Why Aren

1
Why Arent We Better Using the Partograph that
Saves Womens Lives? Karen Levin, Jeanne DArc
Kabagema and Peter Mukasa
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Fistula Care is

• Training doctors in fistula repair surgery and
  strengthening the capacity of hospitals to
  provide fistula care and improving quality of
  services
• Raising awareness about fistula prevention use
  of family planning, use of partograph to monitor
  labor, delivery, use of catheter in prolonged or
  obstructed labor and strengthen appropriate
  cesarean section deliveries
• Removing any other barriers to emergency
  obstetric care that lead to fistula in the first
  place
• Supporting women as they reenter family
  community life.

3
Content of Todays Session

• Introduce the partograph
• History
• Use and Efficacy
• Training
• Barriers to Utilization
• Fistula Cares efforts to strengthen partograph
  use in countries where FC works.
• Hands On Exercise
• Case Study Complete your own partograph

4
Partograph Introduction

• Simple, inexpensive pre-printed form
• Pictorial overview of progression of labor with
  charts of fetal condition and maternal condition
• Assists in identifying deviations from normal
  labor progression
• Prompts alert and action lines showing when
  to assist laboring woman

5
Partograph History

• Friedman in 1954 made a cervicograph showing 4
  phases of cervical dilation
• Philpott and Castle in 1972 added other
  intrapartum information and alert and action
  lines for better management of labor.
• WHO in 1987, promotes the universal use of the
  partograph during the Safe Motherhood Initiative
  Nairobi Conference
• WHO in 1994 publishes Prevention of Prolonged
  Labor a practical guide. The Partograph, a
  four-part manual on partograph use,
• WHO in 2000 revised the partograph omitting
  latent phase and commencing active phase at 4 cm
  dilatation.

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WHO Partographs Original and Simplified
Simplified WHO Partograph
Original WHO Partograph
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WHO Partographs Differences
Simplified WHO Partograph
Original WHO Partograph
8
Use of the Partograph

• Rates of use and knowledge vary widely
• Most often used rarely or incorrectly
• Situated within a larger context of poor labor
  monitoring skills and knowledge
• Even when used, not always correctly interpreted
• Need a functional referral system with essential
  obstetric services available improve labor
  management and patient transport in referring
  centers.

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Use of the Partograph Benefits

• Effective tool to assess progress of labor and
  identify when intervention is necessary
• Obvious improvement of quality of recording
  intrapartum period
• Influences decision making and is found to be
  associated to positive labor outcome
• Reduces prolonged labor, uterine rupture,
  obstructed labor requiring augmentation, number
  of emergency Cesarean sections, intrapartum
  stillbirths, post partum hemorrhage
• Guide for training health personnel and midwifes
• Guide tool for referral and communication between
  shifts and with the site receiving the patient if
  referred.

10
Partograph Training

• Must be appropriate. If poorly done can correlate
  to maternal mortality.
• Appropriate protocols and instructions have to be
  available and provided to health workers
• Introduction of the partograph must be followed
  by supervision, continuous reinforcement of
  implementation and quality assurance
• Knowledge alone is not enough it has to be
  associated with behavior change
• Training and follow up needed for those ACTUALLY
  completing the partograph

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Provider Attitudes and Barriers to Use

• When knowledgeable, have appreciation of the
  positive role of the partograph in labor
  monitoring
• Lack of adequate staffing
• Time pressures
• Supply issues
• Inadequate monitoring due to lack of
  skill/training
• Use of partograph as patient record vs. tool for
  action
• Reduction in autonomy

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What we need to find out

• Operations Research
• Actual use of the partograph as a referral tool
• Role of partograph in decision-making
• Most effective training strategies and outcomes,
  with monitoring and supervision systems
• Reinforcing referral systems
• Basic knowledge/skills training in labor
  monitoring

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Fistula Care Tool

• Fistula Care has developed and is field testing a
  tool for monitoring partograph use onsite.
• Strengthen larger monitoring and supervision
  systems
• Ensure partograph use is carried out consistently
  and correctly

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Complete A Partograph!
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Components of the partograph
Fetal condition -fetal heart rate -membranes
and liquor -moulding
Progress of labor -cervical dilation -descent of
the fetal head -uterine contractions
Maternal condition -pulse, blood pressure,
temperature -urine -drugs and IV fluids -oxytocin
regime
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Management of Labor

• If labor progresses normally
• Do not need oxytocin augmentation or other
  intervetion, unless complications develop.
• Can do ARM (artificial rupture of membranes)
  during active phase

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Management of Labor

• If between Alert and Action Lines
• This means warning
• In health center, transfer to facility with
  C-section capability, unless cervix is almost
  completely dilated.
• Observe labor progress for short period before
  transfer.
• Continue routine observations.
• ARM can be performed if membranes are still
  intact.

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Management of Labor

• If At or Beyond Action Line
• This means danger - - decision needed on
  management by obstetrician or resident.
• Conduct full medical assessment
• Consider IV, catheterization, pain medication
• Deliver by C-section if there is fetal distress
  or obstructed labor
• Augment labor with oxytocin by IV if there are no
  contraindications

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CASE STUDY Mrs. A

• Step 1
• Mrs A. was admitted at 500 am on 12.5.2000
• Her membranes ruptured at 400 am
• Gravida 3, para 20
• Hospital number 7886
• On admission, the fetal head was 4/5 palpable
  above the pelvic bone and the cervix was 2 cm
  dilated.
• What should we record on the partograph?

Source 2008 WHO Managing Prolonged and
Obstructed Labour Education Materials for
Teachers of Midwifery
20
CASE STUDY Mrs. A

• Step 2
• 0900 am
• The fetal head is 3/5 palpable above the pubic
  bone
• The cervix is 5 cm dilated
• What should we record on the partograph?

Source 2008 WHO Managing Prolonged and
Obstructed Labour Education Materials for
Teachers of Midwifery
21
Mrs. A
3
20
7886
12.5.2000
500 a.m.
400 a.m.
x
o
9
22
CASE STUDY Mrs. A

• There are 3 contractions in 10 minutes, each
  lasting 20-40 seconds
• Fetal heart rate (FH) is 120
• Membranes ruptured, amniotic fluid is clear
• Skull bones separated, sutures easily felt
• Blood pressure is 120/70
• Temperature is 36.8 C
• Pulse is 80 per minutes
• Urine output is 200 ml, negative protein and
  acetone
• What steps should be taken? What advice should
  we give?
• What do we expect to find at 100 pm?

Source 2008 WHO Managing Prolonged and
Obstructed Labour Education Materials for
Teachers of Midwifery
23
Mrs. A
3
20
7886
12.5.2000
500 a.m.
400 a.m.
C
1
x
o
9
--
.
--
36.8
--
--
200
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CASE STUDY Mrs. A

• Step 3
• Plot the following information on the partograph
• 0930 a.m. FH 120, contractions 3/10 each 30
  sec, Pulse 80
• 1000 a.m. FH136, contractions 3/10 each 30 sec,
  Pulse 80
• 1030 a.m. FH140, contractions 3/10 each 35 sec,
  Pulse 88
• 1100 a.m. FH130, contractions 3/10 each 40 sec,
  Pulse 88, Temp 37
• 1130 a.m. FH136, contractions 4/10 each 40 sec,
  Pulse 84, Head is 2/5 up
• 1200 pm FH140, contractions 4/10 each 40 sec,
  Pulse 88
• 1230 pm FH130, contractions 4/10 each 45 sec,
  Pulse 88
• 100 pm FH140, contractions 4/10 each 45 sec,
  Pulse 90, Temp 37

Source 2008 WHO Managing Prolonged and
Obstructed Labour Education Materials for
Teachers of Midwifery
25
CASE STUDY Mrs. A

• 100 pm
• Fetal head is 0/5 palpable above the pubic bone
• Cervix is fully dilated
• Amniotic fluid clear
• Skull bones separated, sutures easily felt
• Blood pressure 100/70
• Urine output 150 ml negative protein and acetone
• What steps should be taken? What advice should
  be given?
• What do you expect to happen next?

Source 2008 WHO Managing Prolonged and
Obstructed Labour Education Materials for
Teachers of Midwifery
26
CASE STUDY Mrs. A

• STEP 4
• Record the following information on the
  partograph
• 0120 pm spontaneous delivery of a live female
  infant,
• weighing 2.850 grams

Source 2008 WHO Managing Prolonged and
Obstructed Labour Education Materials for
Teachers of Midwifery