O&G Forum

OBSTETRICS & GYNAECOLOGY FORUM 2021 | ISSUE 3 | 20 a partogramwas used compared to when it was not used. Also, we compared the admission of babies into a High Care Unit, Premature Unit or Neonatal ICU unit when a partogram was used versus when it was not used. Lastly, we planned to compare the number of stillbirths/ intrauterine fetal deaths (IUFD) when a partogram was used versus when it was not used. However, this analysis could not be conducted due to the small numbers of stillbirths (2) and IUFD (1). To assess maternal outcomes, we examined a number of variables such as number of per vaginal examinations, mode of delivery, use of analgesia, augmentation of labour, and the presence of postpartumhaemorrhage. Permission to perform the study was obtained from the Faculty of Health Sciences Postgraduate Education, Training, Research, and Ethics Unit at Walter Sisulu University, Mthatha, with Human Research Committee Ethics Clearance Certi cate no 030/2020. e Chief Executive O cer, Clinical Manager and the Head of Department of Obstetrics and Gynaecology at Dora Nginza Hospital also granted permission. Results Maternal characteristics ree hundred-and-one maternal les were included in the study. e mean age of mothers was 27.1 years [12 – 47 years], with the majority, 163/301 (54.2%) in the age group 21 – 30 years, 47/301 (15.6%) in the age group 11 – 20 years and 91/301 (30.2%) in the age group 31 years and older. One hundred and seventy- ve parturient women (58.1%) were multiparous. A gestational age of 37 weeks and above presented in 246 (81.7%) women, 15 (5.0%) women had a poor obstetric history, 184 (61.1%) presented at the active phase of rst stage of labour. Use of the partogram In248/301 (82.4%) of cases the partogramwas used, of whichonly 48 (19.4%) was completed correctly. e most common errors were: duration of labour in 57 (23.0%) cases, maternal vitals 52 (21.0%) and fetal position 50 (20.2%). Less common errors were: head above pelvic brim 20 (8.0%), incorrect date 17 (6.9%), patient’s age not documented in 17 (6.9%), status of onset of labour and gestational age were missing in 28 (11.3%) and fetal heart rate was not recorded in 7 (2.8%) cases. Partogram use and immediate neonate outcome Apgar scores of neonates were analyzed at one- and ve-minutes a er birth. In the case of twins, data from the rst twin were used. Only individuals with Apgar data were included in the analyses. Two-hundred and ninety-six neonates hadApgar scores, and in 245 (82.8%) of these a partogramhad been used during the birthing process. e di erence in partogram use versus no partogram use was not statistically signi cant, in both the one-minute Apgar score (p=0.638) and ve-minute Apgar score (p=0.372) groups. When the groups ‘partogram used’ versus ‘no partogram used’ were considered in 1-minute (normal and low) and 5-minute (normal and low) Apgar score neonates, the di erence between groups were not statistically signi cant (see table 1). Table 1. Normal and low Apgar scores at 1-minute and 5-minutes a er birth Table 1. Normal and low Apgar scores at 1-minute and 5-minutes after birth Partogram used n = 245 n (%) No partogram used n = 51 n (%) p-value Normal 1-minute Apgar score 219 (89.4) 43 (84.3) 0.333 Low 1-minute Apgar score (<7/10) 26 (10.6) 8 (15.7) Normal 5-minute Apgar score 240 (98.0) 51 (100) 0.592 Low 5-minute Apgar score (<7/10) 5 (2.0) 0 Partogram use and maternal outcome ere was a statistically signi cant di erence in the number of per vaginal examinations dependingonwhether apartogramwas usedor not: theuse of a partogramwas associated with a greater number of per vaginal examinations [Partogram used (median, IQR): 3, 2 to 4; Partogram not used (median, IQR): 1.5, 1 to 2; di erence in location: -1;Wilcoxon rank sumtest, p< 0.001]. Data regarding mode of delivery were available in 248 les. Only 9/248 (3%) of deliveries were assisted. e partogram was used in 143/159 of normal vertex deliveries and in 56/80 of caesarean sections. Partogramuse vs partogramnot used in normal vertex delivery and caesarean section is shown in table 2. Table 2. Mode of delivery Partogram used No partogram used p-value Normal vertex delivery, n(%) n=159 143 (89.9) 16 (10.1) <0.001 Caesarean section, n(%) n=80 56 (70.0) 24 (30.0) Of the 299 participants with documented pain management during labour, the majority (35%, n = 104) of parturient women required no analgesia followed by non-pharmacological labour pain management (27%, n = 80). e majority received pethidine in those who received pharmacological pain management (20%, n = 59). Patients plotted on the partogram were more likely to receive analgesia (p < 0.001). Data for labour augmentationwere available in295 les. No augmentation was used in the majority of deliveries (88%). However, when augmentation was used, a greater proportion of deliveries involved the use of a partogram (97%) compared to when no augmentation was used (82%) (Fisher’s Exact test, p = 0.025). All les contained data for post-partumhaemorrhage, and in themajority of deliveries (95%) there was no post-partum haemorrhage. No statistically signi cant di erence was shown in the proportion of post-partum haemorrhage occurrences between partogram used versus partogram not used (p = 1.00). Discussion e results of the study showed a high utilization, 82.4%, of the partogram for women delivering at Dora Nginza Hospital labour ward. e correct utilization of partogram was however very poor at 19.4 %. e majority of parturient women presented in the active phase of labour, and very few women in the second stage of labour. Keymissing informationonpartograms were: duration of labour, maternal vitals and fetal position. Nearly all les had data on fetal heart rate monitoring. Partogramutilization inour studywas higher thanother publisheddata in SouthAfrica (69%), East Africa andNigeria (8%) and Ethiopia (6.9%). 10 e correct utilization of the partogram in our study was similar to the correct utilization in Ethiopia at 11.5 %, 10 but very low compared to the 91.2 % in the USA.14 e di erence in utilization of the partogram might be due to a number of factors such as study population, sample size, hospital protocols and poor labour ward monitoring. Our setting is a tertiary and teaching hospital and according to hospital protocol all parturient women must be plotted on the partogram during labour; this could have contributed to the high partogram use. Sta shortage, high patient turnaround time in labour ward, health care providers’ negative attitudes towards the partogram and poor knowledge of how to plot on the partogram could be some of the reasons for the high incorrect partogramutilization in our study. Our study failed to show a statistical relationship between the use of the partogram and improvement of 5-minutes Apgar scores. is nding was similar to evidence from the 2018 Cochrane systemic review, showing no clear di erences between partogram use and no partogram use in terms of lowApgar score. 15 Other published data however showed improved perinatal morbidity and mortality with partogram utilization. 3,10 is variation could be due to di erence in Apgar score assessment, neonatal unit admission protocols, study setup, availability of labour ward monitoring tools such as O&G Forum 2021; 31: 19 - 21 ORIGINAL RESEARCH