Iffat Javed ( Jinnah Postgraduate Medical Center, Karachi. )
Shereen Bhutta ( Jinnah Postgraduate Medical Center, Karachi. )
Tabassum Shoaib ( Jinnah Postgraduate Medical Center, Karachi. )
Objective: To determine the effect of partogram on the frequency of prolonged labour, augmented labour, operative deliveries and whether appropriate interventions based on the partogram will reduce maternal and perinatal complications./p>
Method: A case controlled, prospective and interventional study on 1000 women in labour was carried out in the obstetric unit of Jinnah Post graduate medical center, Karachi, from 1st July to 30th December, 2002. Five hundred women were studied before and after the introduction of partogram. Duration of labour, mode of delivery, number of cases augmented and neonatal outcome were noted
Results: Labour was shorter than 12 hours in 80.8% primigravida, 18.4% had labour shorter than 24 hours and only 0.8% had labour longer than 24 hours. After introduction of partogram 91.6% delivered within 12 hours and rest (8.4%) delivered within 24 hours. Normal vaginal delivery was had in 88%, 5.6% had operative vaginal delivery and 6.4% had caesarean section. Introduction of partogram showed significant impact on duration of labour (p<0.001) as well as on mode of delivery (p<0.01).In multigravidae 94.4% delivered within 12 hours and rest 5.6% delivered within 24 hours when partogram was used while 88.4% delivered within 12 hours and the rest 11.6%) within 24 hours before the use of partogram. Partogram showed significant reduction in duration of labour (p<0.01). Results also showed significant reduction in number of augmented labour (p<0.001) and vaginal examinations (p<0.001).
Conclusion: By using partogram, frequency of prolonged and augmented labour, postpartum haemorrhage, ruptured uterus, puerperal sepsis and perinatal morbidity and mortality was reduced (JPMA 57:408:2007).
Labour has been termed the most dangerous journey a human ever under takes. The reason being that although it is a natural process but complications can arise at any time during its course. Maternal mortality remains between 500.1 and 1000 deaths for 100,000 live births in developing countries. A major cause of these deaths is prolonged obstructed labour primarily because of cephalopelvic disproportion. In those who survive, morbidity is significant due to complications like sepsis, postpartum haemorrhage, ruptured uterus and urinary fistula. Obstructed labour is also a major precedent of perinatal deaths, birth asphyxia and neonatal sepsis.
The partogram initially introduced by Philpott2 and endorsed by WHO is a simple and accurate instrument for early recognition during labour. This makes timely remedial intervention possible and alters the maternal and foetal outcome favourably. This study was undertaken to validate this claim in a tertiary care public hospital where junior doctors and midwives undergo training under supervision.
Subjects and Methods
It was a case control, prospective and interventional study and was carried out in obstetric unit of Annah Post Graduate Medical Centre, Karachi, from 1st July to 30th
December, 2002. Of the 1000 women in labour included in the study,500 women were studied as controls before and 500 after the introduction of partogram Among each group 250 were primigravidae and 250 were multigravidae. The following data was collected prospectively: Duration of labour, mode of delivery and complications during and after delivery. Number of cases augmented, number of vaginal examinations and neonatal outcome was noted. Then partogram was introduced to the staff through presentations and lectures. Then same data was collected prospectively on 500 women. Only singleton pregnancies with spontaneous labour at term were included. The data was analyzed by using SPSS version-10.
The results were evaluated separately in primigravidae and multigravidae women. Before introduction of partogram (Table-1), 250 primigravidae were studied as controls (group -Ia).Results are compared with 250 women in whom labour was monitored with partogram (group-lb) In patients with normal labour curve vaginal delivery was achieved in 80% women (la) as compared to 95.6%(lb) before and after partographic monitoring. The rate of instrumental deliveries fell from 5.6%to 1.5% and that of caesarean section from 6.4% to 2.9% making impact on mode of delivery significant./p>
Table 1. Evluation of impact of partogram on complication of labour and sequelae in primigravidae,
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Length of labour
P = 0.001
Partogram is a simple and efficient method of preventing prolonged labour and its complications. This is very useful in a third world country like Pakistan where there is scarcity of resources. In Pakistan, one of the four common causes of maternal death is obstructed labour, while in Balochistan it is the leading cause.3 A study carried out in a Nigerian hospital4 showed an incidence of 17.8% and 6% in Bangladesh.5
In our unit of Jinnah Postgraduate Medical Centre there were 3911 deliveries in the year 2002. There were 28 maternal deaths in last year and 37.2% were due to obstructed labour. Maternal mortality rate was 7/1000 live births.
Duration of labour did not exceed 24 hours even before the use of partogram because most of the patients were augmented indiscriminately due to lack of scientific monitoring. Oxytocin requirement decreased because progress of labour was adequate. Augmentation was started at the first sign of deviation from normal pattern i.e. 2 hours beyond alert line. O'Drisco116 et al. advocated augmentation when the progress of labour is less than lcm/hour. Others being less stringent advocate augmentation when the progress has deviated to the right of action line giving 2,3 or 4 hours period of grace. In our study caesarean section rate fell form 4.4% to 3.6% multigravidae and from 12.8% to 6.4% in primigravida. The major cause for caesarean section in primigravida was cephalopelvic disproportion (CPD) which could be attributed to malnourishment leading to a smaller pelvis. O'Driscoll and co-workers,6 in a study of 1000 consecutive cases, showed an incidence of CPD of 1 % and no cases of uterine rupture in primigravida patients. In our study there were 2 cases of uterine rupture in multigravidae who had received augmentation with more than required dose of oxytocin and for a longer time. In one patient rupture was diagnosed immediately. Laparotomy was done and we were able to save the baby. The other unfortunate patient was diagnosed late and she had a fresh stillbirth. In a study conducted at a tertiary care hospital? on
In a WHO multicenter trial in Southeast Asia involving 35,484 women9 introduction of the partogram with an agreed labour management protocol significantly reduced both prolonged labour (from 6.4 to 3.4% p= 0.002) and the proportion of labours requiring augmentation (from 20.7 to 9.1% p=0.023). Emergency caesarean sections fell from 9.9% to 8.7% and intraparturn stillbirths from 0.5% to 0.3%.
It is disputed that active management increases perinatal risk. In a studylO neonatal asphyxial seizures were 2.3/1000 with active management as compared to 1.3/1000 without such management. However some other studies" showed no such difference. In our study there was no obvious effect of oxytocin on neonatal outcome.
The frequency of vaginal examination was also dramatically reduced. These were done after every 4 hrs when labour was not stimulated and every 2 hours after augmentation. This reduces puerperal sepsis while improving neonatal outcome and speedy recovery of the mother. A study on prolonged labour carried out in India12 showed that more then 85% cases were grossly infected at the time of admission because of repeated vaginal examinations by dais.
The study concluded that partogram was a very useful tool. Its use reduced caesarean sections, operative vaginal delivery, rate of augmented labours, complications of labour, puerperal sepsis, maternal mortality and morbidity.
It is recommended that implementations of partogram should be encouraged in all hospitals at all levels, and nurses and midwives should be trained to use it for better results.
1. World Health Organization. Maternal mortality rates: a tabulation of available information. Geneva, 1991; (WHO document WHO/MCH/MSM/91.6).
2. Philpott RH.Graphic record in labour.BMJ.1972; 4:163-5.
3. Zaidi S.Seeking solutions.High maternal mortality in Paldstan. (ed) J Coll Phys Surg Pak 1993;31:2-3.
4. Harrison KA.Child bearing health and social priorities.A survey of 227,74 consecutive hospital births in Zaria.Northern Nigeria. Br J Obstet Gynecol 1985:92:1-119.
5 Situation assessment of the women and children in Banladesh.Bangladesh and
J Pak Med Assoc
UNICEF demographic health survey, 1999.
6. ODriscoll K, Jackson RJA, Gallagher JT. Active management of labour and cephalopelvic disproportion. J Obstet Gynecol Br Com Wealth 1970;77:385-9.
7. Khan KS, Rizvi A, Rizvi JH. Risk of uterine rupture after the partographic alert line is crossed. An additional dimension in the quest towards safe motherhood in labour following caesarean section. J Pak Med Assoc 1996; 46:120-2.
8. Chazotte C, Cohen WR. Catastrophic complications of previous caesarean section. Am J Obstet Gynecol 1990; 163:738-42.
9. [No author listed]. World Health Organization.Matemal health and safe motherhood programme. World Health Organization partograph in management of labour. Lancet. 1994;343:1399-1404
10. Cahill DJ, Boylan PC, O'Herlihy C.Does oxytocin augmentation increase perinatal risk in primigravid labour? Am J Obstet Gynecol 1992; 166:847-50.
11. Cohen CR, O'Brien WIT, Lewis L, Knupel RA. A prospective randomized study of aggressive management of early labour. Am J Obstet Gynecol 1987; 157:1174-7.
12. Randhawa 1, Gupta KB, Kanwal M. Astudy of prolonged labour. J Ind Medical Assoc 1991; 89:161-3.