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International Journal of Clinical and Experimental Medicine Research

Clinical Audit on Effective Usage of Partogram in Obstetric Unit B of DGH-Kalutara from 01st March 2016 to 31st May 2016

Author:Dhanushka Jayaweera Date:November 29,2017 Hits:

Abstract

World Health Organization (WHO) recommends partogram for universal use during labour as a necessary tool. Continuous monitoring during labour provides a safe care. Further it prevents adverse outcomes relating to child birth. The tool helps to identify early deviations and intervene timely. Annually, a huge sum of money is spent on maternal health by the government of Sri Lanka to deliver a free health care to the public. The maternal mortality is reported to be low despite that Sri Lanka is a developing country. Hence, it is the duty and responsibility to keep the statistics further low and maintain excellent quality of care with the available resources.

Since partogram can detect obstructive labour early, it helps to reduce maternal deaths by preventing uterine rupture, postpartum haemorrhage and puerperal infections. Perinatal mortality is reduced when traumatic deliveries are less.  It appreciates the use of the tool as it is simple, inexpensive and freely available. The goal of this audit is to assess the effective use of partogram in the local setting.

A descriptive study was conducted in obstetric unit B of District General Hospital(DGH)-Kalutara. A total of 571 of deliveries from March to May in 2016 were selected for the audit. Effective use of partogram was assessed by executing partograms of relevant BHTs. Data collection and analysis was done by the auditor.

Client information is included in majority of partograms. Position, caput, moulding, cervical dilatation, contraction free interval, duration of contraction and abdominal descent were not marked in the majority and the technical errors were noted during marking.

Practical issues in monitoring and documenting of contraction free interval and duration of contraction should be addressed. Maternal monitoring and second stage foetal monitoring should be encouraged. A proper training programme of National Partogram should be arranged.

References

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Clinical Audit on Effective Usage of Partogram in Obstetric Unit B of DGH-Kalutara from 01st March 2016 to 31st May 2016

Dhanushka Jayaweera

Nilmini, Balakawala, Akuressa, Sri Lanka

 

 

How to cite this paper: Dhanushka Jayaweera (2017). Clinical Audit on Effective Usage of Partogram in Obstetric Unit B of DGH-Kalutara from 01st March 2016 to 31st May 2016.  International Journal of Clinical and Experimental Medicine Research, 1(2), 1-5.
http://dx.doi.org/10.26855/ijcemr.2017.02.001

 

 

 

 

Abstract

World Health Organization (WHO) recommends partogram for universal use during labour as a necessary tool. Continuous monitoring during labour provides a safe care. Further it prevents adverse outcomes relating to child birth. The tool helps to identify early deviations and intervene timely. Annually, a huge sum of money is spent on maternal health by the government of Sri Lanka to deliver a free health care to the public. The maternal mortality is reported to be low despite that Sri Lanka is a developing country. Hence, it is the duty and responsibility to keep the statistics further low and maintain excellent quality of care with the available resources.

Since partogram can detect obstructive labour early, it helps to reduce maternal deaths by preventing uterine rupture, postpartum haemorrhage and puerperal infections. Perinatal mortality is reduced when traumatic deliveries are less.  It appreciates the use of the tool as it is simple, inexpensive and freely available. The goal of this audit is to assess the effective use of partogram in the local setting.

A descriptive study was conducted in obstetric unit B of District General Hospital(DGH)-Kalutara. A total of 571 of deliveries from March to May in 2016 were selected for the audit. Effective use of partogram was assessed by executing partograms of relevant BHTs. Data collection and analysis was done by the auditor.

Client information is included in majority of partograms. Position, caput, moulding, cervical dilatation, contraction free interval, duration of contraction and abdominal descent were not marked in the majority and the technical errors were noted during marking.

Practical issues in monitoring and documenting of contraction free interval and duration of contraction should be addressed. Maternal monitoring and second stage foetal monitoring should be encouraged. A proper training programme of National Partogram should be arranged.

 

Keywords

National partogram of Sri Lanka, labour management, clinical audit

 


I. INTRODUCTION

A partogram is a composite graphical record of events of labour (maternal and fetal) entered against time on a single sheet of paper. Relevant parameters might include statistics such as cervical dilation, fetal heart rate, duration of labour and vital signs [1-4].

National Partogram of Sri Lanka was newly introduced by Sri Lanka College of Obstetricians and Gynecologists which was proposed in 2013 [2].

II. JUSTIFICATION

Annually, a huge sum of money is spent on maternal health by the government of Sri Lanka as its free health system and has achieved less number of maternal mortality, which is approximately as that in a developed country. So it is our sole responsibility to stick to our health goals and overcome obstacles on our way.

As effective use of partogram can early detect obstructive labour, it reduces maternal mortality by preventing ruptured uterus, postpartum heamorrage and puerperal infections. And traumatic delivery can be avoided by reducing perinatal mortality.

Early detection of adverse outcomes by this simple, inexpensive tool should be used effectively.     

This study aims to explore the effective use of partogram in obstetric unit B.

III. METHOD

A descriptive retrospective study was conducted in obstetric unit B of DGH-Kalutara. A total of 571 deliveries from March to May in 2016 were selected for the audit. No sampling was done. Effective use of partogram was assessed by executing partograms of relevant BHT (Bed Head Ticket)s. National partogram of Sri Lanka was used as the study instrument.

Emergency caesarean sections, which were directly sent to the operation theatre from obstetric ward, and elective caesarean sections were excluded because partogram maintaining was not relevant.

IV. LIMITATIONS

Following limitations were identified during this audit:

Only 82.04% (n=345) of relevant BHTs were found from medical records unit.

Executer bias cannot be excluded since relevant BHTs and partograms were executed by the auditor himself.

Some technical errors (ex; incorrect symbols) in maintaining partogram were not considered since almost all the partograms were found to have same technical errors.

V. STUDY FINDINGS

A. Statistics of the Period of Interest

Table A1: Statistics of the period of interest in Obstetric unit B DGH-Kalutara.

 

March 2016

April 2016

May 2016

Total

NVD

112

105

125

342

LR-EM/LSCS

13

30

29

72

Vaccum Deliveries

2

2

1

5

Forceps Deliveries

1

1

1

3

Breech Deliveries

1

0

0

1

Twin Deliveries (Vaginal)

1

1

0

2

IUD(Vaginal Delivery)

1

1

0

2

Total

129

140

154

423

BHT found

120

108

117

345

%  of BHT found

93.02%

77.14%

75.97%

82.04%

Total No of Births of Unit B

185

179

207

571

 

According to ward statics, 423 of relevant deliveries were occurred during the period of interest and only n=345 (82.04%) BHTs were found, due to logistic problems, and included for the audit.

B. Details of Partogram Attached in the BHTs

Table B1- Details of Partogram attached in the BHTs of relevant deliveries

 

Number

%

Partogram Not Found

32

9.28%

Partogram Found

313

90.72%

 

Majority of relevant BHTs were attached with a partogram (90.72%, n=313) and n=32, 9.28% of relevant BHTs were found to not have partogram.

Partogram without BHTs were further described as follows.

Table B2 –Description of partogram without BHTs

Partogram Not Found

Number

2nd Stage admission to LR

4

IUD

2

EM/LSCS

14

Other NVDs

12

 

C. Information of the Client in the Partogram

Table C1- Information of the Client in the Partogram

Information of the client

Included

Not Included

Name of the client

97.49%

2.51%

Age of the client

96.87%

3.13%

Gravida of the client

95.92%

4.08%

Parity of the client

94.36%

5.64%

Blood group of the client

96.55%

3.45%

Date and time of onset of Partogram

89.34%

10.66%

Special problems of client/pregnancy

25.08%

74.92%

Special instructions regarding delivery

1.88%

98.12%

 

D. Monitoring of Foetal Wellbeing during the Labour in the Partogram

Table D1-Monitoring of Foetal Wellbeing during the Labour in the Partogram

Monitoring of foetal wellbeing during labour

Documented

Not Documented

Fetal Heart Record in 1st Stage

80.88%

19.12%

CTG (Cardiotocography) comment

4.08%

95.92%

Liquor colour

34.17%

65.83%

Position of the foetus

2.82%

97.18%

Caput in the partogram:

8.78%

91.22%

Moulding of the foetal skull

7.84%

92.16%

 

E. Progress of the Labour in the Partogram

Table E1- Progress of the Labour in the Partogram

Progress of the Labour

Recorded

Not Recorded

Contraction free interval

6.58%

93.42%

Duration of contractions

6.27%

93.73%

Oxytocin Dose/Drop Rate

29.47%

70.53%

Abdominally Descent

0.31%

99.69%

Cervical dilatation

11.29%

88.71%

Alert line

67.08%

32.08%

Action line

65.83%

34.17%

Descent Vaginally

23.20%

76.80%

 

F. Monitoring of Maternal Wellbeing during the Labour in the Partogram

Table F1- Monitoring of Maternal Wellbeing during the Labour in the Partogram

Monitoring of Maternal Wellbeing during labour

Documented

Not Documented

Maternal pulse

50.16%

49.84%

Maternal blood pressure

43.26%

56.74%

Maternal body temperature

35.11%

64.89%

 

G. Monitoring of the 2nd stage of Labour

Table G1- Monitoring of the 2nd stage of Labour

Monitoring of the 2nd stage of Labour

Documented

Not Documented

Fetal Heart Record in 2nd Stage

0.63%

99.37%

Time of Fully Dilated

0.94%

99.06%

Commenced Pushing

0%

100%

 

H. Action Taken

Action taken was not documented in any partogram executed (0%).

I. Closing of the Partogram

Partogram was closed at the end of the delivery/sending for EM/LSCS 3.14%.

J. Date and Time of the Delivery

Date and time of delivery documented in 70.22% of partograms.

K. Post Partum Modified Early Warning System

Post Partum Modified Early Warning System was maintained with 81.19% of the partogram.

 

VI. DISCUSSION

This audit provides an overview of effective use of partogram in obstetrics unit B, General Hospital, Kalutara.

Partograms of relevant BHTs from 1stMarch 2016 to 31st May 2016 were assessed.

Total number of birth in study period was 571 and 423 deliveries were selected after applying of exclusion criteria.But, only 345 (82.04% of relevant BHTs) were found due to logistic issues.

A. Details of Partogram attached/Not attached in the BHTs

Majority of relevant BHTs were attached with a partogram (90.72%, N=313) and n=32, 9.28% of relevant BHTs were found to have no partogram. (Table B1)

N=313 is used for statistical purposes throughout the execution.

Relevant BHTs without a partogram (9.28%, n=32) were further described as 2nd stage admission to LR (n=4), IUDs (n=2), EM/LSCS (n=14) and other NVDs (n=12). (Table B2)

B. Information of the Client in the Partogram

Information of the client were completed in majority of partograms as name of the client 97.49%, n=311, age 96.87%, n=309, gravida 95.92%, n=306, parity 94.36%, n=301, blood group 96.55%, n=308. (Table C1)

Date and time was mentioned in 89.34%, n=285 partograms.

In majority of the partograms special problems (25.08%, n=80) and special instructions (1.88%, n=6) were not given.

C. Monitoring of Foetal Wellbeing during the Labour in the Partogram

Foetal heart rate in 1st stage of labour was recorded in the majority (80.88%) while 19.12% of partograms were not recorded. (Table D1)

Comment of CTG wasincluded only in 4.08%, n=13 partograms.

Liqour colour was mentioned in 34.17%, n=109 partograms while position (2.82%, n=9), caput (8.78%, n=28) and moulding (7.84%, n=25) mentioned in minimal number of partograms.

D. Progress of the Labour in the Partogram

Contraction free interval (6.58%, n=21) and duration of contraction (6.27%, n=20) recorded in very few partograms technical errors of recoding were noted in each and every partogram which were recorded. (Table E1)

Oxytocin drop rate was mentioned only in 29.47%, n=94 partograms.

Abdominal descent was marked only in one partogram (0.31%, n=1) and it was technically incorrect.

Cervical dialatation was marked only in 11.29%, n=36 partograms.

The majority of the partograms alert line (67.08%, n=214) and action line (65.83%, n=210) were drawn.

Descent vaginally was marked only in 23.2%, n=74 partograms but correct technique was not followed in marking.

E. Monitoring of Maternal Wellbeing during the Labor in the Partogram

Maternal pulse was documented in only 50.16%, n=160 partograms and maternal blood pressure (43.26%, n=138), maternal body temperature (35.11%, n=112) were recorded only in minority. (Table F1)

F. Monitoring of the 2nd stage of Labour

Fetal heart record in 2nd stage was noted only in two partograms (n=2, 0.63%).(Table G1)

The time of fully dilated was noted only in three partograms (n=3, 0.94%).

Commenced pushing was not documented in any of partogram (n=0, 0%)

G. Action Taken

Action taken was not documented in any partogram executed (0%, n=0).

H. Closing of the Partogram

Partogram was closed only in 3.14%, n=11.

I. Date and Time of the Delivery

In the majority (70.22%, n=224) date and time of delivery documented in thePost Partum Modified Early Warning System.

J. Post Partum Modified Early Warning System

In the majority (81.19%, n=259) Post Partum Modified Early Warning System was maintained but technique was not assessed.

VII. CONCLUSION

This audit assessed the effective use of partogram. Client information was included in majority of partogram but position, caput, moulding and CTG comments, were not included in majority. Contraction free interval, duration of contraction and abdominally descent were not marked in the majority and the technical errors were noted during marking.

Though alert line and action line were drawn frequently cervical dilatation was not marked in the majority. Maternal monitoring during labour was not documented in the majority.

Action taken was not documented in the partogram. Fetal monitoring of the 2nd stage was not documented in almost all the time. Closing of the partogram was done hardly.

Date and time of the delivery and Post Partum Modified Early Warning System was maintained in majority.

VIII. RECOMMENDATIONS

Training programme on maintaining of National Partogram should be arranged and encouraged and value of partogram in monitoring during the labour should be discussed.

Practical issues in monitoring and documenting of contraction free interval, duration of contraction and in the 2nd stage of labour should be addressed. Importance of maternal monitoring during labour should be highlighted.

Reaudit should be done after a proper training programme in the days to come and further studies on maintaining partogram should be encouraged.

 

REFERENCES

[1] Lavender T, Hart A, Smyth RMD, Effect of partogram use on outcomes for women in spontaneous labour at term, Cochrane Library, www.cochrane.org;10 July 2013.

[2] Management of labour, Clinical guidance, Sri Lanka Journal of Obstetrics and Gynaecologists. 2013 Dec; Pages 130, www. slcog. lk/sljog.

[3] Fernando TRN, Pregnancy and labour, first edition, 2015 sept; 39,40(78)

[4] Park K.; Park’s Text Book of Preventive & social Medicine, 20th edition 2009 Feb; 19(745).

 

Acknowledgment

To Obstetric unit B,General Hospital-Kalutara and those who supported for the study.

 

 

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