on the cesarean section rate in women in spontaneous labour (PARTODYS). clinicaltrials.gov/show/NCT02741141 (first received 12 January 2016).
NTR5543 {published data only}
    1. NTR5543. Randomized controlled trial comparing the currently used Friedman partogram with a four hour action line to the newly developed simple partogram, based on the 95th percentile normogram of the consortium on safe labor to evaluate early versus delayed cesarean section. trialregister.nl/trialreg/admin/rctview.asp?TC=5543 (first received 4 October 2015).

Additional references

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References to other published versions of this review

Lavender 2005
    1. Lavender T, O'Brien P, Hart A. Effect of partogram use on outcomes for women in spontaneous labour at term. Cochrane Database of Systematic Reviews 2005, Issue 3. [DOI: 10.1002/14651858.CD005461] - DOI
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Lavender 2013
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