RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

Mrs. NIMA.V.P.
I Year M.Sc Nursing
Obstetrics and Gynaecological Nursing
Year 2008-2009

PADMASHREE INSTITUTE OF NURSING

GURUKRUPA LAYOUT, NAGARBHAVI,
BANGALORE – 72

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

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 1 NAME OF THE Mrs. NIMA .V. P.
I Year M.Sc Nursing
CANDIDATE AND
Padmashree Institute of Nursing
ADDRESS Nagarbhavi,
Bangalore - 72

2 NAME OF THE Padmashree Institute of Nursing

Nagarbhavi,
INSTITUTION
Bangalore - 72

3 COURSE OF THE I Year M.Sc Nursing

Obstetrics and Gynecology Nursing
STUDY AND SUBJECT
4 DATE OF ADMISION TO
30th June 2008
THE COURSE
5 TITLE OF THE STUDY Assessment of the knowledge, attitude and
practice regarding partograph among staff
nurses.

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION

An important development in the management of labour was the introduction of

the partogram. Friedmen discovered partograph in 1954. It is modified by Hugh Philpott
in 1972 to identify abnormally slow labour.1A partograph is a representation of the
changes that occur in labour, including cervical dilatation, fetal heart rate, maternal pulse,
blood pressure and temperature. It also shows a numerical record of features such as
urine output and the volume and type of intravenous infusions (including oxytocin drips).

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It is therefore possible at a glance to identify deviations from normal in any of this
variables.2

Safe Motherhood Conference organized jointly by The World Bank, WHO and the
United Nations Population Fund at Nairobi in 1987 concluded with a “Call to Action.”
This call demands that health workers involved in the care of mothers and children take
positive action now to reduce maternal mortality and morbidity. Among the actions called
for are to ensure that all pregnant women are screened by supervised and appropriately
trained non-physician health workers where appropriate, with relevant technology
including partographs as needed, to identify those at risk and to provide prenatal care and
care during labour, as expeditiously as possible.3
As part of the Safe Motherhood, World Health Organization promoted a
partograph with a view to improving labour management and reducing maternal and fetal
morbidity and mortality. Introduction of the partograph with an agreed labour
management protocol reduced both prolonged labour (from 6·4% to 3·4% of labours) and
the proportion of labours requiring augmentation (from 20·7% to 9·1%). Emergency
caesarean sections fell from 9·9% to 8·3% and intrapartum stillbirths from 0·5 to 0·3%. 4

The World Health Organization model of the partograph was devised by an

informal working group, who examined most of the available published work on
partographs and their design. It represents in some ways a synthesized and simplified
compromise, which includes the best features of several Partographs. This partograph
clearly differentiates normal from abnormal progress in labour and identifies those
women likely to require intervention. Its use in all labour wards is recommended. 5

When the partograph is used effectively it will prevent prolonged or obstructed

labour, which accounts for about 8% of maternal deaths. 6 The majority of the deaths and
complications could be prevented by cost-effective and affordable health interventions
like the partograph and indeed the same measures that would prevent maternal deaths
would also prevent morbidity and improve neonatal outcome.
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The partograph has following advantages:-

• It depicts the progress of labour at a glance,

• It enables failure to progress to be readily recognized,

• It is simple to use,

• It provides a practical teaching aid, and

• It is an efficient means of exchange of technical information about labour

progress between teams of care givers.2

The partograph can be used by midwives personnel to assess the progress of

labor to identify when intervention is necessary. Studies have shown that using the
partograph can be highly effective in reducing complications from prolonged labor for
the mother such as postpartum hemorrhage, sepsis, uterine rupture and its sequelae
and for the newborn like death, anoxia, infections, etc. It is very useful to assist in
make the correct decision about transfer, Caesarean section, or other life-saving
interventions.

Partograph is one of the very important tools for monitoring the labour. This
helps in identifying the prolonged labour, decision for augmented labour and for the
operative deliveries. This make to reduce the maternal mortality rate during the intra
natal period.

6.2 NEED FOR THE STUDY

Maternal mortality ratio continues to be the major index of the widening

discrepancy in the level of care and the outcome of reproductive health between the
advanced and developing countries.

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 This observation is supported by the global maternal mortality pattern in which
annual loss of more than 515,000 maternal deaths from complications of pregnancy and
childbirth occurring in developing countries. Among those who survive childbirth at least
8 million develop serious morbidities and a further 50 million suffer minor complications.

Approximately half a million women lose their lives every year because of
complications of pregnancy and about 99% of these occur in developing countries. The
risk of a woman dying as a result of a complication related to pregnancy in developing
countries can be as much as a hundred times that of women in Western Europe or North
America.7

The partograph should be used for all women admitted in established labour. When
the partograph is commenced at the beginning of the induction process the alert and
action lines are drawn when the women is in the active phase of labour.

The partograph serves as an “early warning system” and assists in early decision on
transfer, augmentation and termination of labour. It also increases the quality and
regularity of all observations on the fetus and the mother in labour and aids early
recognition of problems with either.

Prolonged labour in the developing world is commonly due to cephalopelvic

disproportion which may result in obstructed labour, maternal dehydration, exhaustion,
uterine rupture and vesico-vaginal fistula. Early detection of abnormal progress of labour
and the prevention of prolonged labour would significantly reduce the risk of postpartum
haemorrhage and sepsis and eliminate obstructed labour, uterine rupture and its sequelae. 8

A study conducted on the uses of Partogram among maternity nurses, showed

partograph was used in 98% of all cases, in 13.3% cases of partogram completion
stopped before delivery. Overall completion was less good. These results reveals that

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very high coverage of partogram use, but inadequate quality and thus demonstrate the
need for refresher training for maternity staff about partogram use.9

The investigator from her personal experience during clinical postings had seen
inadequate care of mothers in intranatal periods at maternity units . Most of staff nurses
are unaware and having inadequate knowledge, attitude and practice regarding
partograph.

Maternal mobility rate increases because of insufficient facilities in the health care
settings, inadequate attitude and knowledge of plotting the interventions in the
partograph.

So, staff nurses need adequate knowledge regarding the partograph and its uses to

reduce the maternal mortality and morbidity rate. Partograph knowledge helps to improve
good attitude and practice in the clinical performance. Maternal mobility rate increases
because of insufficient facilities in the health care settings, inadequate attitude and
knowledge of plotting the interventions in the partograph.

Hence, there is need to assess the knowledge, attitude and practice of partograph
among staff nurses. For that reason investigator select the study to assess knowledge,
attitude and practice regarding partograph among staff nurse to improve their knowledge
and awareness about partograph

6.3 STATEMENT OF THE PROBLEM

A study to assess the knowledge, attitude and practice regarding partograph

among staff nurses at maternity units of selected hospitals, Bangalore.

6.4 OBJECTIVES OF THE STUDY

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 1. To assess the knowledge regarding partograph among staff nurses at maternity
units of selected hospitals.

2. To assess the attitude regarding partograph among staff nurses at maternity units of
selected hospitals.

3. To assess the practice regarding partograph among staff nurses at maternity units
of selected hospitals.

4. To correlate the knowledge, attitude and practice regarding partograph among staff
nurses at maternity units of selected hospitals.

5. To associate the knowledge, attitude and practice regarding partograph among staff
nurses at maternity units of selected hospitals with their selected demographic
variables.

6.5 OPERATIONAL DEFINITIONS

1. Knowledge:

It refers to the understanding of partograph among staff nurses.

2. Attitude:

It refers to opinion or belief of partograph among staff nurse.

3. Practice:

It refers to staff nurses implementation of partograph in the clinical area.

4. Staff nurse:

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 It refers to the nurse graduate who has acquired diploma or degree and
registered as nurse midwife and they are working in maternity wards.

5. Partograph:

It is the graphical representation of the changes that occur in the labour for
monitor the fetal and maternal well being to reduce the maternal morbidity and
mortality.
6. Maternity units:
It refers to antenatal, labour and postnatal wards in selected hospitals.

6.6 ASSUMPTIONS

1. Staff nurses who are working in maternity units may have inadequate knowledge,
attitude and practice regarding partograph.

2. The level of knowledge, attitude and practice regarding partograph among Staff
nurses may vary with their selected demographic variables.

6.7 RESEARCH HYPOTHESIS

H1: There is significant correlation between knowledge, attitude and practice

regarding partograph among staff nurses at selected maternity units.

H2: There is significant association between knowledge, attitude and practice

regarding partograph among staff nurses with their selected demographic variables of
staff nurses.

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6.8 REVIEW OF LITERATURE

Review of literature is an essential step in the research project. It provides basis

for future investigation, justifies the need for study, throws light on the feasibility of the

study, Reveals constrains of data collection and relates the findings from the study to

another with a hope to establish a comprehensive study of scientific knowledge in a

professional discipline, from which valid theories developed.10

A descriptive study was conducted to evaluate the health workers in the use of
partograph among fifty-six health workers offering delivery services in primary health
care facilities after 7 months of training. A total 242 partograms of women in labour were
plotted over a year period in which 76.9% of them plotted correctly193 (79.8%)
Community health workers plotted and 49 (20.2%) nurse midwife plotted correctly.
Inappropriate action based on the partograph occurred in 6.6%. The findings reveals that
lower cadres of primary health care workers can be effetely trained to use the partogram
with satisfactory results and thus improved the maternity outcome.11

A prospective study was conducted to assess the effectiveness of the maternal

care by using manual of the perinatal education programme to interpret antenatal cards
and partogram among 193 midwives. They were compared by the study group for
questions from the antenatal card and the partogram improved by 33.0% (p < 0.001) and
17.5% (p = 0.001), respectively. No changes were observed in the control group. This
study concluded that midwives that studied the Maternal Care Manual significantly
improved their ability to interpret clinical information and apply knowledge. If this

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ability is applied in clinical practice, a reduction in maternal and perinatal deaths is
possible.12

An interventional study was conducted to determine the effect of partogram on

the frequency of prolonged labour; augmented labour, operative deliveries will reduce
maternal and perinatal complications. The study involved 1000 women in labour in
which 88% had normal vaginal delivery, 5.6% had operative vaginal delivery and 6.4%
had caesarean section. This study reveals that by using partograph frequency of
prolonged and augmented labour, postpartum hemorrhage, ruptured uterus, puerperal
sepsis and perinatal morbidity and mortality was reduced. 13

A retrospective study was conducted to assess the frequency and mode of

delivery of women admitted in the latent and active labour using the World Health
Organization partograph. That women admitted in the latent phase had more operative
deliveries as labour progressed to the right of the alert line in active phase compared to
women admitted in the active phase of labour. The study concluded that one-third of the
women were admitted in the second stage of labour need criterion-based audits would
definitely improve management of labour. 14

A descriptive study was conducted to the quality of partograms used to

monitor labour. This study involve 20 midwives and of all partograms reviewed in this
50% had no records of duration of labor, 97% cervical dilation and 94% fetal heart rates
were recorded , 94% had not recorded blood pressure, temperature, and pulse rates and
91% of these were judged to be substandard. These finding reveal that poor management
of labor and urgent in-service training about the importance of documentation and regular
partogram audit in order to reduce maternal and perinatal deaths.15

A prospective study was conducted to assess the effect of three different

partograms on caesarean section and maternal satisfaction among 928 primigravid
women with uncomplicated pregnancies are selected having duration of 2,3,4 hours
monitoring of partograph. Caesarean section rate was lowest when managed using a

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partograph with 4 hour action. This study reveals that caesarean women prefer early
active management of labour is possible that partograms which favour earlier
intervention. 16

A descriptive study was stated to evaluate the effect of partogram use on

early recognition of dystocia and help avoid Caesarean section and they selected 1932
primiparous women with uncomplicated pregnancies at term. They assigned as a standard
group, who had the progress of labour charted in written notes and the partogram group,
whose progress in labour was recorded using a bedside graphical partogram as well as in
written notes. The primary outcome was the rate of Caesarean, secondary outcome
measures were rates of obstetric intervention for dystocia. The findings reveals that no
significant difference between the groups in rates of Caesarean section (partogram 24%,
standard notes 25%).17

A descriptive study was conducted to assess the partogram utilization rate and
quality of its use in urban and rural. In that 984 partogram examined 98% cases the
partograph stopped before the completion of delivery, action taken before the alert line
was crossed incorrect in 48% of cases of oxytocin use, and alert line was crossed in
13.5% of the cases but correct action always followed by artificial rupture of
membranes, oxytocin administration. The study reveals very high coverage of partogram
have inadequate quality of use and thus demonstrate the need for refresher training for
maternity staff about partogram use.18

A prospective study was conducted to assess the predictive value of partogram on

the outcome of labour in vaginal birth after caesarean section among nurses. The study
involved 102 women with one previous caesarean section and they measure the duration
of labour, cervical dilatation rate and average cervical dilatation rate. A successful
vaginal delivery rate of 72.5% was achieved. The findings reveals that important
implications in establishing policies for monitoring labour.19

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 An evaluatory study was conducted to assess the knowledge and use of
partograph among staff nurses at the peripheral maternity centers .In this study 396
maternity care-providers selected it include nurses/midwives (45.5%) and community
health extension workers (42.7%). Out of the 216 personnel (54.5%) who were aware of
the partograph, 36 (16.7%), 119 (55.5%) and 61 (28.2%) demonstrated poor, fair and
good levels of knowledge respectively. This study reveals that there is inadequate
knowledge among staff nurses regarding partograph so adequate training of care-
providers at the peripheral delivery units. 20

7. MATERIALS AND METHODS

7.1 SOURCE OF DATA

Staff nurse working in maternity units in managing antenatal, natal, and postnatal
mothers.

7.2 METHOD OF DATA COLLECTION

i. Research design

Non – experimental descriptive correlational design.

ii. Variables

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 1. Study Variables: Knowledge, attitude and practice regarding partograph among
staff nurses.
2. Extraneous variables: It contains demographic variables of staff nurses such as
age, qualification, area of work and experience & previous source of knowledge.

iii. Setting

Maternity units at selected hospitals in Bangalore.

iv. Population

All staff nurses working in maternity units at selected hospitals in Bangalore.

v. Sample

Staff nurses in maternity wards that fulfill the inclusive criteria are considered as
sample and sample size is 60.

vi. Criteria for Sample Collection

Inclusive Criteria: The study includes

1) Those who are working maternity units as a staff nurses.

2) Staff nurses having more than 1year experiences.

Exclusive criteria: The study excludes

1) Staff nurse who are unwilling to participate in the study.

2) Staff nurse who are not available at the time of data collection.

vii. Sampling technique

Non –probability convenience sampling technique.

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viii. Tool for data collection

Section A: Demographic variables of the staff nurses such as age, qualification,

area of work and experiences.

Section B: Structured Questionnaire to assess the knowledge regarding partograph

among staff nurses.

Section C: Likert scale used to assesses the attitude regarding partograph among
staff nurse.

Section D: Checklist used to assess practice regarding partograph among staff

nurse.

ix. Method of data collection

Formal permission will be obtained from the head of the institution. After
obtaining the informed consent from the staff nurses working in maternity units and
assuring about confidentiality of the information obtained, the investigator will assess the
knowledge of staff nurse regarding partograph at selected hospitals. Duration of the data
collection will be 4-6 weeks.

x. Plan for Data analysis

The data collected will be analyzed by using the descriptive and inferential
statistics.

Descriptive statistics:

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 Frequency and percentage distribution will be used to analyze the demographic
variables. Mean and standard deviation will be used to analyze the knowledge, attitude
and practice regarding partograph among staff nurses.

Inferential statistics:

Correlation coefficient will be used to analyze correlation between knowledge,

attitude and practice regarding partograph among staff nurses a nd Chi-square will be
used to analyze the association between knowledge, attitude and practice regarding
partograph with their selected demographic variables.21

xi. Projected outcome

After the study of the investigator will know the level of the knowledge, attitude,
practice of staff nurses regarding partograph. Based on the data the investigator will
prepare and distribute the pamphlets to improve knowledge, attitude and practice of staff
nurses regarding partograph.

7.3 Does the study require any interventions or investigation to the

patients or rather human beings or animals?

No, the study requires no intervention or investigation to the patients or

rather human beings or animals.

7.4 Has ethical clearance obtained from your institution?

I. This study does not involve administration of any intervention to the patients.

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 II. The requisition letter for the permission to conduct the study in KCG and
Ghosia Hospital has been sent and waiting for the reply. When the permission letter
is received, a copy will be sent to Rajiv Gandhi University of health sciences in
future.

III. Informed consent from the samples will be obtained.

8. LIST OF REFERENCES

1. D.C Dutta. Textbook of Obestetrics: partograph. Calcutta: New Central book

agency; 2004. P131-2

2. Emest.Orj. Evaluatory progress of labour in nulliparous and multiparous using

modified WHO partograph.2008september249-552.

3. WHO. Preventing prolonged Labour – A practice guide: Partograph. Programme

of maternal midwife and safe motherhood programme manual; 1994. P 2-24

4. Diane.M.Fraser, Margerat A cooper. Myles textbook of midwives: partograph.

New York: Churchill livingstone;2003. P164-5

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5. Barbara E. Kwast, Pia Poovan, Edita Vera, Elaine Kohls. The modified WHO
partograph. African Journal of Midwifery and Women’s Health. 2008 july
18;vol 2(3):pp143-48

6. Azandeqbe N, Testa J, Makontoda M. assessment of partogram utilization in

benin. International journal of obstetrics and gynaecology; 2001 Sep-Oct;129(9-
10). P 239-42

7. Meghendra banerjee, Deeksha Sharma. Acute management: style of Labour.

Mertanity child health Journal; 2008 june; 50(2).p32-7

8. Tina Lavendra, Zarko Alfresic. Partograph action line study; randamised trail.
International journal of obstetrics and gynaecology ; 2005 aug; 105 (9)

9. Omole-Ohosia,Muhammed.Z.,Iliysuz. Value of partograph in vaginal birth after

caessarian section.2007April27(3). p264-6.

10.Denis E Polit, Chery Tanto Beck. Nursing Research: review of literature. New
Delhi: Wolters Kluwer. 2008. P. 134-37

11.Theron.G.B. Effect of maternal care manual of the perinatal education

programme to interpret antenatal cards and partogram: international journal of
obstetrics and gynaecology; 1999 September19(6). p432-5.

12.Olandapoo.T.,Daniel .O.J,OlantitiyaA.O. Knowledge and use of partograph

among health care workers at the pheripheral maternity centers; International
journal of obsteritics and gynecology; 2006September26(6)538-541.

13. Javed. I, Bhutta.S , Shoaid.T, Role of partogram in preventing prolonged

labour. International journal of obstetrics and gynaecology 2007 august57(8)
408-11.

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 14. Fatusi A.O.,Makinde.O.N.,Adeyemi.A.B.,Oriji.E.O.,Onwndieawn.U. Health
worker training in use of the partogram: International journal of obstetrics and
gynaecology . 2008January100 (1).p41-4.

15. Windrim . R, Seewad P.G, Hodnett.E ,Akoury.H., Kingdom.J, Salenicks M.E.

et al. Partogram in the active management in the primiparous women.
International journal of obstetrics and gynaecology.2007January 29(1)27-34.

16. Lavender. T, Alfirevicz,Walkinshaws. Partogram action study. International

journal of obstetrics and Gynecology Nursing 1998 September 105 (9)976-801.

17. M Rolle Groeschal ,RMauline. The partograph used rarely questioned .

Australian journal of midwife ; 2001September 14(33) 22-27.

18. Barbara E. Kwast, Pia Poovan, Edita Vera, Elaine Kohls. World Health
Organization partograph in management of labour. African Journal of
Midwifery and Women’s Health. 2008 July 18(2).p34-7

19. WHO. Maternal health and safe motherhood programme : African Journal of
Reproductive Health.2008 april Vol 12(1). P 23-36
20. MN Norelle Groeschel, Pauline. The partograph.Used daily but rarely
questioned nurse; Australin Journal of midwife; Sep 2001; Vol 14(3).
p22-27

21. BK Mahajan. Methods in Biostatistics: Measures of location. New Delhi:

Jaypee Brothers (P) Ltd; 1997. P35-58,158-87.

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9. Signature of the Candidate :

10. Remarks of the guide :

11.1Names and Designation of the guide :

11.2 Signature :

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11.3 Co-Guide :

11.4 Signature :

11.5 Head of the Department :

11.6 Signature :

12.1 Remarks of the principal :

12.2 Signature :

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