Partograph in Labor: Challenges and Solutions
The greatest challenge in partograph use is to enhance its effective
implantation in the management of all labors universally. Unfortunately,
the partograph is still not considered as mandatory or central in routine
care of all laboring women [23]. This may be because of lack of
commitment and inconsistent acceptability for the usage of the
partograph in labor rooms. At present though a majority of health-care
workers do possess positive attitudes toward the partograph, a few
challenges need to be tackled to ensure a favorable environment. These
challenges are support by the health system, availability of resources,
competence in use and monitoring and evaluation of the partograph in
practice.
Positive validation, facility level guidance, evaluation and audit of
partographs from experienced seniors and supervisors will enhance the
value of the partograph in clinical practice. Adequate availability of
resources, (i.e., the partograph and accessory equipment) will result in
completion, which is essential to ensure consistent use, but sadly this is
still lacking. Individualized training improves knowledge about the
partograph [24], but the use of multidisciplinary training strategies
results in understanding of roles and promotes coordinated team work
[25]. Hands-on training methods improve patient outcomes [26, 27]. All
staff members providing care for women in labor should be trained and
regularly updated in partograph use. Training should consist of
completion and decision-making, like when to start the partograph,
when to take action and appropriate referral. A limitation with the
partograph use in current practice is the failure to evaluate the tool at
facility level in terms of outcomes. This is paramount in evaluating the
level of impact partograph use has on care provision and referrals as
well as on specific labor outcomes. Hence, if positive outcomes from
partograph use are observed and informed to all involved in the birthing
process, then certainly it will be embedded into routine labor ward
practice.
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Paperless Partograph
Even after the WHO simplified the partograph, it is rarely used in rural
parts of India. The main reasons being it may be too time-consuming for
overburdened doctors and may be too complicated for the birth
attendants present in rural settings. Therefore, there is an urgent need to
make the partograph more user-friendly.
Dr. A.K Debdas from India has proposed a new low-skill method called
paperless partogram to adapt to local needs [28]. In the paperless
partograph, the birth attendant calculates two times, an ALERT ETD
(estimated time of delivery) and an ACTION ETD.
The ALERT calculation uses the principal that cervix dilates 1 cm/h when
woman is in active phase. So the birth attendant simply adds 6 h to the
time at which a woman becomes 4 cm dilated. This way ALERT ETD is
calculated. To calculate ACTION ETD, 4 h is added to ALERT ETD. Both
the timings are written on patient’s indoor paper. The ACTION ETD is
circled in red.
At the time of ALERT ETD, if the patient has not delivered and the
current setup lacks the operative facility, then the arrangement for
transportation should be made. At the time of ACTION ETD, the woman
is at risk of prolonged labor. So an immediate action must be taken to
deliver her promptly.
This strategy is cheap and easy to use. It takes only few seconds for
calculation, requires only basic addition and has the potential for
preventing prolonged labor.
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ePartograph
Jhpiego and the Johns Hopkins Center for Bioengineering Innovation and
Design (JHU-CBID) have developed the ePartograph, a handheld device
and software platform based on the current partograph recommended
by the World Health Organization [29].
The device, which incorporates traditional best practices and clinical
algorithms from the paper partograph, facilitates broader use and
expands the benefits of the paper-based version through the following
improvements:
Features efficient data entry, automatic plotting of observations
Provides instant graphing of data
Reminds providers when to measure and record critical
observations
Stores multiple patient data in one device
Provides indicators when complications arise
Limits retroactive data entry after delivery (a current practice that
reduces the current paper partograph into a mere recording tool)
Transmits data to off-site experts who can provide guidance and
support
Jhpiego and JHU-CBID engineers are working with end-users to refine
the device interface and gather data about user needs and preferences
for device improvements, manufacturing and additional field studies.
The Jiv Daya Foundation launched the India Maternal Health Initiative
aimed to strengthen hospital based care of mothers and newborns
during labor and delivery and partnered with over 15 hospitals all over
India [30]. The Foundation has devised an electronic partograph system
to facilitate the early detection of labor abnormalities and initiation of
timely interventions, as unmanaged complications often result in
preventable death.
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