i

REPUBLIC OF CAMEROON REPUBLIQUE DU CAMEROUN

Peace-Work-Fatherland Paix-Travail-Patrie

****** ******

MINISTRY OF HIGHER EDUCATION MINISTERE DE L’ENSEIGNMENT SUPERIEURE

Molyko Buea
AMERICAN DITEK INSTITUTE (+237) 651 044 896
PO BOX 31460
( ADI UNIVERSITY BUEA)
Check Point, Wokoko Quarters www.adiuniversity.com

IN AFFILIATION WITH THE UNIVERSITY OF NGOUNDERE

SCHOOL OF MEDICAL AND BIOMEDICAL SCIENCES

DEPARTMENT OF NURSING

FACTORS AFFECTING THE EFFECTIVE UTILISATION OF THE PARTOGRAM BY NURSES

AND MIDWIVES IN EKOUMDOUM BAPTIST HOSPITAL.

A Research Project submitted to the School of Medical and Biomedical Sciences in partial fulfilment of the
requirements for the award of a Bachelor of Nursing Sciences (BNS)

BY:

MIH MILDRED NAIN

MATRICULE: NS23A20

PROGRAM DIRECTOR ACADEMIC SUPERVISOR:

MADAME KOMBOU TSE GRACE L . MADAME KOMBOU TSE GRACE L.

ACADEMIC YEAR: 2023/2024

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DEDICATION

TO MY HUSBAND, MY CHILDREN AND MY SUPERVISOR.

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CERTIFICATION

This is to certify that this Project titled “FACTORS AFFECTING THE EFFECTIVE UTILIZATION OF
THE PARTOGRAM BY NURSES AND MIDWIVES IN EKOUMDOUM BAPTIST HOSPITAL” is a
piece of work carried out , and written by Mih Mildred Nain under the supervision of Madam Kombou Tse
Grace L being my original work and has not been published in any journal house before, in partial
fulfillment for the award of a BACHELOR IN SCIENCES in AMERICAN DITEK INSTITUTE
UNIVERSITY UNDER THE MENTORSHIP THE UNIVERSITY OF NGAOUNDERE

Supervisor………………………………………… Signature……………………………………………

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ACKNOWLEDGEMENT

First of all, I thank the God Almighty for guidance and protection throughout my course .

I appreciate all those who assisted me in the realization of this project.

Special thanks go to my able Supervisor, Madam KOMBOU TSE GRACE L. for her kindness devotion,
encouragement and her relentless effort put in place to ensure the success of this project .

My sincere thanks go to my entire staff of the AMERICAN DITEK UNIVERSITY BUAE for the
theoretical knowledge and skills impacted on me during my one year training .

I am very thankful to my lovely husband Mr. NKAIN EPHRIAM YUH, my children, Yuh Enid, Yuh
Marvel, and Yuh Marion, who stood by me throughout my one year of training .

I am equally thankful for my wonderful parent Mr. MIH STEPHEN, MIH CONCILIA for their love and
spiritual support.

Special thanks go to the Ekoumdoum Baptist Hospital for their assistance and guidance during the data
collection process.

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TABLE OF CONTENTS

DEDICATION ...................................................................................................................................................ii
CERTIFICATION ........................................................................................................................................... iii
ACKNOWLEDGEMENT ................................................................................................................................ iv
LIST OF TABLES ...........................................................................................................................................vii
LIST OF ABREVIATIONS: ......................................................................................................................... viii
OPERATIONAL DEFINITION OF TERMS ............................................................................................... viii
ABSTRACT ...................................................................................................................................................... ix
CHAPTER ONE : INTRODUCTION ............................................................................................................. 10
INTRODUCTION ....................................................................................................................................... 10
THE BACKGROUND TO THE STUDY ................................................................................................... 10
STATEMENT OF THE PROBLEM ........................................................................................................... 11
RESEARCH QUESTION ............................................................................................................................ 12
RESEARCH OBJECCTIVES ..................................................................................................................... 12
STUDY HYPOTHESIS ............................................................................................................................... 12
SCOPE OF THE STUDY ............................................................................................................................ 12
SIGNIFICANCE OF THE STUDY.......................................................................................................... 12
DEFINITION OF KEY TERMS. ................................................................................................................ 12
CHAPTER TWO : LITERATURE REVIEW .............................................................................................. 13
2.1. INTRODUCTION ................................................................................................................................ 13
2.2. CONCEPTUAL REVIEW................................................................................................................... 13
2.2.1. FIRST CONCEPT ..................................................................................................................... 13
2.2.2. SECOND CONCEPT ................................................................................................................ 16
2.2.3. CONCEPTUAL FRAMEWORK ............................................................................................. 17
2.3. THEORETICAL REVIEW / CONCEPTUAL MODEL ................................................................ 18
2.4. EMPERICAL REVIEW .................................................................................................................... 18
2.4.1. LITERATURE RELATED TO LABOR OUTCOME. ............................................................ 18
2.4.2. LITERATURE RELATED TO THE USE OF THE PARTOGRAM AND ITS
EFFECTIVENESS. .................................................................................................................................. 19
2.5. GAPS AND CONTRIBUTIONS ..................................................................................................... 23
CHAPTER THREE : RESEARCH METHODOLOGY ................................................................................ 25
3.0. INTRODUCTION ................................................................................................................................ 25
3.1. RESEARCH DESIGN. ........................................................................................................................ 25
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3.2 STUDY AREA ..................................................................................................................................... 25

3.2. STUDY DESIGN.................................................................................................................................. 26
3.3 THE STUDY POPULATION ............................................................................................................... 26
3. 4 . SAMPLE AND SAMPLING TECHNIQUES PROCEDURE ......................................................... 26
3.5. INSTRUMENTS................................................................................................................................... 26
3.5.1. INSTRUMENTS FOR DATA COLLECTION AND VALIDATION ........................................ 27
3.5.2 .INSTRUMENTS DATA ANALYSIS ........................................................................................... 27
3.5.3. MEASUREMENTS OF STUDY VARIABLES ......................................................................... 27
3.6. DATA COLLECTION PROCEDURE................................................................................................. 27
3.7. DATA ANALYSIS PROCEDURE .................................................................................................... 27
3.8. ETHICAL CONSIDERATIONS ......................................................................................................... 28
CHAPTER FOUR : PRESENTATION AND ANALYSIS OF THE RESULT ............................................. 29
4.1. PRESENTATION OF FINDINGS ....................................................................................................... 29
4.1.1. RESPONSES ACCORDING TO PROFESSIONAL QUALIFICATION .................................... 29
4.1.2 Responses of respondents according to Longevity in service. ....................................................... 30
4.1.3 .Respondents knowledge on the partogram ................................................................................... 30
4.1.4 Respondents notion on the definition of the partogram. ................................................................. 31
4.1.6 Respondents responses according to the use of the partogram ..................................................... 32
4.1.7. Responses on the consequences of not using the partogram. ....................................................... 32
4.2.1. Respondents attitudes on the use of the partogram. ....................................................................... 33
4.2.3. Responses on how often parameters are monitored during labour ............................................... 34
4.2.5 Respondent’s responses on how often they complete the partogram while in use. ........................ 35
4.3.1 Responses on difficulties faced ....................................................................................................... 36
4.3.2 Responses on whether the respondents like using the partogram in their daily practices. ............. 37
4.3.3 Responses on whether the respondents desire training on the use of the partogram. ..................... 37
CHAPTER FIVE DISCUSSION, CONCLUSION AND RECOMMENDATIONS ..................................... 38
5.1. DICUTION OF RESULTS ACCORDING TO OBJECTIVES .......................................................... 38
5.1.1. SOCIO _ DEMOGRAPHY ........................................................................................................... 38
5.1.2. KNOWLEDGE ON THE PARTOGRAM ................................................................................... 38
5.1.3. HE ATTITUDE OF NURSES/MIDWIVES TOWARD THE USE OF THE PARTOGRAM..... 39
5.1.4. THE DIFFICULTIES FACED BY NURSES/MIDWIVE IN USING THE PARTOGRAM . ..... 39
5.2 CONCLUSION ...................................................................................................................................... 41
5.3. RECOMMENDATIONS ...................................................................................................................... 42
5.2.1. TO THE ADMINISTRATION OF EKOUMDOUM BAPTIST HOSPITAL .............................. 42

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5.2.2. TO THE DELEGATION OF PUBLIC HEALTH YAOUNDE .................................................... 42

REFERENCES

APPENDICES

APPENDIX1:QUESTIONAIRE
……………………………………………………………………………………….........................

APPENDIX 2: AUTHORISATION LETER FROM THE DELE GATION OF THE PUBLIC HEALTH
……………………………………………………………………………………………………….

APPENDIX 3:AUTHORISATION FROM THE CHIEF MEDICAL OFFICER EBH

………………………………………………………………………………………………………...

APPENDIX 4 LAYOUT OF EKOUMDOUM BAPTIST HOSPITAL

…………………………………………………………………………………………………….……

LIST OF TABLES
TABLE 1: DISTRIBUTION OF RESPONDENT ACCORDING TO PROFESTIONAL QUALIFICATION
……………………………………………………………………………………………………………..1

TABLE 2: DISTRIBUTION OF RESPONDENT ACCORDING TO DURATION OF

WORK………………...…………………………………………………………………………………..1

TABLE 3: DISTRIBUTION OF THE RESPONDENT ACCORDING TO THEIR KNOWLEDG E

PARTOGRAM
………………………………………………………………………………..………................................2

TABLE 4: DISTRIBUTION OF RESPONDENT ACCORDING TO USE OF THE PARTOGRAM

……………………………………………………………………………………………….......…………3

TABLE 5: DISTRIBUTION OF RESPONDENT ACCORDING TO THE CONSEQUENCIES OF NOT

USING THE
PARTOGRAM……………………………………………………………………………………………..3

TABLE 6: DISTRIBUTION OF RESPONDENT ACCORDING TO WHETHER THEY ROUTINELY

USE THE
PARTOGRAM………………………………………………………………………………………………4

TABLE 7: DISTRIBUTION OF RESPONDENT ON WHEN TO ENTER INFORMATION ON THE

PARTOGRAM IN THE LABOR ROOM
…………………………………………………………………………………………………

TABLE 8: DISTRIBUTION OF RESPONDENTON HOW THEY MONITOR VITAL SIGNS DURING

LABOR …………………………………………………………………………………….6
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TABLE9: DISTRIBUTION OF RESPONDENTS ON THE IMPORTANCE ALERT AND ACTION

LINES …………………………………………………………………………………………………5

TABLE 10: DISTRIBUTION OF RESPONDENT ON HOW OFTEN THEY COMPLETE THE

PARTOGRAM WHILE IN USE
…………………………………………………………………………………………………....6

TABLE 11: DISTRIBUTION OF RESPONDENTS TO DIFFICULTIES FACED

…………………………………………………………………………………………………………..7

TABLE 12 : DISTRIBUTION OF RESPONDENTS ACCORDING TO WHETHER THEY LIKE USING

THE PARTOGRAM IN THEIR DAILY PRACTICES
……………………………………………………………………………………………………..9

TABLE 13: DISTRIBUTION OF RESPONDENTS ACCORDING ON WHETHER THE

RESPONDENTS DESIRE TRAINING ON THE PARTOGRAME
…………………………………………………………………………………..………………….8

TABLE 14: DISTRIBUTION OF RESPONDENTS ACCORDING TO THEIR NOTION ON THE

DEFINATION OF
PARTOGRAM…………………………………………………………………………………….9

LIST OF ABREVIATIONS:
BP: BLOOD PRESSURE

EBH: EKOUMDOUM BAPTIST HOSPITAL

UNICEF: UNITED NATIONS INTERNATION CHILDREN’S EMERGENCY FUND

SRN: STATE REGISTERED NURSE

WHO: WORLD HEALTH ORGANISATION

OPERATIONAL DEFINITION OF TERMS

PARTOGRAM: The partogram is a pre-printed paper or form in which labor observations are recorded.
(Lavender, Hart and smith 2009:3)

LABOUR: Labour is a series of continuous, progressive contractions of the uterus that help the service
dilate and efface (ACOG 2017)

Effective: Successful in producing a desired or intended result.

Practice: A method, Procedure, process or rule use in the particular field or profession.

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ABSTRACT

Background: The partogram is usually a pre-printed paper form on which labour observations are
recorded. The aim of the partogram is to provide a pictorial overview of labor to alert midwives and
obstetricians to deviations in maternal and fetal well-being and labor progress. It enables timely
diagnoses of abnormalities and helps in decision making .
Objectives: This study was carried out to assess the factors affecting the effective use of the
partogram by nurses and midwives and to appraise their attitudes and challenges toward the
utilization of the partogram.
Methods: A descriptive cross sectional study design was used in which partograms questionnaires were
administered to nurses and midwives working in the labour and delivery ward of EBH. The main
information extracted from the partogram included: cervical dilatation, station/descend ,Fetal heart, state of
amniotic fluids and vital signs and from the questionnaires. Responses that showed how effective the
partogram is being used in following up labour and delivery were obtained.

Results: The results showed that all respondents use the partogram though ineffectively as there are some
lapses when there are many parturient in labour . Despite the willingness of staff to effectively use the
partogram , 15 (75%) of the staff admitted that ,there is the problem of limited staff as seen in chapter
four which sometimes cause them not to fully use the partogram from labor onset till delivery.

Conclusion: They had a positive attitude toward the use of the partogram. Not withstanding, this
indispensable tool is not appropriately used in cases where fewer staff attends to many parturient in
labour . We recommend that the staffing situation should be ameliorated and supportive supervision
and regular in-service training be encouraged.
Keywords :The Partogram ,maternal/fetal mortality , labour and delivery.

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CHAPTER ONE : INTRODUCTION

INTRODUCTION

Partograms are vital tools in labour monitoring , helping healthcare providers in the identification of
potential complications and ensuring a safe birth for both mothers and their babies. Studies have shown
mixed results regarding knowledge and usage of the partogram by nurses and midwives .Hence, the need for
continuous assessment on the effective use of the partogram during labour and delivery, Case study, EBH.
This will be examined in 5 different chapters; Chapter 1, Chapter 2 Literature review, Chapter 3 Research
methodology, Chapter 4, Presentation of findings and chapter 5 discussions, conclusion and
recommendations.

THE BACKGROUND TO THE STUDY

The partogram is a pre-printed paper or form in which labor observations are recorded . The aim of
the partogram is to provide a pictorial overview of labour to alert midwives and obstetricians to
deviations in maternal and fetal wellbeing and labour progress (Lavender, Hart and Smyth, 2009:3 )

A partogram is a composite graphical record of key data (maternal and fetal) collected during labor ,entered
against time on a single sheet of paper. Relevant measurements might include statistics such a cervical
dilatation, fetal heart rate, duration of labor and vital signs (lavender et al 2008). It is intended to provide an
accurate record of the progress in labour so that any delay or deviation from normal may be detected
quickly and treated accordingly (lavender et al 2008). The first person to use a graph to follow up labour
was Friedman in 1954. Following studies in Zimbabwe to fully utilize midwives where there was a shortage
of doctors, the alert line and then the action line were then added to the original cervicograph developed by
Friedman by Phipot and Castel in 1972 .Since then, studies have shown that the partogram is a useful tool
in the management of labour especially in developing countries (Lavender et al , 2009:3 and Soni 2009).

According to Magon (2011:1), since 1990 the partogram has been revised by WHO purposely to better
monitor not only the progress of labor but the condition of the mother and the fetus during labour .

In a partogram, variables like fetal heart rate, dilatation of the cervix, contractions and pulse rate of the
mother are plotted and if there is any deviation from normal, it is an indication for prompt decisions to be
taken.

According to WHO 2015, the partogram currently used was introduced in 2000. Its implementation has
greatly improved labor outcome and the management of high risk labor cases. It increases the quality and
regulation of all the observations of labor on the fetus and the mother in labor and helps in early recognition
of problems (GENEVA 2006). Of the estimated annual tool of half a million maternal deaths, 99% occurs in
developing countries. An unknown proportion of this number follow prolonged labor due to mainly
cephalopelvic disproportion which may result in destructed labor or without rupture of the uterus .

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According to Hofme and Fawole (2000), it serves as an early warning system of arising complications
during labor as it assists with intervention decisions, reduces maternal and neonatal mortality resulting from
obstructed labor.

From a research carried out in Uganda, it shows that it is making progress in reducing maternal mortality.
Mortality ratio has declined by 47% over the past 20 years. From 600 maternal deaths per 100,000 live
births in 1990 to 438 per 100000 in 2011 (UBOS) and ICF International ,2012, WHO et al 2012.

Obstructed labor is a cause of maternal and new born morbidity and mortality in developing countries such
as Uganda .It can lead to postpartum hemorrhage, infection and fetal death, as well as obstetric fistula. The
risk of experiencing these birth - related injuries or death increases in low resource setting with limited
health services.

The partograph is a preprinted form on which labor observation are recorded .It is a low- tech, inexpensive
tool, designed to monitor labor and prevent obstructed labor .The WHO recommends partograph use (1994).
However, in many low- resource settings including Uganda, the tool is under-utilized and many health care
providers do not know how to use it properly (Levin kabagema 2012).

In Cameroon according to gynecology and obstetrics research,the use of partogram has been shown to be
important in reducing maternal and neonatal deaths. Dohbit et al in 2010, working in hospitals around
Yaoundé found out that the staff caring for women in labor had satisfactory knowledge of the partogram and
more than 83% of them desired additional training in its use.

Since the introduction of the partogram in Bamenda in 2003, little study has been carried out to assess the
extent of its use. It was also observed that the use of the partogram was frequent and sometimes
inappropriate. Thus the need to carry out this research .

STATEMENT OF THE PROBLEM

The use of WHO partogram, which has been widely listed, clearly differentiates normal labor from
abnormal progress of labor and identifies those women likely to require interventions (Kwast 1994).

Despite the WHO advocating and accommodating that the partogram be compulsorily used in monitoring
labor progress, it was still reported to be used in a limited extent in Africa or elsewhere in developing
countries especially in primary health care centers where most of the deliveries take place (Okechukwu et al
2007).

Globally, there was an estimated 287000 maternal deaths in 2010 cause by obstructed and prolonged labor
(WHO and UNICEF 2012. These deaths could be prevented by cost affective health intervention, like the
use of partogram and being alert. Doctors, nurses and midwives should be encouraged and cautioned on the
importance of partogram use during labor and delivery.

In Cameroon, according to Halle (2005), there was an estimated 669 deaths out of 100,000 women in labor
due to ineffective use of the partogram , and so the provision of quality care during child birth is believed to
make a difference between life and death (Ganesh et al 2007).

In 2011, maternal mortality ratio was estimated at 782 deaths per 100,000 live births with a 48% reduction
between 2011 and 2018 (406 deaths per 100000 live births). Thus achieving the national target of 140

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deaths per 100000 live birth in 2030 will require strong commitments and interventions from the health
sector through effective use of the partogram.

The utilization of the partogram is insignificantly related to staff strength. It is probably because of staff
shortages that some nurses consider the use of the partogram as a waste of valuable time (Sarah et al 2001)

RESEARCH QUESTION

How effective is the use of the partogram among midwives and nurses in the Ekoumdoum Baptist Hospital
Yaounde ?

RESEARCH OBJECCTIVES

a) General objective

To assess the factors affecting the effective use of the partogram in EBH.

b) Specific objective

To assess the respondents’ attitudes on the use of the partogram.

STUDY HYPOTHESIS

Nurses and midwives who are competent and willing to use the partogram may likely not use the partogrm
effectively from the onset of labor till delivery.

SCOPE OF THE STUDY

This present study is focuse on nurses and midwives working in the labour and delivery ward of
Ekoumdoum Baptist Hospital .The study was carried out from Febuary-July 2024 and was based only in
the maternity unit excluding antenatal unit ,vaccination unit, and other units not related to labour and
delivery. This study assesses the factors affecting the utilization of the partogram by nurses and midwives in
the Ekoumdoum Baptist Hospital.

SIGNIFICANCE OF THE STUDY.

This study is of great advantage to the community and parturient in reducing complications and the
emotional stress they sometimes go through during labor and delivery. It will also help the health
authorities in drawing up better policies to emphasize the use of the partogram in the
monitoring and evaluation of labor in order to improve on maternal and child health during
labor and delivery.

DEFINITION OF KEY TERMS.

Partogram: A partogram or partograph is a composite graphical record of key data (maternal and fetal )
during labour, entered against time on a single sheet of paper. ( Wikipedia 2011 )

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Labour: Labour is a series of continuous, progressive contractions of the uterus that help the cervix to
dilate and effaced (thins out) ( hopkinsmedicine org)

Knowledge : Knowledge is a complex concept with many facet that can be outline as follows, gaining
awareness and understanding of facts, ideas or situations, accumulating information through studies
,observations or experiences. Its involves justification or strong basis of Pickard 2013).believing the
information is true (AJ Pickard 2013

Practice: A method, procedure, process or rule used in a particular field profession.

CHAPTER TWO : LITERATURE REVIEW

2.1. INTRODUCTION

Effective labour monitoring is crucial for ensuring the safety and wellbeing of both mothers and newborns
during childbirth. The partogram, a graphical representation of labour progress, plays a vital role on this
process. By tracking cervical dilatation and fetal descent over time, health care providers can prevent
complications and intervene promptly if necessary. Nurses and midwives are at the forefront of labour care,
and knowledge and practice of using partograms significantly impact patient’s outcomes .This literature
review aimed to review the recent state of knowledge and practices among nurses and midwives regarding
the effective use of the partogram.

2.2. CONCEPTUAL REVIEW

A conceptual review involves examining and analyzing existing theories concepts and ideas related to a
particular topic or research. Its aim is to provide a comprehensive overview of the theoretical framework
and key concepts that underpin a specific subject matter. It also reviews scholarly printed materials, audio
visual materials and personal communications (7)

This chapter explores a number of studies that have been conducted in Africa and overseas pertaining to the
utilization of the partogram. Grove, Burns and Gray ( 2013:97), ascertain that literature review includes
both theoretical and empirical sources that document the current knowledge of the problem .The related
literature review is organized under the following headings:

1.) Literature related to the use of partograph and it effectiveness .

2.) Literature related to early identification of complications.

3.) Literature related to labor outcome .

2.2.1. FIRST CONCEPT

2.2.1.0. THE PARTOGRAM OVERVIEW.

The first obstetrician to describe the progress of labor graphically was Friedman (Friedman 1954) following
his study of cervical dilation of 100 African primidgravidae at term. The women were given frequent rectal
examination and their progress was recorded in centimeters of dilation per hour producing a slope

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resembling a sigmoid curve (“s” shape ). This became known as the cervicograph in an attempt to utilize
midwives efficiently in a hospitals and clinic services. The next stage of partogram development was the
introduction of an action line four hours to the right of the alert line (philpott1972c). This line was
developed to identify primary inefficient uterine activity to prompt appropriate management. Correction of
primary inefficient uterine activity would usually be with an intervention such as amniotomy or oxitocin or
both .A partogram is a composite of graphical record of key data (maternal and fetal) during labor entered
against time on a single sheet of paper. Relevant measurements might include statistics such as cervical
dilation, fetal heartrate, duration of labor and vital signs. It is intended to provide an accurate record of the
progress in labor so that any delay or deviation from normal might be detected and treated according to
(Lavender et al, 2008).

The partogram is a graphical representation of the progress of labor .It enables clinicians (midwives and
Doctors )to plot cervical dilation ,frequency , intensity and duration of uterine contractions maternal
conditions ( pulse rate blood pressure ,and temperature ) fetal condition (fetal heart rate and rate of amniotic
fluid ),descent of the fetal head and other features that aid the progress of labor ( Friedman E. the graphical
analysis of labor )

COMPONENTS OF THE PARTOGRAM.

 Patient identification: Patient’s name, Gravida para, patient’s ID number ,date of admission,
ruptured membranes(16)
 Time :Its recorded in an interval of one hour . Zero time for a spontaneous labour is the of
admission in the labour ward and for induced labour is time minutes.
 State of the membranes and liguor:’ I’ designates intact membranes ‘ c’ designates of
induction.
 Fetal heart rate :It is recorded in an interval of thirty
 clear , ‘M ’ designates meconuim stained ligour and ‘B’ designates blood stained.
 Cervical dilatation and descend of the head.
 Uterine contractions: Squares in vertical columns are shade according to duration and
intensity.
 Drugs and fluids
 Blood Pressureis :Itisrecorded in vertical lines at an interval of 2 hours.
 Pulse rate: It is also recorded in vertical lines at an interval of 30 minutes .
 Oxytocin :Concentration is noted down in upper box,while dose is noted in lower box.
 Urine analysis
 Temperature record.
Use of partogram in established labour is recommended by the National Institute for Clinical
Excellence (NICE)in the ‘intrapartum care ‘ quite lines(10)

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2.2.1.1. LITERATURE RELATED TO EARLY IDENTIFICATION OF

COMPLICATIONS IN LABOUR

Safe Childbirth is paramount in obstetric and early identification of complications during labour is crucial
for timely interventions and improved maternal and fetal outcome. This review explores the exiting
literature on methods of early detection of complications in labour.

Intrapartum monitoring techniques . Fetal monitoring is the cornerstone of intrapatum. Electronic fetal
monitoring allows continuous assessment of fetal heart rate (FHR) patterns . Abnormal FHR patterns such as
decoration or variability outside expected ranges ,can indicates fetal distress and necessitate intervention
(ACOG 2020).

Ultrasound imaging during labour plays an essential role in assessing fetal position, amniotic fluid volume
,and placenta position.These factors can significantly influence labour progress and flag potential
complications like malpresentation or placenta abruption(Gribbinet al,2023).

Clinical assessment remains vital.Vagina bleeding and labour progress allow health care providers to
identify early signs of complications such as uterine rupture post-partum haemorrhageor obstructed
labour(ACOG 2014)

Despite advancements , challenges persist. EFM can have false positive and negative requiring skilled
interpretation (ACOG , 2020) .Resource limitations may restrict the availability of advanced monitoring or
highly trained personnel . Additionally , communication breakdown between health providers can delay
intervention(Gribbin et al,2023)

Purandre ,Singh et al (2013) conducted a study to investigate the possible benefits in terms of obstetric and
neonatal outcome of a prolonged augmentation with oxitocin in majority of patients(65.5%) of nulliparas
and 83.8% of multiparas responded with satisfactory progress within the first four hours of augmentation
and caesarian section rate was low in this group .In this group, (1.3%)in those with unsatisfactory progress
during the first four hours of augmentation a further 4hours period of augmentation resulted in vaginal
delivery for 50.7% of nulliparas with primary dysfunctional labor and 33.3% of those with secondary arrest
in labor corresponding to figures for multiparas were 41.7% and 25.0% respectively . The neonatal outcome
was good .It was concluded that the management protocol presented for augmentation seem to be a safe
procedure and might reduce the rising caesarian rate for dystocia .

Biswajit Paul et al (2011) conducted a study in Orisha tertiary health care center to investigate causes and
contributing factors for maternal death occurring during natural process of childbirth and most of them
were preventable .All maternal death occurring in the year in the study hospital were traced and interviews
were taken from relatives and health care providers who were present at the time of death of the woman.Out
of total maternal death, 72% of them were between the ages of 20 and 30 .Also, 46.5% were illiterate and
majority deaths (60.5%) of low socio- economic status .Direct causes of death were (76.5%) of the total
death hypertensive disorders most common (32.6%), malaria ( 9.3%) and the most common indirect causes
was anemia ,that is ,( 7%) .Delays at different levels was a contributing factor for maternal death .The study
is an eye opener for community and health facilities to take appropriate measures to prevent maternal death
in the community.

To conclude, Early identifications of complications in labour requires a multi-faceted approach. Prenatal risk
stratification ,meticulous intrapartum monitoring with EPM ,ultrasound and clinical assessment are key. The
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field continuous to evolve, with potential for emerging technology like biophysical makers to improve
detection. However addressing challenges like false positive rates and communication gabs is essential for
optimal maternal and fetal outcomes.

2.2.2. SECOND CONCEPT

2.2.2.1. LABOUR OVERVIEW

Labor is a physiologic progress during which the fetus membranes ,umbilical cord and placenta are
expelled from the uterus ( Sara , 2016), labor occurs in three stages but physiologically a fourth stage also
occur.

2.2.2.2. THE FIRST STAGE OF LABOUR

During the first stage of labor , the cervix dilate (opens)from (0_10cm) .This stage is sub divided in to sub
phases namely , the latent and active phase It is also characterized by rhythmic uterine contraction of the
descent of the presenting part down the birth canal During the latent phase , progress of labor is very
slow(cervical dilation from (0_3cm) .The active phase of labor is fast( from 4cm dilation) ,from (0_8cm)
,the transitional phase (cervical dilatation from 8_10cm.(encyclopedia of medicine 2008).

This is the period from full cervical dilatation to the birth of the baby. This stage can last anywhere between
a few minutes (15_30minutes) to a couple of hours but if the parturient had a baby before it is likely to take
less time(Bounty 2016)

2.2.2.3. SECOND STAGE OF LABOUR

This the period from full cervical dilatation to the birth of the baby .This stage can last minutes between a
few minutes anywhere (15-30) to a couple of hours but if the parturient had a baby before its likely to take
less time(Bounty2016)

2.2.2.4.THE THIRD STAGE OF LABOUR

This is characterized by the separation and the delivery of the placenta, membranes and the control of
bleeding .It start from the delivery of the baby ( 30minutes).

THE FORTH STAGE OF LABOUR

It is the stage from the delivery of the placenta until the uterus returns on its own. Here ,the uterus make its
initial readjustments to the non pregnant (AGOG, 2003).

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2.2.3. CONCEPTUAL FRAMEWORK

Nurses and Midwives

Knowledge on the use of the Lack of or limited knowledge on the

partogram during labor partogram in the delivery of care during
labor

Adequate extrinsic and intrinsic Lack of intrinsic and extrinsic motivation

motivation for the use of the partogram for the use of the partogram

Proper use of the partogram in the Improper or non-usage of the partogram in

delivery of care during labour the delivery of care during labor

Early identification and prevention of Late identification of adverse outcomes and

adverse outcomes (complications) improper management

Positive outcomes delivery Negative outcomes of delivery

Low maternal and infant mortality and High maternal and infant mortality and
morbidity morbidity

Happy family Job satisfaction Unhappy family Job

to the nurses dissatisfaction to
and midwives the nurses and
midwives

Source: Made by MIH MILDRED NAIN.

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2.3. THEORETICAL REVIEW / CONCEPTUAL MODEL

The conceptual model used in the study is Virginia Handerson’s theory of need .According to her,
the unique function of the nurse is to “ assist the individual , well or sick , in the performance of
those activities contributory to health or its recovery or to a peaceful death that he would perform
unaided if he had the necessary strength , will or knowledge and do so in such a way as to help
him gain independence as rapidly as possible “(Virginia Handerson 1963). According to her , an
individual has 14 fundamental basic needs . Out of these 14, one will be selected which is “The need
to work in such a way that there is a sense of accomplishment”.

According to Dujardin et al (2008) , the lack of support and motivation are profound problems in the
delivery of care and also in the adoption and utilization of the partogram. When there is no
motivation , nurses and midwives will not work in such a way that there is a sense of
accomplishment .Instead ,there will be job dissatisfaction and thus , poor outcomes.

For these functions to be effective, there has to be adequate knowledge on the partogram use and
proper motivation in order to effectively monitor the parturient and intervene promptly to manage any
adverse outcome , thus reducing maternal and infant morbidity and mortality and enhancing a happy
family and job satisfaction.

2.4. EMPERICAL REVIEW

2.4.1. LITERATURE RELATED TO LABOR OUTCOME.

Marcee et al (2012) conducted a qualitative study. Interview schedule was on the use of partograph to
manage child birth in selected health centers. The twenty midwives were interviewed on labor management
and decision making in health centers .A midwife who used the partograph for labor assessment had
confidence in making decision. The partograph used had a powerful impact on labor outcome.

Yasmin H et al( 2008) reviewed a retrospective study of 105women with a known history of infertility, of
these 105 women , 77 (73%)conceived spontaneously and 28(27%) had assisted conception .The findings
confirmed higher perinatal complications. Relative ratio ( RR) for pre-eclampsia was 4.6(95%,C1=2.1-9.9)
,intrauterine growth restriction 4.8(95%) C1=1.9__12.0) , gestational diabetes 1.8(95%C1=0.5_5.8) ,
,preterm premature rupture of membrane 2.3(95%C&=1.6_8.8 ) and with history of infertility are at high
risk of such obstetric complications may benefit from intensified antenatal care .

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2.4.2. LITERATURE RELATED TO THE USE OF THE PARTOGRAM AND ITS EFFECTIVENESS.

Azandegba, N and Jesta, et al (2007) conducted a study on safe motherhood program lauched in Benin One
of the method to decrease maternal mortality and morbidity was partogram. They conducted a survey in
maternity facilities in urban and rural Benin to assess the utilization rate. Result completion stopped before
delivery overall completion was not good : of 984 partogram examined , administration data were
completed only in 20%, medical delivery data on 50% Action taken before the alert line was crossed in
13.5% of cases, correct action always followed, artificial rupture of membrane, Oxytocin administration.
The patient’s transfer rate was13% and the caesarian rate 5.2%.This result thus shows very high coverage
of partogram use but inadequate quality and training for maternity staff about the partogram used.

Mlandenovia D.et al (2006) conducted a study on the role of partogram in the modern conduction of labor
.The authors presented on the original partogram showing the course of labor. The partogram consist of
three parts. Its first part contains columns for general data, the position of fetus, the results of amnioscopy
and pre-partial cardiotocography with the oxytocin test .The other contains the data on the progressed
dilatation of the cervix, the condition of bag of waters , quality of amniotic fluid ,uterine contractions and
the interpretation of cardiocography in the course of labor .The third part contains diagrams of deliveries
and the new born vital symptoms Six partogram of women with different characteristics and different
pathologic conditions are prevented .The authors underlined the simple way of composing and using the
partogram as well as the benefits from it, especially when several deliveries are conducted at the same time .

With regards to the knowledge of different components of the partogram, Yisma et al( 2013:4) in a cross
sectional quantitative study to assess knowledge and utilization of partogram among obstetric care givers in
public health institutions of Addis Ababa ,affirms that knowledge of the functions of both alert line and
action line were poor.

A Cochrane Review found that the use of partograms may make little or no difference to the length of
labour or the number of women who receive oxytocin to speed up labour. However, the quality of evidence
is low.

A realist review of the partogram :When and how does it work for labour monitoring ?

This review suggests that the partograph’s effectiveness depends on several factors ,including health care
providers training , partograph design , and compliance with partogragh guidelines .

Feasibility and effectiveness of electronic Vs Paper partograph on improving birth outcomes : A study
found that both paper and electronic partographs were effective in documenting labour progress. However,

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the electronic partograph group had a higher rate of deliveries occurring within a normal range and a lower
rate of interventions.

2.4.2.1. ADVANTAGES OF USING A PARTOGRAM DURING

LABOUR AND DELIVERY

1. It serves as a warning tool. The partogram serves as a warning system of arising complications
during labor as it assist with intervention , decisions and the ongoing evaluation of the effects of the
implemented intervention ( Fawole et al ,2008)

Furthermore, the partogram have been widely accepted as one of the measures that assist in reducing
maternal and neonatal mortality resulted from obstructed labor (Hofme 2004).

The focus in using the partogram in developing countries including south Africa as stated by Windrim et al
(2007)is on the prevention of maternal and fetal morbidity related to prolong labor .

2. Early Identification of prolong labor. Prolong labor is a leading cause of death among mothers and
new born in developing world .it is mostly if the woman’s uterus does not contract sufficiently (Fawole,
2008)

If her labor does not progress normally, the woman may experience serious complication such as obstructed
labor , dehydration ,exhaustion or rupture of the uterus. Prolong labor might also contribute to maternal
infection or hemorrhage and to neonatal infection (Adesegun et al (2007).

3. Increase the delivery of quality care according to ( Fawole et al ,2010) appropriate usage of
partogram can be highly effective in reducing complications from prolong labor for the mother / postpartum
hemorrhage, sepsis, uterine rupture and its seguelae

2.4.2.2. CONDITIONS NECESSARY FOR THE PROPER USE OF THE

PARTOGRAM

 Use one partogram for each parturient

 Start recording one of the partogram when the labor is in active stage (cervical dilatation of
5cm and above ).
 Recording should be clearly visible so that anybody who knows about the partogram can read.
 Understand and interpret the marks you have made.

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2.4.2.3. FACTORS HINDERING THE UTILIZATION OF PARTOGRAM

Despite the WHO advocating and recommending that the partogram be compulsorily used in monitoring
labor progress, it is still reported to be used in a limited extend in Africa or elsewhere in developing
countries (Maimbowa et al, Windrim et al 2007) especially in primary health care where most of the
deliveries take place. These include.

a. Shortage of staff and increase workload, the utilization of the partogram is insignificantly
related to staff strength. It’s probably because of staff shortage that some nurses consider the use of
the partogram as a waste of viable time (Sarah et al 2001 and T W Bedwell 2017

b. Inadequate knowledge; A notable fact in developing countries is that knowledge on the use
of partogram for labor is very low among nurses, midwives and doctors working in the primary level
care (D Fernandes 2015)

c. Non- availability of the partogram ,The lack of availability of the partogram in the maternity
reflects a lack of commitment to its use and its effect , a lack of commitment to reduce maternal
mortality (Oladapo et al 2006)

d. Time consuming, some nurses, midwives or doctors consider the filling of the partogram or
completing the partogram as an additional time consuming task and as such has no understanding on
how it can serve a woman’s life (Mac Artur et al 2002). Late admission in labor, an important factor
reported as limiting partogram use.

2.4.2.4. FACTORS PROMOTING THE UTILIZATION OF THE

PARTOGRAM

Following the recommendation of the WHO the maternal and neonatal health program promotes the use
of the partogram to effective management of labor and to support decision making regarding interventions.

- Proper training of health workers on partogram use.

-Provision of guidelines for use and adequate resources like motivation, appropriate midwives/nurses and
availability of te partogram.

- Shaping the social network and developing leadership, assessment and accountability for clinical quality
improvement could support the application of learning.

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THE KEY OBJECTIVES OF THIS STUDY ARE

1)Evaluating knowledge and skills : Assess the level of the knowledge that nurses and midwives possess
regarding the proper use of the partogram for labour monitoring .This Include understanding how to
interpret the partograph’s various elements(alert lines ,fetal descent, cervical dilatation)and how to use it to
identify potential complications .

2) Analyzing practice patterns; Investigate how nurses and midwives actually utilize the partogram in their
practice. This may be done by observing their charting habits, documentation methods ,and decision making
processing during labour.

3) Identify Knowledge Gaps And Barriers: Explore areas where nurses and midwives might have
knowledge deficiencies or limitations in using the partogram effectively. This can help identify areas for
educational interventions .

4) Improve maternal and neonatal outcome: Ultimately if effective partograph use by nurses and translates
to better outcomes for mother and newborns. This could include reductions in maternal mortality, prolonged
labour, an instrumental deliveries .

a) The Research Design is a descriptive cross -sectional study

b) From Questionnaires issued to nurses and midwives
c) Data analysis method used was, Content analysis for qualitative data with open ended
questions .An ethical approval and data confidentiality from CBC irbh
d) Measurement of varables use was Self reported practices
e) Findings from this research were as follow

 Knowledge:
Genlerally ,good understanding of basic partogram components study often she nurses and
midwives have a descent grasp of the partograms layout and key elements(alert lines ,cervical
dilatation curve )
 Gaps in knowledge about interpretation and use:
Studies may identify knowledge gaps in interpreting partograms to identify complications like
prolonged labour fetal distress. Additionally, understanding of how partogram findings should
guide clinical decision making might be lacking.
 Attitudes:
Positive attitude toward partogram Many nurses and midwives recognize the value of the
programs in monitoring labour progress and improving communication.

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Concerns about time constraints: Some studies reports concerns about the it takes to complete
partogram accurately especially during busy deliveries.
 Practices:
Inconsistent completion rate; Studies often find a range in partogram completion rates across
facilities or regions. while some demonstrate high completion rate others show significant
numbers of deliveries with incomplete partograms.

Overall findings; These findings suggest that while nurses and midwives understand the importance of
programs, knowledge gaps and practical challenges can hinder their effective use.

THE LIMITATIONS OF THE STUDY

Sample size and representativeness; A sample size of 20 doesn’t reflect the diversity of the population ( only
nurses from one hospital ) might not provide results that can be generalize

Self Reported knowledge ; Participant may not accurately report their knowledge on a questionnaire . They
might over estimate their abilities or under report gaps in knowledge .

2.5. GAPS AND CONTRIBUTIONS

Current assessment of nurses and midwives regarding the qualitative and quantitative use of partograph
might be lacking as outlined below.

 Limited geographical scope: many studies focus on specific regions or countries making difficult
to generalize findings globally .i am convinced that my study which is done in the center region of
cameroon will increase this geographical scope.
 Knowledge gaps; Beyond basics: traditional assessment often focuses on theoretical
knowledge of partograph component and plotting . They may not delve into the nuances of
interpretation, in identifying concerning patterns or using the partograph for timely
intervention.This study which assesses both the knowledge and the practices of nurses and
midwives on the effective use of the partograph will certainly go a long way to bridge this gap.
 Clinical decision-making: Current assessment might not evaluate how nurses and midwives
use partogram information to make informed clinical decisions. These include recognizing
deviations from normal labour, identifying potential complications, and initiating appropriate
actions.
The findings from this study will be of great importance in this direction as they will give
orientations concerning the training programs .
 Practice gaps: Assessment might not capture the actual completion and documentation
practices. Are partogram charts filled out accurately and consistently? .Does documentation
reflect clear decision making based on partogram findings?.
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My study will contribute towards the identification of areas for improvement , exploring attitudes and
uncovering potential barriers. The study can guide targeted interventions like traning programs or workflow
adjustment to address those barriers.

 Standardization of practice assessment: Lack of standardized methods to measure nurses’

and midwives ‘ actual use of partograms in clinical settings .
This study will help in addressing these gaps and leveraging the contributions of such
assessments. We can create training programs , develop support tools , and improve resources
allocation ,leading to a more effective and sustainable use of partograms by nurses and
midwives. Ultimately, this translates to improved maternal and neonatal health outcomes .

Promoting evidence based practice .A more accurate assessment can lead to improve data on the
effectiveness of partogram training and implementation strategies ultimately, contributing to a better
maternal and newborn out comes.

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CHAPTER THREE : RESEARCH METHODOLOGY

3.0. INTRODUCTION

This chapter delve in the core of our study: evaluating the knowledge and practices of nurse and midwives
regarding effective use of the partogram . The partogram is a crucial tool in labour monitoring allowing
Healthcare providers to identify potential complications and ensure safe deliveries for mother and
newborns. We will be examining, the study design, study area, data collection and analysis tools just to
name a few.

3.1. RESEARCH DESIGN.

A descriptive cross-sectional study design was used because it offers a valuable means of capturing a
comprehensive snapshot of the challenges encountered by nurses and midwives in real life.

This was done by assessing their knowledge and practiceson the effective use of the partogram in delivery of
care to the parturient.

3.2 STUDY AREA

Ekoumdoum Baptist Hospital is one of the referral hospital in the Central region of cameroon in which this
study was carried out. It serve as a referral hospital for the district hospital and Polyclinics of the central
region especially Yaounde 4. Its situated in Ekoumdoum , with Pinancle primary and secondary
international school being North of the hospital, Petou bilingual primary and secondary school East and
Carrefour de l’amitie northwest of the hospital. Patients from other health units with complications like
returned placenta, labor dystocia, postpartum hemorrhage and prolonged labor just to name a few, are sent
for better management.

The EBH was opened on the 6/11/2006 with Mr Sam Pius as the chief of center, till 2020 where they were
authorized to function as a hospital, then as a referral hospital 2021 under the leadership of Miss Tangwa
Faith who later handed over to Mr. Ntef Jonathan who is the present administrator .It is headed by the
Director of CBC health services. The hospital offers specialized services like ophthalmologist ,dentistry
,obstetrics and gynecologist ,internist, Pediatrician services and cardiologist’s consultation. There’s male
,female, children’s medical wards with an average monthly admission of 1000 patients and approximately
8000 from out consultation and approximately 1185clients admitted in the maternity department monthly.

Maternity ward being my specific area of concern, is made up of :

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 13 postpartum beds,
 2 private wards
 A labour ward with 7 beds
 Expanded Program for immunization
 ANC area with two palpation beds. ( Their ANC area is still under construction)
 A nursing station,
 OB Gyneacological consultation rooms with 3 Gyneacologist.
 Post partum unit

3.2. STUDY DESIGN

A descriptive cross sectional design was used in which data was collected from nurses and midwives
working in the labor and delivery ward of Ekoumdoum Baptist hospital .This was done by assessing their
knowledge and practices on the effective use of partogram in the delivery of care to the parturient. This is
efficient for gathering data at a single point in time making it feasible for busy healthcare settings.

3.3 THE STUDY POPULATION

The study population was nurses and midwives working in the labor and delivery ward of Ekoumdoum
Baptist hospital

3. 4 . SAMPLE AND SAMPLING TECHNIQUES PROCEDURE

A sample size of 20 nurses and midwives working in the labor and delivery ward of the Ekoumdoum Baptist
hospital was used

A convenient sampling method was used due to the fact that the study population was small. So every nurse
/midwife working in the labor /delivery ward of Ekoumdoum was administered a structural questionnaire
to obtain participant for the research.

3.5. INSTRUMENTS

Data was collected using a structural questionnaire designed in English Language by the investigator, with
both open and close ended questions. The questionnaire was arranged in four sections, that is:

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a) Socio-demographic data,
b) Respondent knowledge on the partogram,
c) Respondent’s difficulties face in the use of the partogram,
d) Respondent attitude toward the use of the partogram .

3.5.1. INSTRUMENTS FOR DATA COLLECTION AND VALIDATION

A well structured questionnaires consisting of open and closed ended questions were administered to nurses
and midwives met on duty and those who were busy chose to answer the questionnaire the next day
.Proper explanation was given to participant who had difficulties filling the questionnaire ,and each was
reassured that his or her information will be kept purposely for the project and no third party will be
allowed to see or use it. This questionnaires were pretested on 18nurses and midwives of Etougebe Baptist
Hospital to make sure that the questionnaire meet the stated objectives. These questionnaires were reviewed
with the help of my supervisor for better structuring before the final data collection.

3.5.2 .INSTRUMENTS DATA ANALYSIS

The returned questionnaires were visually checked for completeness, coded and entered into a SPSS version
25. Results were displayed on tables, pie charts and figures for better understanding.

3.5.3. MEASUREMENTS OF STUDY VARIABLES

The measurements of variable was self- reported practices.

3.6. DATA COLLECTION PROCEDURE

Questionaires were given to respondents and the purpose of the study explained to them. Some
questionnaires submitted were completed at the spot while other respondents who were busy, an
appointment for the collection+ of the questionnaires was made .

3.7. DATA ANALYSIS PROCEDURE

Data collected was coded using SPSS version 25. After coding the responses were carefully entered in to the
application and cross checked severally by a senior colleague to avoid errors. The data was analysed using
the same application and presented in tables , pie charts and figures .

The results of the study will be presented before the jury for scrutiny and corrections, after which the
corrected copies will be send to the CBC IRB , AMERICAN DITEK INSTITUTE UNIVERSITY ,
BUEA.

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3.8. ETHICAL CONSIDERATIONS

An administrative authorization and an ethical clearance was obtained from the REGIONAL
DELEGATION FOR PUBLIC HEALTH Yaounde with the help of a letter of application for authorization
from school and permission obtained from the CBC institutional research board after careful assessment of
the research proposal. In the course of collection of data, the significance of the study was explained to each
respondent and were assured that the information gotten from the questionnaires will be handled with strict
confidentiality .

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CHAPTER FOUR : PRESENTATION AND ANALYSIS OF THE RESULT

This chapter consists of the presentation of collected data in the form of tables , pie charts and analysis of
the data in each table or figures is as follows.

 Socio-demographic data,
 Respondents’ knowledge on the partogram,
 Respondents’ attitude on the use of the partogram,
 Difficulties faced by the respondents in using the partogram

4.1. PRESENTATION OF FINDINGS

SOCIO-DEMOGRAPHIC DATA

4.1.1. RESPONSES ACCORDING TO PROFESSIONAL QUALIFICATION

Figure 1.Distribution of respondents according to professional qualification.

50%
10

25%
5

15%
3

10%
2

Midwives SRN Degree Assistant

Nurses

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30

From the above table, the lowest qualification (Assistant Nurses) out of 20 respondents was 2(10%) while
the highest qualification (Midwives ) was 10 (50%) .

4.1.2 Responses of respondents according to Longevity in service.

Figure 2. Distribution of respondents according to longevity in service

35%
7
30%
6
20%
4 15%
3

3-9 Months 11 years and

1-2 years 3-10 years
above

From the above table, the highest duration of work is 7(35%) which falls within the range 3_10 years and
the lowest duration of work is 3(15%) which falls within 11 years of work and above.

4.1.3 .Respondents knowledge on the partogram

Figure 3. Distribution of respondents according to their knowledge and utilization of the partogram

KEY

KEY NO

YES
18
YES 2

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31

From the table above, 18(90%) of workers who responded to the questionnaires said they knew how to use
the partogram, and 2(10%) said they have difficulties using it as they were trained only in school .

4.1.4 Respondents notion on the definition of the partogram.

Figure 4. Distribution of respondents according to the definition of the partogram

70% KEY
14
A tool used to monitor
cervical dilatation.

A format put in place by

WHO follow the progress of labour in
2 4 women from active phase to delivery.

A graph used to
monitor the progress of labour

10% 20%

From the above table, it has been seen that 14 (70%) of the respondents said it is a graph used to monitor
the progress of labor while 2 (10%) said it is a format put in place by the WHO to follow the progress of
labour in women from active phase to delivery .

4.1.5 Factors affecting the use of the partogram .

Figure 5: Distribution of respondents according to where trained

20%
KEY 4
50%
55 School
10
6
Seminars

30% In-service training

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From the pie chart above, it is observed that out of 20 respondents, 10 (50 %) were trained in school,
6 (30%) were trained in seminars and 4 (20%) underwent in-service training .This indicates that
after school little is done to reinforce the use of the partogram and so new skills are not introduced
making it difficult for some to fill it with confidence .Some respondents admitted they need in-service
training on the partogram.

4.1.6 Respondents responses according to the use of the partogram

Figure 6. Distribution of respondents according to the importance of the partogram

Key

Helps to detect
2(10%) abnormal labour
4(20%)
Monitors maternal and
5(25%) fetal status
9(45%)
Follow up of women in
labour

No response

From the table above, out of 20 respondents 9 (45%) have highest response on the importance of partogram
while 2(10%) had no response.

4.1.7. Responses on the consequences of not using the partogram.

Table 1. Distribution of respondents according to the consequences of not using the partogram

Responses Frequencies Percentage

(%)

Can help in decision making 4 20

Cannot determine whether labor is progressing well or 16 80

when to take action

Total 20 100

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From the table above, It shows that 4(20%) of the respondents did not know when to take an action when
labour is not progressing well . 16(80%) acknowledged they know when an action is suppose to be taken in
labour.

4.2.1. Respondents attitudes on the use of the partogram.

Figure 7. Distribution of respondents according to whether they routinely use the partogram.

KEY
18
Yes

No 2

from the table above 18(90%) of the workers attending to women in labour said the partogram was
necessary in the follow up of women in labour and so they routinely use it while 2(10%) of the nurses and
midwives did not see the partogram as useful and so didn’t use it regularly .They thought the partogram was
too cumbersome and time consuming.

4.2.2. Responses on when to enter information on the partogram in the labor room.

Figure 8. Distribution of respondents according to when to enter information on the partogram in the labor
room.
KEY

Open partogram when dilation is 5cm

20

100%

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34

From the above figure, all respondents 20 (100%) know when to open the partogram when monitoring a
woman in labour

4.2.3. Responses on how often parameters are monitored during labour

Figure 9.Distribution of respondents according to how often they monitor the following parameters.

90%

18

10%

Vaginal examination Vaginal examination

every 4hours every 2 hours

From the above figure majority 18( 90 %) of the respondents do vaginal examination every 4 hours
while 2 ( 10 % ) of the respondents do vaginal examinations every 2 hours.

Figure 10.Maternal vital sign

70 %
14

30 %
6

Maternal vital signs Maternal vital

every 2 hours signs every 4
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From the figure above figure 14( 70 % ) which is the majority indicated that maternal vital signs ( BP )
is supposed to be monitored every 4 hours and 6 ( 30 %) said that it is supposed to be monitored
every 2 hours.

Figure 11 Respondents responses on how long abdominal contractions are to be monitored.

90%

18

5% 5%

Over 10 minutes Over 30 minutes Over 20 minutes

From the above figure 18 (90%) admitted that abdominal contractions be monitored over 10 minutes
while 1 ( 5% ) said abdominal contractions be monitored over 20 minutes and 1(5 % ) said it should be
monitored over 30 minutes.

4.2.5 Respondent’s responses on how often they complete the partogram while in use.

Figure 11. Distribution of responses according to how often partograms are completely filled during labor
and delivery.

20% KEY

YES 4

NO
1
80%
6
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From the above table 16, (80%) have the highest positive responses showing that they filled the partogram
completely during labor and delivery while 4(20%) have the lowest negative responses .

4.3. Respondent’s difficulties face when using the partogram

Figure 12. Distribution of respondent according to difficulties faced when using the partogram.
KEY
YES
25%
5
NO
15
75%

From the above table ,the highest 15(75%) faced difficulties in using the partogram while 5(25%) do not
face

difficulties in using the partogram .

4.3.1 Responses on difficulties faced

Figure 13. Distribution of respondents according to difficulties faced

9 45% 45%

10%
2

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Time constraints Lack of knowledge Limited staff

From the table above 9(45 %) had difficulties in documentation due to time constrain , 9(45%) have
difficulty due to limited staff, and 2 (10%) due to lack of knowledge .This shows that the number of nurses
and midwives attending to parturient in the labour and delivery room are few and this sometimes cause
them not to effectively fill the partogram despite the knowledge on its use.

4.3.2 Responses on whether the respondents like using the partogram in their daily practices.

Figure 14.Distribution of respondents according to whether the respondents like using the partogram

In their daily practice

KEY
100%

YES

20

From the above table, it shows that all the respondent like using the partogram in their daily practice.

4.3.3 Responses on whether the respondents desire training on the use of the partogram.

Figure 15.Distribution of respondents according to whether the respondent desire training on the use of the
partogram .

100% KEY

YES
20

From the above table , it has been seen that all respondents desire training on the use of partogram.

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CHAPTER FIVE DISCUSSION, CONCLUSION AND RECOMMENDATIONS

5.1. DICUTION OF RESULTS ACCORDING TO OBJECTIVES

This chapter is discussed following the analyses in chapter four.

5.1.1. SOCIO _ DEMOGRAPHY

This study revealed that the majority of respondent 10(50%) were midwives and 2(10%) was assistant. It
shows that they were more qualified health personnel to monitor the parturient hence quality care. Again
7(35%) respondents have worked for 11years, which implies that most of the respondent’s have work in the
labor ward especially in the use of partogram (reference lavender et al 2008).

5.1.2. KNOWLEDGE ON THE PARTOGRAM

It was observed that all respondent 20(100%) knew of the partogram and uses it very well in order to
prevent birth complication. This is justified on table 4 of chapter four above where 14 (70%) of the
respondent admitted that the graph is used to monitor mother and child in the active stage of labor. This is in
accordance with the research carried out in Uganda which shows that maternal and fetal morbidity has
greatly reduce by 47% over the years (UBOS) and ICF international 2012 WHO et al 2012

Mean while 10% defines the partogram as a format put in place by WHO to be use as from active phase to
delivery .Concerning the importance of the partogram , all the respondent employed in the study, 20 (100%)
admitted that it is useful as seen in table 7 of chapter 4 and table 5 indicates 9 (45%) the majority admitted
the partogram is important and help to detect abnormal labor and increases the quality and regularity of all
observations on the fetus and the mother in labor and aids early recognition of complications .This is in
confirmation with (Fawole et al 2008), which states that ,it serves as a warning sign of arising complications
during labor and delivery and aids in early intervention.

Responses on how frequent parameter should be monitored during labor, majority 18 (90%) said vagina
examination should be monitored every 2 hours and 2(10%) were for 4hourly monitoring .

Again on maternal/fetal vital signs especially blood pressure, pulse 14(70%) indicated 4hourly while 6(
30%) admitted it should be monitored every 2hours .

As concerns abdominal contraction, majority which was 18(90%) said it should be monitored over 10
minutes, while 2 respondent, 10 percent said otherwise.
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From this analysis, it shows that, they have a fair knowledge to how the above parameter should be
monitored during labor as evidence by WHO 1994 which stipulated that fetal heart beat should be monitored
every 30minutes, temperature every 2hours ,BP, after every 4 hours, maternal pulse every 30minutes
vagina examination, after every 4 hours and urine output each time urine is passing out and abdominal
contraction every 30minutes over 10 minutes .

Concerning where the respondents were trained to use the partogram , all participant 20(100%) said they
have been trained on the use of the partorgam .This in line with WHO 2003 which stated that a partogram is
considered as a valuable tool in the improvement of maternity care that allows trained health personnel to
record intrapartum details gradually such that problems of labor are identified early for prompt intervention
.Although all have been trained , a majority of the respondents were trained in school 10(50%), 6(30%) in
service, and 4(20%) in seminars. This shows that refreshal courses or seminars are very necessary so as to
upgrade their competence.

5.1.3. HE ATTITUDE OF NURSES/MIDWIVES TOWARD THE USE OF THE PARTOGRAM

As to when a partogram is to be initiated in labor ,all the respondents 20(100%) employed in the study
admitted that it is initiated at the onset of the active phase of labor (4cm cervical dilatation) at the first stage
of labor , as stipulated by Yisma et al 2013.

Despite the initiation of the partogram at 5cm dilatation of the cervix , 6(30%)of the respondents stopped
this monitoring as labor progresses ,14(70%)of the respondents followed it till delivery. This is in
accordance with a study conducted in Benin by Azandegba , N and Jester et al (2007). They affirms this
with a survey in maternity facilities in urban and rural Benin to where the utilization rate of the partogram
was assessed and found out that the partogram utilization was not the best as many were not followed till
delivery

5.1.4. THE DIFFICULTIES FACED BY NURSES/MIDWIVE IN USING THE PARTOGRAM .

Regarding the difficulties faced by respondents in using the partogram a great percentage 15( 75%)
admitted they faced chalenges in documenting on the partogram effectively time constrain ,whereas
5(25%)had no difficulty in documenting .Again 7(35%)admitted that there is limited staff as seen in
chapter4 .This in conformity of( Sarah et al 2001) who stated that it is because of staff shortage that some
nurses consider the use of the partogram as a waste of variable time.

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concerning time constrain, Mac Authur et al 2002 said some nurses, midwives and doctors consider the
filling of the partogram or completing the partogram as an additional time consuming task and as such have
no understanding of how it can save a woman’s life.

Also 6(30%)of the respondent admitted lack of knowledge on the use of the partogram. This is in
confirmity with (Gynacol,1999)who stated the knowledge on the use of partogram is very low among nurses
midwives and doctors .working in the primary and secondary health care centers when compared with the
tertiary level care .

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5.2 CONCLUSION

After a careful collection, analysis, interpretation,and discussion of data, the following conclusions were
made.

From the above it was observed that, although mastery of the use of the partogram is primordial, this alone
does not guarantee its qualitative use because other factors come into play .These include limited staff, time
constraints and late admission of paturients in labor. Also from the responses gotten from the majority of the
respondents willing to be retrain or allow to attain serminars or inservice trainings on the use of the
partogram shows little is done to retrain nurses and midwives to upgrade their competence after leaving
school.

Secondly, although most participants in this study demonstrated competence and good attitudes toward the
utilization of the partogram, they couldn’t use it effectively from labor onset till delivery due to the above
mentioned challenges.

This confirms the hypothesis which stated that nurses and midwives who are competent and willing to use
the partogram may likely not use the partogram effectively from labor onset till delivery.

Despite all these, the use of the partogram have improved in the labor ward of EBH, hence reducing the
rate of birth complications.

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5.3. RECOMMENDATIONS

The following recommendations were made.

5.2.1. TO THE ADMINISTRATION OF EKOUMDOUM BAPTIST HOSPITAL

a) Should employ more nurses /midwives in order to reduce the problem of limited staff and time
constraint.
b) More and well organized serminars on the new update on the proper use of the partogram

5.2.2. TO THE DELEGATION OF PUBLIC HEALTH YAOUNDE

 They should organize in service training and serminars frequently to update the knowledge of
nurses and midwives on the partogram to maintain standard scientific approach
 Monitoring and supervision of staff in the OB/ Gynecological unit to reinforce it use
 Further research on the topic should be encourage.

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REFERENCES.

1. Opiyo et al (2022). Identify a Knowledge gap on partogram utilization .

2 .ACOG (2009) intrapartum monitoring technology(Practice bulletin No.106).

3. DOhbit JS, Nana, NP Foumane P Mboudou ET Mbu RE , leke R 2006 (2010) . A survey of the
knowledge ,attitude and practices of labor partogram among health personnel .

4. Philpott RH, Castel WM, Friedman( 1972) .Cervicographs in the management of labor in primigravidae

5. Lavender T, Hart A, Smyth RMD. (2013). Effects of the partogram use and outcomes for women in
spontaneous labor at term.

5. World Health Organisation ( 2000) partograph in management of labor.

6. Cochrane ( 2013). Insights on partograph use in labour monitoring.

7. Friedman E 1954 .The graphical analysis of labor

8. Mlandenovia D, et al (2006)literature review related to the use of the partogram and its effectiveness.

9. Maimbowa (1997), Windrim (2007).Factors hindering utilization of the partogram

10. Azandegba , N and Jester (2007) literature review related to use of partogram and it effectiveness .

11. Marcee C et al (2012) Literature review related to labor outcome .

12. Fawole AO Hunyinbo KL , Adekunle DA (2008) Knowledge and utilization of partogram among
obstetric care givers in South west Nigeria Niger

13. Magon N ( 2011), partograph revisited .International journal of clinical cases investigations.

14. Olandapo OT , Daniel OJ and Olatunji AO (2006) Knowledge and use of the partogram among health
care personnel at the peripheral maternity centers in Nigeria , Journal of obsteric and Gynacology , 26:538-
541.

15. Yisma , Dessalegen B , Astatkie ( 2013) A Fesseha N Knowledge and utilization of partogram among
care giver in public health institution of Ababa , Ethopia BMC pregnancy child birth .

16 .World Health Organization(2014) preventing prolong labor ,a practical quide .The partograph user’s part
two , user’s manuel 2012 .

17. Hofme andFawole (2000) Early warning signs arising complications in labor.

18. World Health Organization ( 2014) maternal mortality in 2000 estimate developed by WHO, UNICEF
and UNFPA

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19. World Health Organisation beyond the numbers (reviewing maternal death and complication to make
pregnancy safer

20. UBos and ICF international WHO ( 2012.A decline maternal mortality ratio has reduce , improving
maternal health in Uganda

21. Dujardin et al (2008) lack of motivation in the delivery of care and utilization of the partogram.

22)”The partogram “(Wikipedia 2011)

23)”Effects of the partogram use on outcomes for women in spontaneous labourat term and their babies (
“Cochrane 2018)

24) “Cervical dilatation over time is a poor predictor of severe birth outcomes.

25 ) Intrapartum care , care of healthy women and their babies during childbirth

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DITEK INSTITUTE (ADI UNIVERSITY), BUEA RESEARCH QUESTIONAIRE

Dear respondent

I am Mih Mildred Nain ,a level 400 student of American Ditek institute Buea

I am carrying out a research on the topic “ FACTORS AFFECTING THE EFFECTIVE UTILIZATION
THE PARTOGRAM BY NURSES AND MIDWIVES IN EKOUMDOUM BAPTIST HOSPITAL
YAOUNDE “

INSTRUCTIONS : Please tick ✅ the correct answer

SECTION 1: SOCIO-DEMOGRAPHICS DATA

1) Qualifications

a) Assistant nurse b)SRN c ) Midwives

d ) BNS Midwives e) Degree nurses

2) For how long have you been working?

a ) 3-9 months b ) 1_2years c) 3-10years d )11 and above

3) Marital status

a) Single b) Married.

4) Religion

a) Christianity b) Muslem

SECTION 2: RESPONDENT KNOWLEDGE ON THE PARTOGRAM

1) Have you heard of the partogram? A)Yes B)No

If yes, what is the partogram? ...............................................................................

…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
………………………………

2) Have you been train to use a partogram? A)Yes B)No

If yes, where were you trained? A) in school b) In-service c) in serminar

c) others …………………………..

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3) Is the partogram useful? A) Yes B) No

If yes what is the importance? .................................................................................

…………………………………………………………………………………………………………………
………………

5 ) Are there consequence of not using the partogram? A) Yes b) No.

If yes list some :

…………………………………………………………………………………………………….……………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
……………

SECTION3: RESPONDENT’S ATTITUDES ON THE USE OF THE PARTOGRAM

1 ) Do you use the partogram routinely?

a) Yes b) No c) sometimes d) never.

2) When do you enter information in the partogram in the labor room?..........................................

3) How often do you monitor vagina examination during normal labor?

a). As often as possible b) every 2hours c) every 4hours d) others.

4) How frequently do you usually monitor vital signs?

a) just as the woman arrives b)every 2hours c) every 4 hours d) others.

5) For how long do monitor abdominal contractions?

a) For 30 mins b) 10mins c) 20mins d )others

What is the importance of

A)Action line:
………………………,…………………………………………………………………………………………
…………………………………………………………………………………………………….

B) Alert line:

…………………………………………………………………………………………………………………
………………………………………………………………………………………………………

7) Do you always assess a parturient using a partogram till the end of labor and delivery?

a) Yes b) No

if no why?
……………………………………………………………………………………………………………
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SECTION 4: DIFFICULTIES FACED BY THE RESPONDENTS IN USING THE PARTOGRAM

1) What difficulties do you face using the

patogram?...............................................................................................................................
............................................................................................................................
2) Do you desire to be retrain sin the use of the partogram.
A) yes b) no
3) Would you like to use the partogram in your daily practice?
A) Yes B) No

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