The PartographTool Name: The Partograph Origin: Maternal Health and Safe Motherhood Programme, Division of Family Health, World Health Organization, Geneva The Partograph (350KB) Partograph Maunal: Facilitator's Guide (http://whqlibdoc.who.int/hq/1993/WHO_FHE_MSM_93.10.pdf; 3MB) Order the complete Partograph Manual from WHO. Basic Description: The partograph is a tool for managing labor. It is basically a graphic representation of the events of labour plotted against time in hours. It consists of three components: a) the fetal condition, b) the progress of labour and c) the maternal condition. It can be used for all labours in hospitals and health centres and at domiciliary level where trained nurse/midwives are practicing midwifery. The partograph does not replace adequate screening of women on arrival to exclude conditions that require urgent attention or immediate transfer. It is designed for early detection of abnormal progress of labour and the prevention of prolonged labour which would significantly reduce the risk of postpartum haemorrhage and sepsis, and eliminate obstructed labour, uterine rupture and its sequelae. The partograph serves as an "early warning system" and assists in early decision on transfer, augmentation and termination of labour. It also increases the quality and regularity of all observations on the fetus and the mother in labour, and aids early recognition of problems with both. Country Applications: Africa: in many countries as it originated in Zimbabwe before it was applied by WHO. Zambia, Malawi, South-Africa, Angola, Guinea Bissau, Ghana, Nigeria, Kenya, Tanzania, Uganda, Egypt, Tunisia, Morocco, Cameroon etc. Asia/Western Pacific Region: Thailand, Malaysia, Indonesia, selected places in India and Nepal, Singapore, and others. Latin America: Several countries and selected hospitals. Language(s) Available: French, English, Arabic,? Portuguese Technical Scope/Purpose: See basic description. Of the estimated 600,000 annual maternal deaths, about 8% are due to obstructed labour due mainly to cephalo-pelvic disproportion. The purpose of the partograph is to reduce maternal and perinatal mortality and morbidity worldwide. The sequelae for the mother of prolonged and obstructed labour are maternal dehydration, sepsis, haemorrhage, ruptured uterus and obstetric fistulae. In the infant prolonged obstructed labour may cause asphyxia, brain damage, infection and death. The partograph has been in use in many countries for over 25 years but could be adopted more widely. In order to promote its wider and more rapid adoption, WHO held consultations to produce and agree on a standard format. This standard tool was used in a WHO multicentre trial conducted in Indonesia, Malaysia and Thailand. The report of the trial confirmed what had been found in earlier studies concerning its effectiveness, low cost and feasibility. Method: Quantitative Frequency of Administration: The partograph should ideally be used routinely for every delivery. Key Users of the Information: Care providers of all levels: Primary, secondary, tertiary Objectives and Scope of the Tool: Objectives:
Tool Design: see electronic copy
It is based on the following principles:
The rate of progress of labor is plotted against the expected rate of progress. If the rate of progress of labor is lower than normal, the plot of cervical dilatation will cross the "alert" line and then the "action line". The "action line" denotes the critical point at which specific management decisions should be made to expedite delivery. Implementation and Training: The principle and strategy of introduction of this tool is to start training in the referral hospital first. Staff on all shifts must be included in the training process. Once this hospital is familiar with the application and interpretation of the tool, the partograph should be introduced in the periphery. It is important that the same format of partograph is applied both in the referral hospital and the periphery in order to avoid confusion and demoralization of health staff in the periphery. The initial training process in the hospital takes about five days with simultaneous theory and clinical application. It then takes about two to three months clinical practice and supportive educational supervision with clinical audits to have the use of the partograph established. The educational objectives are set out in the User's and Facilitator's Manual cited in the next section. Manuals and Guidelines: WHO: Prevention of
Prolonged Labour: a practical guide. The Partograph,
Lancet, Vol. 343, June 4, 1994, pp1399-1404
American College of Nurse-Midwives (ACNM), Washington DC
Cost: The use of the partograph is inexpensive because it only requires one A4 sheet of paper. However, some countries cannot even afford paper and in this case it would be good if donors include the initial funding in their budget. UNICEF has done so in some countries. Lessons from Experience: The partograph is a simple, appropriate managerial tool for the management of normal labour and timely recognition of deviation of normal progress requiring referral and/or intervention. It is essential to note that the partograph can only be used by health workers with adequate training in midwifery that are able to:
Both enrolled and registered midwives levels have shown to apply the tool satisfactorily. Midwives in the multicentre trial reported more time for patients, less resuscitation and more bonding of the infant with the mother. Sustained encouragement and educational supervision are required to ensure sustainability. In the WHO multicentre trial, introduction of the partograph with an agreed labour management protocol reduced both prolonged labour and the proportion of labours requiring augmentation. Emergency caesarian sections and intrapartum stillbirths fell (La ncet 1994;343;1399-1404). Beyond the reach of aid through the partograph are the millions who are delivered with no attendant or with the assistance only of a relative or other untrained person. In these circumstances, community education to recognize danger signs and move the woman in prolonged labour (>12 hours) earlier than is now often the case, are critical responsibilities of health workers. References http://erc.msh.org/quality/pstools/psprtgrf.cfm
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