Usefulness of the Partograph
Thank you to our colleages at GANM for an interesting discussion on the use, and usefulness, of partographs. I have added several links clarifying what a partograph is and a few research articles. The Cochrane review (below) was provided by a GANM member. The following is just a sample of the vibrant conversation:
POST: Lucia Buyanza, BScN
There is an interesting discussion currently going on within the Kenya Health Professionals on the Partograph in view of MNH outcomes. Some school of thought is for the continued use,other further research etc. I needed to learn from other country situation what benchmaking strategies have been put forth to encourage the utilization of the partograph. Your views and critique will be helpful.
REPLY: Rachel Breman, MSN, MPH, RN
The WHO Partograph and the manual to use it can be downloaded from this link, page C-57 is where discussion of the partograph begins in the English manual.
Just a few tips when using the partograph:
1) The partograph was designed for use for active labor. It should not be used unless the woman is at least 4 cm dilated
2) Vaginal exams should only occur every 4 hours
3) The tool requires practitioners to understand graphing, which can be challenging in different environments
4) The partograph can be an excellent tool for documenting and monitoring labor, but the challenge in many places has been getting practitioners to use it consistently.
REPLY: Marianne Littlejohn, South Africa
A tool like the partograph may have been designed to save lives, however although it may serve as a guideline, it is extremely restrictive and patriarchal. "A vaginal examination must be done at least every 4hrs after the membranes have been ruptured" - many of my clients have long slow labours with periods of rest and they go on to give birth normally and healthily. To impose 4 hourly or more frequent vaginal examinations seems overly invasive and may impede the mother's progress.
There must be better ways to observe and ensure the safety of women giving birth. I have been a midwife for thirty years and practising for 23 yrs. My experience holds good and gives me a wealth of information on which to draw - A partograph is obviously used by the inexperienced to ascertain progress as if mothers were machines. Education, mentoring and the experience of being at many different births will help midwives to be less invasive, not more. What I am saying, is that the partogram should be a guide, not a rule.
In our secondary level hospitals, Vag exams are being performed every TWO hours by various people, interns, midwives, doctors, students etc. Can you imagine being a woman and having to submit to a vaginal exam every two hours? Surely women cannot progress BECAUSE they are being subjected to examinations that add to their fear which releases adrenalin and shuts down the release of oxytocin and the labour?
It is just another way to subjugate women when they are most vulnerable, and is unconsciously institutionalised by the medical profession as a way to keep women on their backs. We discuss vaginal examinations in a medicalised tone forgetting that there is a person and a woman behind our hand? I often see women scream and writhe in pain while the staff do their job. Gloves are dumped in the bin and the staff walk away.
At the same time, I do understand that for some women, who have complicated labours, regular assessment may be necessary.
REPY: Sabrina Speich, Executive Director Parteras Tradicionales Unidas Tumben Cuxtal AC Enviado
This is all so true. Here in southeastern Mexico I would like to add some points. Here many healthcare providers do not know how to do a vaginal exam without seriously hurting the woman. So as you say women percieve it as painful, because it is. One Obgyn said to me I had to peform the exam during a contraction, doesnt matter if it hurts, its meant to hurt. So maybe gender issues could be important in that discussion. And maybe most logically, if we induce more pain in that area, labour could become more difficult. The issue of obstetric violence and women seeing the vaginal exam as a form of rape. Can a woman then open comftorbly? Or does the adrenalin rush inhibt labour? So the question becomes if more exams threaten a normal progression.
Another point where labour progression is an issue is when working with traditional midwives. Many healthcare workers blame midwives for not making accurate diagnosis. I have noticed a confusing linguistic issue. The traditional midwives, with
no medical instruction dont perform vaginal exams. In their courses given by the government they constantly hear the word dilation. They cannot cognitively apply it to a medical context. To them dilate means prolong. Imagine the confusion that arises. So if she is not dilating she is not prolonging her labour?! There are many many more cultural differences which inhibit coordination. These cultural differences not only affect midwives but also women coming from there culture. The entire birthing process becomes a huge hurdle, where many women percieve the suffering during labour, not the actual contractions but all that happens around them as intrusive and painful. So when the woman says: Doctor doctor, please I want no pain. She referrs to the doctors actions in the process. And many doctors say: women dont want to feel pain, so I prefer epidurals and csections. This is a reality here in mexico.