Research Journal of Women’s Healt

h
ISSN 2054-9865 | Volume 2 | Article 2

Research Open Access

Utilization of the modified WHO partograph in

assessing the progress of labour in a metropolitan area
in Ghana
Baafuor K. Opoku1,2* and Samuel Blay Nguah3

*Correspondence: [email protected] CrossMark

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Department of Obstetrics and Gynaecology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
1

Department of Obstetrics and Gynaecology, Komfo Anokye Teaching Hospital, Kumasi, Ghana. 3Department
2

of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana.

Abstract
Maternal mortality ratio averages 230 per 100,000 live births in developing countries. Obstructed labour,
which is a major cause results from prolonged, neglected labour. The partograph as recommended by the
World Health Organization is a graphical tool used to monitor the progress of the first stage of labour, thereby
preventing prolonged labour. The partograph has been in use in Ghana since 1989. The study was conducted to
ascertain the proportion and correct use of the partograph in monitoring labours in 4 hospitals in a metropolitan
area of Ghana. Partograph use for labour monitoring averaged 54% in this study. Midwives formed 90% of
birth attendants. For the progress of labour, parameters were monitored to standard in 55-60% of cases.
Parameters pertaining to fetal well being were correctly monitored in 30-50%. Maternal well being was
monitored to standard in 40% of cases. Apgar scores at 1 and 5 minutes did not differ whether parameters were
recorded to standard or not. We conclude from our study that almost half of labour cases were not monitored
with the partograph. In those that were monitored with the partograph monitoring to standard was done in 40-
60%. Birth attendants either lack the skill in charting the partograph to standard protocols or do not appreciate
the use of the partograph in monitoring the progress of labour. In resourcelimited centres in the developing
world the use of the partograph to monitor the progress of labour cannot be overemphasized. Skilled attendants
at deliveries must therefore be given regular updates on the proper use of the partograph during labours.
Keywords: Developing countries, partograph, labour, standard recording

Introduction number of parturients in the USA [ 2]. It was further improved

Approximately 300,000 maternal deaths occurred globally in by Philpott and Castle who introduced the alert and action lines
2013, of which 98% occurred in the developing countries. On to facilitate interventions during labour [3]. Since then several
the average 230 women die per every 100,000 live births every types of partographs have been developed in various countries
year in developing countries [1]. Obstructed labour is one to suit local needs [ 4-6]. It is an inexpensive tool designed to
major cause of maternal mortality and usually results from provide a continuous pictorial overview of labour and has been
neglected prolonged labour. Prolonged labour may also lead to shown to improve outcomes when used to monitor and
atonic postpartum haemorrhage, maternal exhaustion and manage labour [3]. The composite partograph was evaluated in
dehydration, uterine rupture and obstetric fistulas. The a multicenter trial that involved 35,484 women [7]. The results
partograph as a graphic assessment is recommended for showed that using the partograph reduced prolonged labour
routine monitoring of the 1st stage of labour to help the birth by about half (from 6.4% to 3.4% of labours) and the
attendant identify slow progress of labour and prevent proportion of labours requiring augmentation from 20.7% to
prolonged labour and its complications. 9.1%. Emergency caesarean sections also reduced from 9.9% to
Originally called the Friedman’s curve, the partograph was8.3% and intrapartum stillbirths from 0.5% to 0.3%. The
designed by Friedman in 1954 following a study on a large modified
 WHO partograph currently being used was introduced in 2000.
© 2015 Opoku et al; licensee Herbert Publications Ltd. This is an Open Access article distributed under the terms of Creative Commons Attribution License
(http://creativecommons.org/licenses/by/3.0) . This permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
It does not have a latent phase and the active phase starts at Sampling method
4.0cm cervical dilatation (Figure 1). While the composite The sample size was determined using a single proportion
partograph was introduced in Ghana in 1989 as part of the formula of n=z2p (1-p)/w2, where n is the required sample size,
Safe Motherhood Initiative’s Life Saving Skills, the modified z is the standard normal deviate set at 1.96 (for 95%
WHO partograph was introduced a couple of years later. It has confidence level), w is the desired degree of accuracy (taken
since been used to monitor labours in health facilities in theas 0.05) and p is the estimate of the proportion of
country. Very few studies have since been conducted on its partographs on which all components are recorded up to
use and impact on labour and delivery in the country. One of standard (estimated to be
such studies looked at the relationship between its use and 40% in this study). This gave a sample size of 380 partographs.
birth outcomes in a teaching hospital [8]. Because of multi-stage sampling, a factor of 2.0 was added
The current study was conducted to assess the proportion giving a final sample size of 760 which was evenly distributed
of labours which is monitored by use of the partograph and to the participating facilities.
also find out their proper completion for women in labour in The components of the partograph were assessed to
public health institutions in Kumasi, Ghana. Kumasi is the determine whether they had been monitored according to
second largest city in Ghana with a population of 2.05 millionstandard protocol [12].
people [9] and covering an area of 254km 2. There are 5 public Standard protocols as defined here include
hospitals, one university hospital, one teaching hospital and 1. Fetal heart rate, maternal pulse and uterine
about 200 other health facilities (mission, quasi-government contractions monitored and charted every 30 minutes.
and private hospitals, clinics and maternity homes) in the city 2. Cervical dilatation, descent of the presenting part
[10]. The study is designed to find out the proportion of and moulding monitored every four hours. 3 . Blood
women whose labours are monitored by the partograph, and pressure monitored every 2 hours.
whether monitoring is done according to standard protocols 4. Condition of the baby after birth (APGAR score) recorded
for use of the partograph. Answers to these questions will be on the sheet. A score of ≥7 is considered satisfactory [ 13,14].
Records that did not meet any of the listed standards or had
important to inform policies and strategies in the provision of
parts missing or inadequate for each parameter of the
maternity care services in the country, especially in the areas
of preventing prolonged labour and its attendant partograph were judged as substandard. Records were judged
complications. as not recorded if no information was documented on the
parameters of the partograph or completely absent from the
Methods file. Records were judged as standard if all the criteria were
A descriptive study based on retrospective document study met for each parameter on the partograph.
was used to review the completion of partographs that have
been used to monitor labours in selected health facilities in Ethical clearance
the metropolis. It was conducted over a 3-month period in 4 Ethical clearance for the study was obtained from the
of the hospitals sampled from public hospitals within the Committee on Human Research, Publications and Ethics
metropolis. The participating facilities sampled were Komfo (CHRPE) of the Kwame Nkrumah University of Science &
Anokye Teaching Hospital, Manhyia, Suntreso and Kumasi Technology and the Komfo Anokye Teaching Hospital.
South District hospitals.
Partographs that were reviewed included those that had Data analysis
complete or partially complete information in them. Data was double entered, compared and cleaned of wrongful
Partographs that were excluded were those that had no entries. It was then exported to Stata SE 12.1 for analysis.
entries at all, had only a delivery summary or had to be Partograph recordings were then put together and tabulated
abandoned due to a developed complication that needed to show the frequencies of “not done”, “partially done” and
urgent operative delivery. “fully done” recordings. The first two categories were
All women who delivered in these hospitals during the combined to form the “Substandard” recording while the
period under study had their partograph sheets retrieved “fully done” group represented the “Standard” recordings.
from their in-patient folders within 24hours of delivery. All The relationship between the APGAR scores at first and fifth
information that was needed, as outlined in a questionnaire minutes and standard of partograph recording were
were extracted from the sheets and entered into EpiData V3.1 determined first (unadjusted) using quantile regression and
database [11]. then adjusted for the clustering within facilities. Finally the
relationship between substandard recording and the cadre

2
performing the deliveries was determined using a chi-square
test and presented as p-values. For all analysis a two sided p-
value of >0.05 was considered statistically significant.

Results
In all, 809 partographs that had been used to monitor labours
in the 4 health facilities during the period of the study were
reviewed. The mean age group was 21-30 years which formed
62.4% of the patients. Nulliparous women formed 34.7%

3
4
 Parameter Frequency %
Demographics
Not done 0 0.0
Partially done 167 20.6
Fully done 642 79.4
while grandmultiparous women formed 3.6%. Table 1 shows Table 2. Fetal heart rate
Recordings of parameters on partographs. Not done 206 25.5
the hospitals sampled and partographs selected. Just about half of all
Partially done 193 23.9
deliveries (54.6%) in the study were monitored with the partograph and
Fully done 410 50.7
their completion was not as expected.
Graph 1 shows standard recordings of seven parameters. The best Nature of liquor
recorded parameter was contractions (60.2%) while the least recorded Not done 359 44.4
parameter was moulding (32.5%). Partially done 176 21.8
Analysis showed that fetal heart rate, which is central to intrapartum Fully done 274 33.9
monitoring of the health status of the fetus, was recorded to standard in Moulding
50% of cases, partially recorded in 24% and not recorded at all in 25% of Not done 392 48.5
cases reviewed (Table 2). Partially done 154 19.0
In about 44% of cases cervical dilatation was not recorded to standard.
Fully done 263 32.5
Standard recordings of contractions were done in 60% of cases. Descent
was properly charted in 55% of cases and not charted at all in 25% of cases. Cervical dilatation
Maternal blood pressure and pulse were properly charted in 40% of cases, Not done 190 23.5
just as for urine protein. In about 12% of cases APGAR scores were not Partially done 169 20.9
recorded at all. In 12% of cases the action line of the partograph was Fully done 450 55.6
crossed. Descent
Table 3 shows the cadre of staff who charted the partographs. About 90% Not done 201 24.9
were midwives. Doctors constituted less than 2% while the rest were Partially done 163 20.2
charted by students and auxiliary staff.
Fully done 445 55.0
Contractions
Table 1. Hospitals included in the study.
Not done 182 22.5
Name of hospital Proportion of deliveries Partograph Partially done 140 17.3
monitored by select ed
partograph Fully done 487 60.2
% n % Maternal BP & Pulse
Komfo Anokye Teaching 50.2 204 25.2 Not done 198 24.5
Hospital (KATH) Partially done 287 35.5
Kumasi South Hospital 61.5 200 24.7 Fully done 324 40.0
(KSH) Urine for protein
Suntreso Government 52.8 206 25.5 Not done 282 34.9
Hospital (SGH) Partially done 204 25.2
Manhyia District 54.0 Hospital 199 24.6
Fully done 323 39.9
(MDH)
APGAR recorded
Total Average: 54.6 809 100
No 98 12.1
Yes 711 87.9
Action line crossed
No 694 88.1
yes 94 11.9

5
30
20
10
Contractions
0 FHRMoulding Liquor Dilataion Descent Mat. BP

Table 4 shows the relationship between Apgar scoring and

Graph 1. Proportion of parameters filled to standard (%).
standard/substandard recordings of 5 parameters. Apgar
score recordings at both 1-minute and 5-minutes did not

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Opoku et al. Research Journal of Women’s Health 2015,
http://www.hoajonline.com/journals/pdf/2054-9865-2-2.pdf doi: 10.7243/2054-9865-2-2

Table 3. Cadre of health worker charting partograph.

Health worker cadre N %
Midwife 725 89.6
Doctor 15 1.8
Student nurse/Midwife 22 2.7
Unclassified 45 5.5
Total 809 100
differ whether these parameters were recorded to standard
or sub-standard. For sub-standard recordings pertaining to
contractions, cervical dilatations and descent, the cadre of
staff charting the parameters did not make a difference Table
5. Oxytocin was used to augment labour in 36.3% of cases.

Discussion
Compared to studies on the use of the partograph done in
other settings [10,15-18], completion to standard (as defined
earlier) in this study is relatively better, although not
acceptable. The various labour parameters were recorded to
standard in 32.5%-79.4% of cases, with the least standard
recording in moulding of fetal skull and the highest in
maternal demographics. It is possible that midwives, who
formed the bulk of birth attendants in the study either have
less skill in determining moulding or placed less emphasis on
its importance in the progress of labour. For parameters
pertaining to the progress of labour (contractions, cervical
dilatation and descent) recording to standard occurred in 55-
60% of cases in this study. This figure is higher than was
found in an earlier study in Accra [ 8] where only 25.6% were
recorded to standard. Sub-standard recordings pertaining to
parameters of the progress of labour did not differ
statistically among the cadre of birth attendants charting the
partographs (0.005<p<0.018). In an Ethiopian study cervical
dilatation, uterine contractions and descent were recorded to
standard in 32%, 21% and 6.9% respectively [ 17]. In at least
40% of cases in this study, abnormal/slow progress could not
have been identified since parameters pertaining to the
progress of labour were not recorded to standard. This
indicates a lack of understanding of what the partograph is
designed for-a tool to monitor the progress of labour.

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Opoku et al. Research Journal of Women’s Health 2015,
http://www.hoajonline.com/journals/pdf/2054-9865-2-2.pdf doi: 10.7243/2054-9865-2-2

Of the parameters pertaining to fetal well being (heart

rate, moulding and nature of liquor), fetal heart rate was
recorded to standard in about half of cases. The other
parameters were recorded to standard in only about a third
of cases. Again, fetal heart rate was recorded to standard in a
higher proportion of cases in this study than in studies done
in Ethiopia and Uganda [17,18]. The ability to pick up
abnormal fetal heart tracings is crucial to diagnosing fetal

Table 4. Relationship between substandard recordings and APGAR Scores.

1-min APGAR median (iqr) Unadjusted Adjusted

Fetal heart rate 7 (7-8) 8 (7-8) -1 (-1.4 to -0.7) <0.001 0 (-0.2-0.2)

Contractions 8 (7-8) 7 (6-8) 1 (0.6-1.4) <0.001 1.000
Cervical dilatation 8 (7-8) 7 (6-8) 1 (0.8-1.2) <0.001 0 (-0.2-0.2)
Descent 8 (7-8) 7 (6-8) 1 (0.8-1.2) <0.001 1.000
BP & Pulse 8 (7-8) 7 (6-8) 1 (0.7-1.3) <0.001 0 (-0.2-0.2)
1.000
0 (-0.2-0.2)
1.000
0 (-0.2-0.2)
1.000
Substandard Standard Diff (95% CI) p-value Diff (95% CI) p-value

5-min APGAR median (iqr) Unadjusted Adjusted

Substandard Standard Diff (95% CI) p-value Diff (95% CI) p-value
Fetal heart rate 9 (8-9) 9 (8-9) 0 (-0.2-0.2) 1.000 0 (-0.2-0.2)
Contractions 9 (8-9) 9 (8-9) 0 (-0.2-0.2) 1.000 1.000
Cervical dilatation 9 (8-9) 9 (8-9) 0 (-0.2-0.2) 1.000 0 (-0.2-0.2)
Descent 9 (8-9) 9 (8-9) 0 (-0.2-0.2) 1.000 1.000
BP & Pulse 9 (8-9) 9 (8-9) 0 (-0.1-0.1) 1.000 0 (-0.2-0.2)
1.000
0 (-0.2-0.2)
1.000
0 (-0.2-0.2)
1.000
Table 5. Relation between cadre of staff and substandard recordings.
Cadre n (%)
Sub-standard Midwife (n=725) Doctor (n=15) Student (n=22) Unknown (n=45) Total (n=809) p-
recording value
Fetal heart rate 352 (48.6) 6 (40) 11 (50) 30 (63.8) 399 (49.3) 0.198
Contractions 282 (38.9) 2 (13.3) 10 (45.5) 28 (59.6) 322 (39.8) 0.005
Cervical dilatations 323 (44.6) 4 (26.7) 5 (22.7) 27 (57.5) 359 (44.4) 0.025
Descent 325 (44.8) 4 (26.7) 6 (27.3) 29 (61.7) 364 (45) 0.018
BP & Pulse 454 (62.6) 9 (60) 13 (59.1) 32 (68.1) 508 (62.8) 0.872
distress in labour. In

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Opoku et al. Research Journal of Women’s Health 2015,
http://www.hoajonline.com/journals/pdf/2054-9865-2-2.pdf doi: 10.7243/2054-9865-2-2

low-resource settings where continuous electronic fetal heart Conclusion

monitoring is not universally available, proper charting of Almost 26 years after its introduction in the country, it is
fetal heart rates on the partograph is key to identifying fetal evident that birth attendants need more education on the
heart rate abnormalities and the early stages of fetal distress. importance and correct usage of the partograph to ensure
Parameters pertaining to maternal well being (blood that all labours are monitored with the partograph. Health
pressure, pulse and nature of urine) were recorded to workers must also be taught to record parameters according
standard in about 40% of cases. It is known that blood to standard protocols as appropriate completion of the
pressure during the 1st stage of labour is influenced by the partograph is key to detecting abnormal progress of labour.
physiological effects of labour itself and the use of drugs such Early detection and timely intervention of obstetric
as oxytocin and epidural analgesia [ 19]. Oxytocin was used to complications are the most important activities to prevent
augment labour in 36% of cases in this study. This figure may maternal and perinatal mortality and morbidity.
not be a true reflection of those who might have needed Training and re-training of birth attendants, especially mid
augmentation since parameters pertaining to the progress of wives (as they form the bulk of health attendants at delivery)
labour were not recorded to standard in 40% of cases. The
need to be done to ensure proper understanding of the
effects of oxytocin on blood pressure could not have been
ascertained in up to 60% of patients because their blood partograph as a tool for labour monitoring and management.
pressures were not recorded to standard. Competing interests The authors declare that they have no
Neonatal outcomes in terms of Apgar scores at both 1- competing interests.
min- ute and at 5-minutes did not differ statistically in this Authors’ contributions
study whether parameters were recorded to standard or Authors’ contributions BKO SBN
were substandard. The WHO expects the partograph to be Research concept and design ✓ --
used in all births attended to by skilled birth attendants in
Collection and/or assembly of data ✓ --
developing countries. The proportion of deliveries attended
Data analysis and interpretation -- ✓
to by skilled birth attendants have steadily increased in the
country from 40% in 1988 to 68% in 2011 [ 20,21]. However, Writing the article ✓ ✓
partograph use in this study was 54%, a figure that is below Critical revision of the article -- --
the national figure of deliveries conducted by skilled Final approval of article ✓ ✓
attendants. Regular in-service training for skilled birth Statistical analysis -- --
attendants has to be undertaken to enhance their
Acknowledgement
understanding and capabilities in using the partograph to
We acknowledge the invaluable contributions of the staff
monitor the progress of labour in the country. There is the of the labour wards of the hospitals involved. We thank
need to ensure that birth attendants see proper completion Jonathan, Emmanuel, Nana Yaw and Cecilia who were the
of the partograph as necessary for proper labour data collectors. We also thank Miss Hannah Kyerewaa
management. A supportive system of peers and supervisors Asiamah for doubly entering all data for the study.
will ensure proper use of the partograph. Publication history
A limitation of this study is that it assessed only the Editor: Erich Cosmi, University of Padua, Italy.
completion of the parameters of the partograph during Received: 20-Feb-2015 Final Revised: 23-Apr-2015 Accepted:
labour and not whether partograph completion was 24-Apr-2015 Published: 02-May-2015 References
translated into labour management. Completion may not 1. Tr
necessarily mean use and the findings of the present study en
ds
may not show the extent of use of the partograph for in
monitoring the progress of labour in the health facilities. m
Partographs may have been used only to record events in at
er
labour rather than to guide actual management of labour. na
Neonatal outcomes in terms of Apgar scores at 1 and l
5-minutes did not differ statistically whether parameters m
were recorded to standard or substandard. The authors ort
ali
cannot comment whether this is incidental or related to the ty
ability of attending staff to properly assign scores to the ra
parameters in Apgar scoring. Further, the reasons why more tio
s:
than half of labours were not monitored by the partograph 19
was also not answered in this study. 90

9
Opoku et al. Research Journal of Women’s Health 2015,
http://www.hoajonline.com/journals/pdf/2054-9865-2-2.pdf doi: 10.7243/2054-9865-2-2

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Opoku et al. Research Journal of Women’s Health 2015,
http://www.hoajonline.com/journals/pdf/2054-9865-2-2.pdf doi: 10.7243/2054-9865-2-2

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http://www.hoajonline.com/journals/pdf/2054-9865-2-2.pdf doi: 10.7243/2054-9865-2-2

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http://www.hoajonline.com/journals/pdf/2054-9865-2-2.pdf doi: 10.7243/2054-9865-2-2

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Citation:
Opoku BK and Nguah SB. Utilization of the modified WHO partograph in assessing the progress of labour in a
metropolitan area in Ghana. Res J of Womens Health. 2015; 2:2.
http://dx.doi.org/10.7243/2054-9865-2-2

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