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Essay: Utilisation of partograph among midwives and doctors at Kapkatet District Hospital

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  • Published: 9 October 2015*
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A partograph is a tool that was designed by Philpot in 1971 in Harare Zimbabwe. By 1973 it was already considered a simple devise used to distinguish abnormal from normal labour as it was used to monitor 15,000 delivers within 18 months (Studd, 1973). It is a pre-printed paper with a visual (graphical representation of observations made on a woman and fetus during the course of labour.
The observations are comprised of the progress of labor, maternal condition and fetal condition. These observations are displayed on the partograph for easy and quick review of ongoing labor and timing of management decisions. It is used as a tool for risk assessment and is effective in detecting abnormal labour during first stage (Philpot, 1972).
W.H.O launched the partograph in 1987 as a safe motherhood initiative following multi centre trial in South Asia that involved 35,484 women. It further tested it’s efficiency and established it’s scientific basis and rationale for it’s use in prevention of prolonged labour. (W.H.O, 1987).When used correctly the partograph helps to identify problems and interventions can be timely initiated thus preventing morbidity and mortality (Friedman, 1955).
In Philpotts partograph he designed alert and action line which helps to capture prolonged labour. It also detects fetal heart abnormalities which results in intrapartum fetal hypoxia. In 1994 WHO declared universal application of partograph in all settings (WHO, 1994) maternal condition is monitored to assess the well being of the mother. If her well-being is affected definitely the fetus is compromised too and interventions should be instituted to save life of both (Neilson, 2010).
Checking of blood pressure helps detect pre-eclampsia and Eclampsia. Pulse rate is checked to identify dehydration or sepsis that could arise during labour. Temperature observation helps identify hyperpyrexia which is a sign of sepsis. Urine output is monitored to exclude ketones, proteinuria and dehydration.
Foetal heart rate is closely monitored to assess its well being. If any deviation from normal is noted then timely interventions of safe life are put in place. Foetal heart rate monitoring is assumed to identify babies who are running short of oxygen. State of membranes show the rise of baby and mother to ascending infections if ruptured for long.
Cervical dilatation denotes behavior progress. It also tells weather labour is precipitated, normal or prolonged. Precipitated and prolonged labor are potential risks of post partum hemorrhage, (Nelson, 2010). Interpretation of cervical dilatation is aided by alert and action lines on the graph. Alert line is a graphic line drawn 4-10 cm. its role is to separate normal from abnormal labour. The crossing of alert line is associated with fetal distress increasing need for resuscitation after birth (Dujardin, 1992). Action line is drawn 4 hours to the right to alert line. The action line represents slow labour progress which is a potential source maternal and fetal sepsis dehydration, rapture of uterus and maternal exhaustion (WHO, 1993).
Consistent and regular monitoring of interactions shows whether labour progress is normal or not. If they are efficient and effective normal progress is anticipated. Descent shows a compatibility of fetal head and pelvis and failure of presenting part of descend in presence of strong contractions indicates Cephalo Pelvic Distribution (C.P.D) which is the common cause of obstructed labour. Monitoring labor in a systematic way with use of partograph is advocated even in low income countries to prevent possible child birth complications. Early detection and early management of complications reduces maternal and perinatal mortality and morbidity, (Chodzaza et al, 2010).
Every year 4,000,000 neonates die worldwide and 1,000,000 are fresh-still births. 1,000 women die everyday from pregnancy or childbirth related complications worldwide (Hogan Naghavi, 2010). Majority of these deaths in low income countries occur from complications of eclampsia, prolonged labor, obstructed and hemorrhage and sepsis.
10-12% of these deaths are due to prolonged/obstructed labour which is one of the underlying causes of ruptured uterus, hemorrhage, sepsis and obstetric fistulas. The use of a partograph is a well known best practice for quality monitoring of labour thus prevention of obstructed and prolonged labour (WHO, 2005).
From literature review it is clear that using the pantograph is evidence based practice. It’s aim is to facilitate maximum monitoring of the mother and fetus during labour. Despite WHO recommendation and advocating it to be compulsory it is used in limited extend in Africa and developing countries (maimbolwa et al, 1997). Various literature justify it’s use as the best tool in establishment of prolonged and obstructed labour (Lavender et al, 2008).
Several findings in Kenya (Rotich et al, 2008) has led to the notation that partograph is used in small proportion of patients to monitor labour progress. Even when one use the partograph it is often incomplete and incorrectly filled. Findings are also oftenly misinterpreted and partographs filled retrospectively when women have already delivered. This is of concern as it seems midwives use partograph as a midwifery record rather than labour management. The reason for this was not known. Various studies have highlighted the possible reasons for not using the partograph but are not from the context of Kenyans.
Therefore this study explores the views of health workers to assess the main reasons for its under utilization at Kapskatet District hospital.
Little is known about; extent of paragraph use, perception of partograph use by skilled birth attendants and factors that hinder its use. Understanding this will be important in addressing gaps in knowledge and perception and enhancement of management protocol. The results of this study will generally help inform institution participating in this study and other midwifery care providers on how use of partograph may be increased for improvement of maternal and fetal outcomes. The results will also inform on areas where teaching strategies need to be enhanced as it relates to instruction on partograph, its purpose and correct use. Ultimately the healthcare workforce will be equipped to effectively monitor the health of the mother and baby
Research objectives
Broad objective
To determine partograph utilization among midwives and doctors.
Specific objectives
I. To determine the extent of partograph use and its completeness.
II. To identify factors that hinders /enhances partograph use.
III. To explore usefulness of partograph as perceived by doctors and midwives
Research questions
I. To what extent is partograph used and completed at kapkatet district hospital?
II. What are factors that hinder or enhance partograph use?
III. What is the perception of doctors and midwives on partograph utilization?
Source population-Comprises of doctors and midwives working in maternity unit.
-Skilled birth attendants who attend to mothers in labor ward
-Those who consent
Health workers who work in other departments
Cross sectional quantitative study
Interviewer administered questionnaire
Use of closed and open ended questions

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