THE EFFECTS OF MODIFIED WHO PARTOGRAPH ON MATERNAL AND PERINATAL

OUTCOMES OF LABOUR IN GAMBO SAWABA GENERAL HOSPITAL, ZARIA.

A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL

COLLEGE OF NIGERIA IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE

AWARD OF FELLOWSHIP IN FAMILY MEDICINE

BY

DR OLORUNMOWAJU, OLUWAFEMI MAGNUS

AHMADU BELLO UNIVERSITY TEACHING HOSPITAL (ABUTH), SHIKA-ZARIA,

NOVEMBER, 2016
 DECLARATION

I declare that this Dissertation is an original work and has not been submitted to any other

college for any award or journal for publication.

………………………………………………..

Dr. OLORUNMOWAJU OLUWAFEMI MAGNUS

ii

1
 ACKNOWLEDGEMENTS

All praise and glory to God almighty for His mercy, favour and grace upon me all through the

course of my training and this research work.

My heart-felt gratitude goes to my supervisor and trainer, Dr. L Akin Moses (Chief Consultant

Family Physician and President of Society of Family Physicians of Nigeria (SOFPON) for his

fatherly role and guidance throughout the training and the research work. His correction,

encouragement, zeal, time and endless support made a whole lot of impact.

I sincerely thank Dr. BY Ibrahim (Chief Consultant Family Physician and Head of department

Family Medicine, ABUTH, Zaria) who is also my trainer and supervisor. His drive for

excellence and attention to minute detail has been of tremendous contribution to this work.

My profound gratitude also goes to my other trainers and consultants in the department, Drs.

Aiyebelehin Alfred and Sule Gbenga for their support and advice.

My warm and sincere appreciation goes to Professor Oguntayo (Consultant Obstetrician and

Gynaecologist), Professor Aliu Abubakar, (Consultant Public Health), Professor Adewuyi

Adeyemi Sunday (Consultant Radio-Oncologist), Dr. Balarabe Yusuf (Head of Department,

English Language), Dr. Sani Ibrahim (Department of Education) and many others that I could

not mention their names.

My gratitude also goes to Dr. Sobowale Adekunle, Dr. Duromola Michael, the Midwives and

other staff of Gambo Sawaba General Hospital, Zaria for their support.

Lastly I am grateful to my lovely wife and children for their sacrifices, support and prayer.

iii

2
 CERTIFICATION
I certify that this dissertation entitled ‘The effects of modified WHO partograph on maternal and
perinatal outcomes of labour in Gambo Sawaba General Hospital, Zaria was carried out under
the supervision of the following consultants in Family Medicine Department;

1. Signature.…………………….. Date………………………

Dr. Lawrence Akin Moses FMCGP, FWACP

i. Chief Consultant
Department of Family Medicine
National Hospital,
Abuja, Nigeria.
ii. Visiting Chief Consultant
Department of Family Medicine
Ahmadu Bello University Teaching Hospital,
Shika – Zaria, Nigeria.

2. Signature................................... Date..................................
Dr. Benjamin Y. Ibrahim FWACP
Chief Consultant and Head
Department of Family Medicine
Ahmadu Bello University Teaching Hospital
Shika-Zaria, Nigeria.

iv

3
 TABLE OF CONTENTS

Title page................................................................................................................................. i
Declaration...............................................................................................................................ii
Acknowledgements.................................................................................................................iii
Certification................................................................................................. ...........................iv
Table of contents..................................................................................................................v-vi
List of abbreviations...............................................................................................................vii
List of tables..........................................................................................................................viii
List of figures..........................................................................................................................ix
Summary...............................................................................................................................1-2
CHAPTER ONE: INTRODUCTION
1.1 Background....................................................................................................................3-6
1.2 Statement of the problem...................................................................................................6
1.3 Aim and objectives............................................................................................................7
1.4 Justification of the study...................................................................................................7
1.5 Hypothesis......................................................................................................... ...............8
CHAPTER TWO: REVIEW OF LITERATURE
2.1 Introduction.....................................................................................................................9
2.2 The burden of maternal mortality and morbidity in Nigeria................................. .....9-18
2.3 Perinatal mortality and morbidity in Nigeria.............................................................18-20
2.4 Physiology of labour..................................................................................................20-31
2.5 Abnormal progress of labour.....................................................................................31-32
2.6 Active management of labour...................................................................................32-34
2.7 The WHO partograph model.....................................................................................34-37
2.8 The principle of partograph use............................................................................. ..37-39
2.9 Problems with the WHO partograph.......................................................................39-41
2.10 Partograph use and maternal as well as perinatal outcomes of labour................ ...41-46

CHAPTER THREE: MATERIALS AND METHOD

3.1 Study site.........................................................................................................................47
3.2 Study population.............................................................................................................47
3.3 Study design..............................................................................................................47-48
3.4 Sample size.....................................................................................................................48
3.5 Sampling method............................................................................................................49
3.6 Study duration...............................................................................................................49
v

4
 3.7 Selection criteria............................................................................................................49
3.8 Tool for data collection..................................................................................................50
3.9 Study protocol...........................................................................................................49-53
3.10 Data analysis.................................................................................................................54
3.11 Hypothesis testing.................................................................................................. 54-55
3.12 Ethical consideration................................................................................................... 55
3.13 Budget..........................................................................................................................56
CHAPTER FOUR: PRESENTATION OF RESULTS ................................................. .57-69
CHAPTER FIVE: DISCUSSION....................................................................................70-77
CHAPTER SIX: CONCLUSION AND RECOMMENDATIONS
6.1 Conclusion ......................................................................................................................78
6.2 Recommendations.......................................................................................................79-80
6.3 Limitations.......................................................................................................................-80
6.4 Relevance of the study to Family Medicine.................................................................80-81
6.5 Further research.................................................................................................................81
6.6 References....................................................................................................................82-91
6.7 Appendices................................................................................................................92-100

vi
5
 LIST OF ABBREVIATIONS

ABUTH …………………………… Ahmadu Bello University Teaching Hospital

ACTH……………………………… Adrenocorticotrophic hormone
AMBU …………………………….. Ambulatory Mechanical Breathing Unit
AML ……………………………… Active management of labour
ARM……………………………… Artificial rupture of membrane
BP ………………………………. Blood pressure
CI ………………………………… Confidence interval
CPD ……………………………… Cephalopelvic disproportion
df…………………………………. Degree of freedom
IMNCH …………………………… Integrated Maternal Newborn and Child Health
IMPAC…………………………… Integrated Management of Pregnancy and Child Birth
MDG……………………………… Millennium Development Goal
MMR……………………………… Maternal Mortality Rate
MPS……………………………… Making Pregnancy Safer
NEEDS ………………………… National Economic Empowerment and Development.
. Strategy
NICU…………………………….. Neonatal Intensive Care Unit
OAUTH ………………………… Obafemi Awolowo University Teaching Hospital
PMMN…………………………… Prevention of Maternal Mortality Network
PMR……………………………… Perinatal Mortality Rate
PPH……………………………… Post-partum haemorrhage
PRD. ............................................... Pregnancy Related Death
RVD.................................................. Retroviral disease
RR.............................................. Risk Ratio
SFH............................................. Symphisis-fundal height
SMI................................................ Safe Motherhood Initiative
SVD............................................. Spontaneous Vaginal Delivery
WHO............................................. World Health Organisation
X2..................................................... Chi square

vii

6
 LIST OF TABLES
Table Page

Table 1: Distribution of Socio-demographic characteristics of the participants..........................57

Table 2a: Distribution of maternal outcomes of labour among the participants…………….….61

.
Table 2b: Distribution of maternal outcomes of labour among the participants ……………....63

Table 3: Distribution of perinatal outcomes of labour among the participants ...........................65

viii

7
 LIST OF FIGURES
Figure Pages

Figure 1: Pattern of Safe Motherhood in Nigeria ...................17

Figure 2: Regulation of uterine activity during pregnancy and labour ......... .................22

Figure 3: Friedman’s curve showing phase of maximum slope ....................................28

Figure 4: Descent of presenting foetal head ......................................36

Figure 5: The old WHO partograph ......................................38

Figure 6: Modified WHO partograph ................................39

Figure 7: Distribution of occupation among the participants .............................................59

Ix

8
 SUMMARY

BACKGROUND: Nigeria contributes significantly (13%) to the global burden of maternal

mortality, ranking second in the number of maternal deaths. Prompt detection of abnormal

progress and prevention of prolonged labour can immensely improve maternal health in the

country. The modified WHO partograph is a simple and inexpensive tool that produces a

significant reduction in maternal and perinatal mortality as well as morbidity when used to

monitor labour.

OBJECTIVES: This study aimed at evaluating the effect of modified WHO partograph on

labour care with a view to improving maternal and perinatal outcomes of labour at Gambo

Sawaba General Hospital, Zaria. The objectives were to determine the socio-demographic

characteristics of the participants, the maternal and perinatal outcomes in both the control and

intervention groups, comparing the outcomes in the two groups and assessing the association

between the use of modified WHO partograph and maternal as well as perinatal outcomes of

labour.

MATERIAL AND METHOD: This was a quasi experimental study, the subjects were 544

women with uncomplicated full term pregnancy with cephalic presentation in active labour,

allocated into the two groups using alternate sampling method (a non- probability sampling

method) with each group having 272 participants respectively over the period of 3 months

(October to December, 2014). The participants in the intervention group had their course of

labour monitored with the modified WHO partograph while those in the control group were not.

Interviewer- administered questionnaires and data recording tools were used to extract

information from the participants. The maternal and perinatal outcomes were measured and

9
analysed after matching the two groups in terms of ages, parity, gravidarity, booking status,

number of antenatal care clinic attendance and socio-economic status.

RESULTS: There was an improvement in the maternal outcomes as evidenced by significant

reduction in the operative delivery in the study with a P=0.019 (rate of caesarean delivery

decreased from 16.2% to 10.3% and instrumental delivery from 8.8% to 4.4%), perineal

laceration (from 41.6% to 16.5%, P=0.0001), augmentation of labour (from 32.4% to 16.9,

P=0.0001) and post-partum haemorrhage (from 25% to 18.0%, P=0.047). The duration of first

stage of labour ≤12 hours increased from 80.5% to 88.2%). There was no incidence of ruptured

or maternal death.

Also an improvement was seen in the foetal outcomes of the participants as reflected in the

reduction of immediate neonatal death (from 7.4% to 2.9%, P=0.020) and admission to NICU

(from 19.5% to 4.8%, P=0.0001). The Apgar score ≥7 of babies of the participants in the

intervention group improved from 52.9% to 65.8% and 55.9% to 69.9% at 1 and 5 minutes

respectively (P=0.003 and 0.001).

CONCLUSION: The use of the modified WHO partograph significantly improved the maternal

and perinatal outcomes of labour in this study. Hence, it is recommended for use in labour

monitoring in the study centre while a further multi-centre study is recommended to increase the

strength of the evidence of the use of the partograph in the state.

10
 CHAPTER ONE

INTRODUCTION

1.1 Background

Worldwide, more than a million women between the ages of 15 and 49 years die each year from

complications of pregnancy and child birth.1 About 500,000 women die annually with a huge

number left with injury as a result of pregnancy related causes.1 For each maternal death more

women suffer serious complications. Unfortunately, developing countries disproportionately bear

this burden despite global attention and efforts. Poor outcome during labour accounts for about

19% of maternal deaths in these countries.2 Maternal mortality remains between 500-1000 deaths

per 100,000 live births in developing countries. Nigeria ranked second globally (next to India) in

the number of maternal deaths.3 It was estimated to be 525 deaths per 100,000 in Nigeria in

2013.4 A population based study reported that maternal mortality ratio is worst in Northern

Nigeria; an average figure of 2,420 deaths per 100,000 live births in Kano, North Western

Nigeria.5 Obstructed and prolonged labour are major causes of these deaths. Also birth asphyxia,

neonatal sepsis and perinatal deaths are common perinatal outcomes observed.6 Perinatal

mortality is on the increase in Nigeria.7 It has been estimated to be between 39-130 deaths per

1000 in a study done in Lagos in 2011.8 Prompt detection of abnormal progress and prevention

of prolonged labour can significantly reduce these complications. Therefore, techniques for

monitoring labour play an important role in preventing poor maternal and perinatal outcomes.

The use of partograph is an important and cheap way of achieving this goal. It is an inexpensive

tool designed to provide a continuous pictorial overview of labour and has been shown to

improve outcomes when used to monitor and manage labour. It is a single sheet of paper where

all information related to labour is obtained. It has three components which include the foetal

11
condition, the progress of labour and maternal condition. Parameters used in monitoring foetal

condition during labour include foetal heart rate, membrane status, liquor quality and moulding.

The progress of labour is central to labour management using a partograph. It records the rate of

cervical dilatation, descent of the presenting part and pattern as well as strength of uterine

contractions. The third component records maternal temperature, pulse rate, maternal blood

pressure and urinalysis.

The evolution of partograph dated back to 1954 when Friedman first described a normal

graphical cervical dilatation pattern which is sigmoid in nature. Friedman’s partograph was

based on cervical dilatation and foetal station against time elapsed in hours from onset of

labour.6, 9
It divided labour into two functional parts; the early or latent phase and the active

phase (phase of rapid dilatation which extends over 8-10 hours and up to about 8 cm cervical

dilatation and deceleration phase).9 This was followed by Hendricks’ partograph (1969) which

observed similar curves between primigravidae and multiparous women. There was no

deceleration phase. Philpot and Castle (1972) added the preset lines (Alert and Action lines). The

alert line represented the slowest 10% of patients in the African population whom they served. It

also separated the majority of normal from abnormal labour. The alert line was drawn at a scope

of 1 cm per hour for nulliparous women starting at time zero. There was also a transfer line

which was 4 hours to the right of the alert line such that when the graph moved to this line at the

periphery centres, the patient was then transferred to the main hospital where active management

of labour should be instituted within 4 hours.6, 9 Crichton in 1974 added the descent of the head

in fifth notation which aimed at avoiding the use of the station notation which could prove

dangerous in the hand of the inexperienced. Stencil was used to show the cervical dilatation from

time zero.6, 9 The expected pattern of progress of labour was predicted based on the extent of

12
dilatation achieved by the time the patient is admitted.6, 9 There were construction of 5 different

patterns representing normal labour progress. Those crossing the normogram line were found to

have a 3 fold increase in instrumental delivery. The WHO partograph was developed in 1988

following the lunch of safe motherhood initiative.9 Its impact was also evaluated in a multicentre

trial involving more than 35,000 women in Indonesia, Malaysia and Thailand. An improvement

in the outcomes of labour; prolonged labour, augmentation of labour, caesarean section and

intrapartum foetal death was noted. The first World Health Organization (WHO) partograph or

‘composite partograph’ covers a latent phase of labour of up to 8 hours and an active phase

beginning when the cervical dilatation reaches 3cm. The active phase is depicted with an alert

line and an action line, drawn 4 hours apart in the partograph. This partograph is based on the

principle that during active labour, the rate of cervical dilatation should not be slower than 1 cm

per hour. However, the usefulness of recording the latent phase of labour in the partograph has

been questioned since the incidence of prolonged latent phase is not usually associated with poor

perinatal outcome.9 To address these disadvantages, in the year 2000 following the lunch of an

integrated management of pregnancy and child birth (IMPAC) program in managing

complications in pregnancy and child birth, a modified WHO partograph was introduced and

incorporated. The latent phase was removed and active phase of labour was defined as beginning

from 4 cm cervical dilatation instead of 3 cm.10, 11

The partograph is a practical device used in a busy labour room to screen for abnormal labour.10

Its use prevents repeated record of labour events. It helps to predict deviation from normal

progress of labour and supports timely and proven interventions. It also helps to facilitate

responsibility to the person conducting labour.9 Other uses of the partograph include; provision

of good vehicle for teaching medical students and student midwives, easy assessment of

13
abnormal features or mismanagement of labour and easy tool for handover of patients during

ward round by doctors and midwives.9 Although partograph is an important tool used in

monitoring of labour, it is not without its own disadvantages which include; need for absolute

attention and close monitoring, exclusion of its use in second stage of labour which is equally

important and subjective assessment due to inter-observer error.10 Worthy of note are some of

the contraindications to the use of partograph which include; women with admission cervical

dilatation of 9-10cm, those scheduled for elective caesarean section and those with gestational

age of less than 34 completed weeks.6

1.2 STATEMENT OF THE PROBLEM

Maternal and perinatal mortality is a major problem in Africa, particularly in Nigeria.2 The rate

is higher in the North, particularly the northwest region of the country, with Kano having a figure

as high as 2,420 deaths per 100,000 live births compared to 450 deaths per 100,000 live births in

North Central and between 454 and 772 deaths per 100,000 live births in Southern parts of

Nigeria.5, 12 It is to be assumed that many of the causes of maternal mortality could have been

prevented if modified WHO partograph was used in monitoring labour.4 The author has observed

that partograph is rarely used for labour monitoring in many of the primary and secondary health

centres in this environment, including Gambo Sawaba General Hospital, Zaria where the study

was carried out.13 The use of partograph seems to be mostly restricted to tertiary centres in

Nigeria, especially the Northern parts of Nigeria even though it was primarily designed for use at

primary and secondary health care level.14 Hence, the decision to carry out this study.

14
1.3 AIM AND OBJECTIVES

1.3.1 AIM

To determine the effects of using the modified WHO partograph on labour care at Gambo

Sawaba General Hospital, Zaria with a view to improving maternal and perinatal outcomes of

labour.

1.3.2 OBJECTIVES

1. To determine the socio-demographic characteristics of the participants.

2. To determine the maternal and perinatal outcomes of labour in the control group.

3. To determine the maternal and perinatal outcomes of labour in the intervention (study)

group

4. To compare the maternal and perinatal outcomes of labour in both groups.

5. To assess the association between the use of the modified WHO partograph and maternal

as well as perinatal outcomes of labour among the participants.

1.4 JUSTIFICATION OF THE STUDY

Maternal and perinatal mortality rate is on the increase in Nigeria. Many of the causes of these

deaths are preventable. The use of partograph, a simple and inexpensive tool has been designed

to improve maternal and foetal outcomes. However, there was no awareness of any study done in

this environment to evaluate the effect of this tool on maternal and foetal outcomes. Many of the

studies done in Nigeria sought to assess the knowledge and use of partograph among health

workers.14 Hence, the results of this study will show if the use of this tool is effective in

improving maternal and perinatal outcomes of labour. The result could also be used by decision

makers in formulating policy while also acting as a template for other research work.

15
1.5. HYPOTHESIS

This is a proposed explanation for a phenomenon. It is a specific statement of prediction.15, 16

Is there an association between the use of the modified W.H.O partograph and the maternal as

well as perinatal outcomes of labour?

Null hypothesis (H0): There is no association between the use of modified W.H.O partograph and

maternal as well as perinatal outcomes of labour among the participants.

Alternative hypothesis (H1): There is an association between the use of modified W.H.O

partograph and the maternal as well as perinatal outcomes of labour among the participants.

16
 CHAPTER TWO

REVIEW OF LITERATURE

2.1 Introduction

Maternal and perinatal mortality present a great challenge to developing countries especially

Nigeria.17 The fundamental causes of these deaths are complex admixture of cultural, socio-

economic and political constraints which lead to poor essential obstetric care services during

antenatal, intrapartum and puerperal periods. Causes of these deaths in Nigeria include prolonged

and obstructed labour of which partograph has been shown to be an efficient tool for

intervention.

2.2.1 The burden of maternal mortality and morbidity in Nigeria

Maternal death rate is still very high in developing countries with regional variation. This is

especially so in Northern part of Nigeria.1 Maternal death is described as a silent tragedy.18, 19 A

woman’s death during child birth is both a health issue and a matter of social injustice reflecting

a failure of the community and government to promote safe motherhood as a human right.20-21

Definitions of related terminologies according to WHO are as follows:1

Maternal mortality- The death of a woman while pregnant or within 42 days of termination of

pregnancy from any cause related to, or aggravated by the pregnancy or its management but not

from accidental causes.

Late maternal death- This is the death of a woman from direct causes greater than 42 days but

less than 1 year after an abortion or term pregnancy.

Pregnancy related death- This is the death of a woman while pregnant or within 42 days of

termination of pregnancy irrespective of the causes of death.

17
Maternal mortality ratio- This is the number of maternal deaths in a given year per 100,000

live births.

Maternal mortality rate is the number of maternal deaths in a given period per 100,000 women

of reproductive age (15-49 years).

Maternal death is a leading cause of death among women of reproductive age in many

developing countries.23 As the maternal mortality increases there is also a high rate of maternal

morbidity. It has been estimated that about 30-50 morbidities occur for every maternal death.23

Nigeria constitutes less than 2% of the world’s population but contributes 10% to the world’s

maternal death.24-25 Maternal mortality was estimated to be 525 deaths per 100,000 in Nigeria in

2013.26 It varies from region to region being highest in Northern Nigeria. Nigeria ranked second

in the world in terms of the actual number of deaths but eighth in Sub-Saharan Africa in terms of

the maternal mortality ratio.23 In Nigeria, there is a 1 in 18 maternal risk of dying during

pregnancy as compared to 1 in 48,000 maternal risk in Ireland.27-28 This shows a great disparity

in the maternal mortality of the two countries. This is unacceptable considering the fact that all

the causes of maternal deaths are well known and many of them are preventable. This disparity

may be explained by accessibility to quality care during pregnancy and delivery. It has been

reported that about one-third of births are assisted by trained attendants in Africa and South Asia

and 64% in Latin America as against 93% in East Asia and virtually 100% in North America.29

Nigeria records about 33,000 maternal deaths each year.29 Nigeria has a female life expectancy

of 47.3 year as compared to other nations; Japan (86.1 year), Ghana (60.5 year), Gambia (60.3

year), Togo (60.1 year), Chad (52.0 year) and Cameroon (50.8 year).29-30 This is unacceptable

18
especially when reduction in maternal mortality by 75% in 2015 was a major target of the

Millennium Development Goals (MDG).31-32 In a WHO estimate, about 1,600 maternal deaths

occur each day worldwide and the total is around 585,000 a year, of which 99% are in the

developing countries.30 This positions Nigeria health status in a deplorable state that calls for

urgent action. Therefore, maternal death should be made a notifiable event.

2.2.2 Risk factors for maternal mortality and morbidity

Maternal mortality is considerably influenced by the socio-economic and political contexts of

care system as well as the cultural and biological realities of women seeking care. The main

causes of maternal mortality in Nigeria include haemorrhage (23%), infection (17%), unsafe

abortion (11%), obstructed labour (11%), eclampsia or hypertensive disorder of pregnancy

(11%), malaria (11%) and anaemia (11%).33, 34 Many of these deaths are preventable; example

being the use of partograph in monitoring labour. These causes are classified into direct, indirect

and fortuitous causes. Direct causes which constitute 75% are those resulting from complications

of pregnancy, delivery or their management. Such conditions include abortion, ectopic gestation,

pre-eclampsia, eclampsia, ante-partum haemorrhages and puerperal sepsis. Indirect causes

accounting for 25% are those resulting from previous existing disease or diseases that developed

during pregnancy but were aggravated by the physiological effects of pregnancy.35 These include

anaemia, cardiac disease, diabetes, thyroid disease and fortuitous causes i.e. those resulting from

unrelated causes that occur during pregnancy or pueperium.35

Gender related issues are also contributory factors to the increasing maternal mortality in Nigeria

and most African countries.36 The female is usually considered inferior to the male hence their

19
lack of power to take vital decisions regarding their health. Tradition, family mores and laws

limit women’s decision making with regard to child bearing, contraception and limitation of

sexual relationship. These create a negative impact on the maternal health. It is also noted that a

preference to male children in the society makes a woman who has female children to continue

to be pregnant with the hope of having a male child.36 This leads to having many pregnancies

which in turn could lead to postpartum haemorrhage, anaemia, ruptured uterus and death.37

Grand multiparity had been shown to significantly increase the risk of maternal death.37

Cultural and religious practices also contribute to maternal mortality. This is seen in the area of

preference of women to have their delivery at spiritual and faith homes, cultural practices like

female circumcision and hot water baths after delivery.21 These have some negative

consequences on maternal health. Other factors that may also contribute to maternal mortality

may include age (less than 20 years and more than 35 years), parity (primigravida and grand

multigravidae), socio-economic strata (low socio economic class), poor antenatal care and

substandard care.31

The above risk factors can be grouped into health service related factors (inadequate healthcare

personnel and supplies, incorrect treatment, incessant industrial actions and poor access to health

care centres), reproductive health factors (pregnancy at early and late ages, too many pregnancies

and too frequent pregnancy), socio-cultural factors (poverty, diet, religion and harmful

practices).36

20
2.2.3 The three delay Model

There are barriers that impede on the accessibility of health care services most especially

emergency obstetric services. They range from economic, cultural and geographical factors. All

these barriers contribute to the increase in maternal mortality in Nigeria. These are summarized

in the three delay model namely:-

Type 1 delay: Deciding to seek care- The delay in women deciding to seek care is influenced by

many factors; the knowledge of the patient and the awareness of her family on the seriousness of

obstetric complications, their knowledge of where to seek health care, cultural beliefs (being

stoic which is common among the Fulani and lack of autonomy on decision relating to their

health), the distance to the healthcare facility and quality of the health care facility. This accounts

for 40%.

Type 2 delay: Delay in reaching medical facility- This is a great factor in maternal health care

services. Most health care facilities that render emergency obstetric services are concentrated in

urban areas and far from the reach of the people. Hence, women have to travel far distance to

access health care. This accounts for 20% of the delay.

Type 3 delay: Delay in receiving treatment- These are delays seen in hospital setting. Most time

women overcome type 1 and 2 delays but are faced with this particular delay. This accounts for

about 40% of the delay. A descriptive study done in University of Calabar Teaching Hospital

showed that type 3 delay was responsible for 48.5% of maternal death while type 1 and 2 were

responsible for 7.4% and 35.5% respectively.37 These findings were similar to related studies in

Benin City and Ile- Ife.39-40 These may be due to inadequate health workers available or lack of

21
appropriate skills, frequent industrial actions (strike), unnecessary bureaucracy and lack of

medications.

2.2.4 Reduction in maternal mortality and morbidity

Universal basic education is a key step to reduction of maternal mortality and morbidity in

Nigeria. A woman’s educational status goes a long way in influencing her health-seeking

behaviour. Improved educational status can reduce the maternal mortality indices by about

50%.26 This is because the more educated a woman is the more likely she will delay her

marriage, use contraception and health services appropriately. Promotion of girl-child education

to at least secondary school level is therefore recommended for reduction of maternal mortality.

In an analytical cross sectional survey designed for WHO global data system, the risk of

maternal death decreases with increased duration of schooling.33

The fertility rate in Nigeria is put at 5.7. This figure is higher in Northern Nigeria partly due to

high preference of having more children and cultural norms. Contraceptive usage reduces the

number of children a woman delivers and hence, a reduction in the burden of maternal morbidity

and mortality if encouraged.42 Contraception helps to reduce maternal mortality by decreasing

the number of times a woman get pregnant, the number of unwanted pregnancy and the risk of

abortion.

Provision of essential obstetric care is a key way of reducing maternal mortality.43-44 These are

elements of obstetric care needed for the management of normal and complicated pregnancy,

delivery and post-partum period. This is very important to manage the five (5) most important

causes of maternal death; sepsis, haemorrhage, eclampsia, obstructed labour and abortion. It

22
includes at least the following components; parenteral antibiotics, oxytocic drugs, sedatives for

eclampsia, manual removal of placenta and retained products, blood transfusion, anaesthesia and

surgery (caesarean delivery).44 It has been recommended that having one (1) basic essential

obstetric care services per 150,000 and one (1) comprehensive emergency obstetric care services

per 500,000 population, will help to reduce maternal mortality.44

The training of healthcare providers on essential skills and procedures for managing obstetric

complications also contribute to the reduction of maternal mortality. Such skills should be on

manual vacuum aspiration, proper antenatal care examination, caesarean delivery, management

of third stage of labour and manual removal of placenta.31

Addressing type 1 delay is by raising awareness in the community about the signs of life

threatening complications and education of women, their partners and their family about when

and where to seek care for complications.31

Addressing type 2 delay is by encouraging families and communities to develop plans of action

in case of obstetric emergency, raising women’s status so that they can be empowered to make

decision on their own, enhancing links between communities and healthcare providers,

improving relationship between traditional healers and skilled health care providers and

encouraging the use of health facilities by adolescents, single and the unmarried.31

Addressing type 3 delay is by encouraging community to create emergency transportation plans,

enhancing referral system between community and health care providers and establishing

maternity waiting home.31

23
Other strategies employed in maternal mortality reduction include promotion of the role of

private sector in the delivery of quality health care services, strengthening partnership, referral

linkage and collaboration between government, non-governmental and private sectors. Ensuring

universal coverage of national health insurance scheme, strengthening the practice of Family

Medicine in Nigeria, using partograph to monitor labour and eradication of social inequality are

other helpful measures to reduce maternal mortality.43-44 In Nigeria, some of the national

intervention packages for the reduction of maternal mortality include; Safe Motherhood Initiative

(SMI), Prevention of Maternal Mortality Network (PMMN), Making Pregnancy Safer (MPS),

National Economic Empowerment and Development Strategy (NEEDS), Integrated Maternal

Newborn and Child Health Strategy (IMNCH) and the Millennium Development Goals

(MDGs).42

2.2.5 SAFE MOTHERHOOD INITIATIVE (SMI)

Maternal mortality is a neglected tragedy.19 It is neglected because those who suffer it are the

neglected people with the least power and influence over how national resources are spent; they

are the poor, the rural peasants and above all, women.19 Every minute of every day, somewhere

in the world and most often in the developing world, a woman dies from complications related to

pregnancy or child birth.19 When a woman dies it represents an enormous loss to her nation, her

community and her family. In this case children lose their primary caregiver, the community is

denied her paid and unpaid labour and countries forgo her contribution to economic and social

development.

24
The concept of Safe Motherhood Initiative (SMI) emanated from Nairobi in 1987, out of the

need to reduce maternal mortality to half by the year 2000.24 However, in 2015 such goal is yet

to be achieved.

Figure 1: The pillars of Safe Motherhood in Nigeria

The above figure shows the essential services for Safe Motherhood Initiative in Nigeria. The

activities of Safe Motherhood Initiative includes the following:24, 31, 43

1. Increasing the awareness of the dimension of problems and the need for action through

seminars, workshops and audio visuals. These should be carried out among community leaders.

There should be political commitment to Safe Motherhood Initiative to identify the problems of

women and ensure that they have the right to make an informed decision and also have access to

good quality care.

25
2. Strengthening of maternal health services like provision of good antenatal care services,

revitalization of primary health care, expansion of Bamako Initiative, appropriate training of

health care workers, intrapartum care (with use of partograph) and post-partum care.

3. Reduction of unwanted pregnancy and unsafe abortion by access to good quality and

confidential family planning, offering reliable information and counselling, ensuring women

have control over their sexuality and reproduction, offering of safe abortion services and

contraception.

4. Training of health workers, economic empowerment of women and conducting research into

maternal health are also parts of the focus of Safe Motherhood Initiative.

These activities targeted toward the goals of Safe Motherhood Initiative will go a long way in

reducing maternal mortality in Nigeria. However, some of the constraints to achieving these

objectives include problems of logistics in the health system, scarcity and inaccessibility as well

as high cost of health care delivery.

2.3 PERINATAL MORTALITY IN NIGERIA

Maternal and perinatal deaths reflect the standard of obstetric care in a community.

Perinatal mortality is the total of all still births and deaths of neonate in the first week of life.

Early neonatal death is the death of a child in the first 7 days of life.

Late neonatal death is that which occurs after 7 days but before 28 days of life.

Still foetal death (still birth) is the death of the foetus from 28 completed weeks of gestation till

birth.45

26
Perinatal Mortality Rate (PMR) is an important indicator of the level and quality of antenatal,

obstetrics and neonatal services provided in a country.45 Perinatal mortality is grossly under

reported in developing nations especially in Nigeria.46 However, it is heart-breaking that

developing nations have perinatal rate that are several folds that of the developed countries. 47

Over 98% of still birth and early perinatal deaths occur in low income countries and regional

estimate suggests that countries in sub Saharan Africa have one of the highest perinatal mortality

rates in the world.47 In 2004, WHO estimated world-wide Perinatal Mortality Rate to be 43 per

1000 births with Africa having 56 per 1000.48 Of particular note is that West Africa (of which

Nigeria is a major stakeholder) is ranked 2nd to Central Africa with PMR of 69 per 1000.48

Nigeria contributes significantly to the global perinatal, neonatal and under 5 mortality in the

world in spite of her minute contribution (2%) to the world population.49 It contributes about 8%

of the world’s annual mortality in neonate with an annual figure of 242,000 neonatal deaths. 49

The perinatal death in Nigeria is 30 per 1000 live births.50 This high level of perinatal mortality

was noted to be an impediment to achieving MDG-4 by the year 2015.49 Nigeria is among the top

ten countries which together contribute 54% of total world birth but also accounts for 67% of all

still birth.7 About 24-37% of newborns, as still birth, die intrapartum. Intrapartum foetal death is

about 25% in Nigeria.46 A retrospective study by Adimora and Odetunde in University of

Nigeria Teaching Hospital, Enugu State, Nigeria, revealed perinatal mortality rate of 123.94 per

1000 birth.7

The determinants and causes of Perinatal Mortality include obstetric complications such as

obstructed labour, pregnancy induced hypertension, eclampsia, ante-partum haemorrhage and

27
anaemia. Social factors such as poverty, illiteracy and poor antenatal care are also important

causes of Perinatal Mortality. In addition, there are maternal and foetal factors like teenage

pregnancy, high parity, low birth weight, birth asphyxia and birth trauma.45 The 3 delay model

could also explain the proportion of intrapartum death.

The health status of the mother and that of the baby are intimately related. The death of the

mother spells doom for the newborns that survive the cause of the demise of their mother. Many

of these causes are preventable with the use of partograph in monitoring labour.51 Other

contributors to perinatal mortality are rural-urban dwelling migration and low contraception

practices.

The prevention of perinatal death is key to improving the health status of the country and this is

embedded in the ability of the nation to address the social factors and integrate primary health

care with community participation.46 Addressing the delays in accessing health care delivery and

the reduction in the maternal mortality and morbidity will also contribute a great deal to the

reduction of perinatal mortality and hence the achievement of the MDG-4.46 Also, an

improvement in the neonatal care services, obstetric practices will also help in reducing perinatal

mortality in Nigeria.

2.4 PHYSIOLOGY OF LABOUR

Rhythmic spasmodic uterine contractions are the hall mark of labour. Although there are wide

variations in frequency, intensity and duration of contractions, they remain usually within normal

limits and follow the following patterns;

- There is good synchronization of the contraction waves of both halves of the uterus

28
 - There is fundal dominance with gradual diminishing contraction waves through mid zone

down to the lower segment which takes about 10 to 20 seconds.

- The waves of contractions follow a regular pattern.

- The intra-amniotic pressure rises beyond 20 mmHg with the onset of true labour pains

during contraction.

- Good relaxation occurs in between contractions to bring down the intra-amniotic pressure

to less than 8 mmHg.

The regulation of uterine activities during the later part of pregnancy and labour can be described

under four physiologic phases:52-53, 56

1. Phase 1 (functional quiescence) – During pregnancy the uterus is maintained in a state of

functional quiescence by one or more of a series of inhibitors. The progesterone decreases

the production of prostaglandin which in turn inhibits gap junction formation by preventing

the expression of connexion 43 and inhibits oxytocin release. Other inhibitors include

prostacycline, relaxin (which helps to inhibit myosin light chain phosphorylation and inhibit

uterine stimulants like oxytocin and noradrenalin), nitric oxide, parathyroid hormone,

intestinal peptide hormone and human placental lactogen.

2. Phase 2 (Activation/pre-labour) – This phase is marked with increased expression of a series

of contractile associated protein, functional activation of ion channels and increase in

connexin 43 (a key component of the gap junction). These activities are in response to the

effect of uterothropins.

29
 3. Phase 3 (Stimulation/labour) – The uterus is already primed, following the phase of

activation, and can be acted upon by the uterothropins such as oxytocin, prostaglandin F2α.

The uterus is stimulated to contract. The pace makers of the uterine contraction are located in

the region of the tubal ostia from where the waves of contractions spread downward.

4. Phase 4 (Involution /pueperium) – This occurs after delivery and is mediated by oxytocin and

possibly thrombin. These phases are represented in figure 2 below.

Figure 2: Regulation of uterine activities during pregnancy and labour

Inhibitors
PG
Prostacycline
Relaxin
Uterine contraction

Time

Phase 0 Phase 1 Phase 2 Phase 3

(Quiescence (activation) (Stimulation) (Involution)
)
Parturition

2.4.2 ANATOMY OF LABOUR

Anatomic changes are also noted in labour.52, 54 During descent of the foetus, there is progressive

dilatation of the vagina with the anterior structures (urethra and bladder) displaced upward and

forward and the posterior structures (pouch of Douglas, rectum, anal canal, perineum and

30
anococygeal raphe) displaced downward and backwards. The bladder remains a pelvic organ at

the first stage of labour but later becomes an abdominal organ in the second stage with the

urethra being pushed anteriorly. The perineum thins out and becomes a membranous structure of

less than 1cm of thickness. The anus which was initially a closed opening becomes dilated to

about 2-3cm. The posterior wall of the birth canal becomes about 23cm in length, 11.5cm for the

depth of the sacrum and 11.5cm for the stretched soft tissue, while the anterior wall remains the

same 4cm in length making the canal a semi circle in shape.

2.4.3 Onset of labour

The uterus maintains relative quiescence throughout pregnancy in most women. Usually the

uterus contracts spontaneously but the contractility is suppressed by the progesterone secreted by

the placenta thereby maintaining the foetus in the uterus. The cervix also remains firm and non

compliant. However, at term, changes occur that make the cervix softer and uterine contraction

more frequent and regular.

The mechanism of initiation of labour is not known. However, some hypotheses have been put

forward. These include the following: 52, 56

1. Optimal distension theory- This postulates that the stretching effect of the myometrium to an

optimal point resulting from the growth of the foetus and liquor amnii especially in twin

gestation, causes the initiation of labour. However, this fails to explain preterm labour.

2. Feto-placental contribution- There exist a cascade of events which activates foetal

hypothalamic-pituitary-adrenal axis prior to the onset of labour. This causes increase in

corticotrophin hormone (CRH) and adrenocorticotropin hormone (ACTH). These hormones

31
 act on the foetal adrenal glands and cause increase in the production of cortisol secretion

which in turn increase oestrogen and prostaglandin production from the placenta. These

hormones are essential to the initiation of labour. The cortisol promotes surfactant production

in the lung by increasing liver glycogen content and intestinal enzyme production. It also acts

on the placenta to stimulate enzymatic synthesis (17a-hydroxylase, aromatase) resulting in a

shift in steroidogenesis following the delta-5 pathway (a decrease in progesterone and an

increase in estradiol production). This cortisol excreted in the foetal kidney may activate

prostaglandin synthesis in the foetal membrane.

3. Oestrogen- Increased production of oestrogen at term promotes uterine contractility by

increasing oxytocin from the maternal pituitary, promoting the synthesis of receptors for

oxytocin in the myometrium and decidua, increasing lysosomal disintegration in amnion cell,

stimulating the synthesis of myometrial contractile protein and increasing the excitability of

the myometrial cell membrane (the formation of gap junctions – synthesis of connexions-

between the walls). Oestrogen also decreases the consistency of cervical mucus by

liquefaction of the cervical plug and sensitizes target tissue to relaxin.

4. Progesterone- The increased foetal production of dehydroepiandrosterone sulphate (DHEA.

S) and cortisol inhibits the conversion of foetal pregnenolone to progesterone. Progesterone

levels therefore fall before labour. It is this alteration in the ratio of progesterone and

oestrogen rather than that of the fall in the absolute concentration of progesterone that is

linked with prostaglandin synthesis.

32
5. Prostaglandins- These are important factors that initiate and maintain labour. The major sites

of synthesis of prostaglandins are the amnion, chorion, decidual cells and myometrium. The

synthesis of prostaglandins is triggered by; the rise in oestrogen level, glucocorticoid,

mechanical stretching of the uterus in late pregnancy, increased in cytokines, infection,

vaginal examination and separation or rupture of the membrane. Prostaglandins enhance gap

junction (inter-membranous gaps between two cells through which stimulus flows)

formation.

6. Oxytocin- This hormone is important for the initiation of labour and expulsion of the foetus.

At term, there is an increase of oxytocin receptor concentration in the myometrium and

decidua. This leads to induction of myometrial contractions. It is increased at term and it

promotes the release of prostaglandin from the decidua. Uterine muscle stimulation during

labour results from the interaction of oxytocin and prostaglandin F2 alpha (PGF2α). Oxytocin

is responsible for the initial phase of labour whereas the synthesis of PGF2α is essential for

the progress of labour.

7. Neurological factors – Labour may start in denervated uterus or through the nerve pathway

via the α and β receptors present in the myometrium. The oestrogen and progesterone act on

the α and β receptors respectively in order to initiate labour. The contractile response is

initiated through the α receptors of the post ganglionic nerve fibres in and around the cervix

and the lower part of the uterus.

33
 Other factors associated with the initiation of labour include increase prostaglandin

production, decrease concentration of progestin and alteration of oestrogen: progesterone

ratio.56

2.4.4 NORMAL PROGRESS OF LABOUR

Labour is a series of events that take place in the genital organs in an effort to expel the viable

product of conception.52 It is characterized by uterine contractions that increase in regularity,

intensity and duration to cause progressive effacement and dilatation of the cervix and permit

descent of the foetus through the birth canal.52 A labour is termed normal when it is spontaneous

in onset at term, the presentation is vertex, without undue prolongation, has natural termination,

with minimal aids and without having complications affecting the health of the mother or the

baby.52, 53 However, any deviation from the above definition is termed abnormal labour.53-54

The progress and final outcomes of labour are influenced by the 5 ”P- factors” which are the

passage (the bony pelvis and the soft tissue of the maternal pelvis), the power (the contractions

or forces of the uterus), the passenger (foetus), the psyche and the provider. Any abnormality in

any of these components may result in dystocia.54-55

Normal labour is a continuous process however; it is divided into four (4) major stages for

research purposes. Each of these stages has its own characteristics and duration. These stages are

first, second, third and fourth stages of labour.52, 56-58

2.4.5 First stage of labour

This stage begins with the onset of regular uterine contraction and ends with complete cervical

dilatation. This stage is further divided into latent phase and active phase of labour.57 This

34
division was done by Friedman as shown in figure 3. The former phase reflects the preparatory

duration. This begins with the onset of regular uterine contractions and extends to the beginning

of the active phase of cervical dilatation.58 The progressive cervical dilatation gives rise to the

symptoms and signs of labour. The plug of mucus at the cervical Os (protecting against the

entrance of bacteria during pregnancy) emerges as show. In pregnancy there is hypertrophy and

hyperplasia of the uterine muscle and the enlargement of the uterus beyond the attachment of the

round ligament. The dilatation of the uterus also reduces the support of the foetal membrane

which later ruptures and initiates active labour. The strength of the uterine contraction increases

from 20mmHg at the onset of labour to 50-80mmHg later during the course of labour. This

process also gives rise to effacement (thinning of the cervix with a shortening of the endocervix),

cervical dilatation and descent of the presenting part. The mean duration is about 8.6 hours. The

active phase which is the dilatational phase begins about 4cm of cervical dilatation and is

characterised by rapid cervical dilatation and descent of the presenting foetal part. The mean

duration of active phase in nullipara is 4.9 hours with standard deviation of 3.4 hours.56 The rates

of dilatation ranged from 1.2cm per hour to 6.8cm per hour. It is considered normal in nullipara

when it is 1.2cm per hour and 1.5cm per hour for multipara. However, in the WHO partograph,

the cervical dilatation rate is 1cm per hour in the active phase. This phase is further divided into

an accelerated phase, phase of maximum slope and a deceleration phase. The first stage of labour

ends with complete cervical dilatation at 10cm.56-58

35
Figure 3: Friedman’s curve showing phase of maximum slope

2.4.6 Second stage of labour

This begins with complete cervical dilatation and ends with the delivery of the foetus. It consists

of two phases; the descent phase (from full cervical dilatation to crowning) and the expulsion

phase which starts from crowning to delivery of the foetus. The time for this stage is between 30

minutes to 3 hours in primigravidae (if regional anaesthesia is administered) or 2 hours in the

absence of regional anaesthesia. In multiparous women it could be up to 1 or 2 hours without or

with regional anaesthesia respectively. Any increase in time beyond the one stated above is

36
termed prolonged second stage of labour. Studies have shown increased risk of poor maternal

outcomes when second stage labour is prolonged.

2.4.7 Third stage of labour

This is the period between the delivery of the foetus and the delivery of the placenta and foetal

membranes. This stage may be managed expectantly via spontaneous delivery of the placenta or

actively which involves prophylactic administration of oxytocin or other uterotonics, cord

clamping and cutting followed by controlled cord traction of the umbilical cord. Study have

shown that active management is superior to expectant management because it shortens the

duration of third stage and reduces the risk of post-partum haemorrhage.56

2.4.8 Fourth stage of labour

This is the stage of observation of the parturient for at least 1 hour after the expulsion of the

placenta and membranes. The general condition of the patient and the behaviour of the uterus are

observed.

2.4.9 Mechanism of labour

This is termed the cardinal movement of foetus in the birth canal that culminates in its

expulsion. The ability of the foetus to successfully negotiate the pelvis during labour involves

changes in the position of its head during its passage.

These movements involve the following:56

a. Engagement- The foetus is said to be engaged when the presenting part enters the maternal

pelvis to a level beyond the plain of the pelvis inlet or the presenting part is at station 0 or at

the level of the maternal ischial spines.

37
b. Descent- This is a downward passage of the presenting part through the maternal pelvis. It is

a continuous process. It is slow or insignificant in first stage of labour but is pronounced in

the second stage. It is completed with the expulsion of the foetus which is facilitated by

uterine contraction, retraction and bearing down efforts.

c. Flexion- This is a passive flexion of the foetal occiput. The chin is brought into contact with

the foetal thorax and the presenting diameter changes from occipitofrontal (approximately

11.0cm) to suboccipitobregmatic (approximately 9.5cm) for optimal passage through the

pelvis. This is achieved either due to the resistance offered by the unfolding cervix, the walls

of the pelvis or by the pelvic floor.

d. Internal rotation- This occurs when the anterio-posterior diameter of the head is brought in

line with the anterio-posterior diameter of the pelvis.

e. Crowning- This occurs after internal rotation. Further descent occurs until the sub-occiput lies

underneath the pubic arch. At this stage, the maximum diameter of the foetal head (bi-

parietal diameter) stretches the vulval outlet without any recession of the foetal head even

after the contraction is over.

f. Extension- This is an extension of the occiput and rotation around the maternal pubic

symphysis. The driving force pushes the head in a downward direction while the pelvic floor

offers a resistance in the upward and forward direction. The remaining forward thrust helps

in extension.

g. Restitution- This is the untwisting of the foetal head about 450 left or right returning to its

original anatomic position in relation to the body. It involves the rotation of the foetal head in

38
 the direction opposite to that of internal rotation. The occiput thus points to the maternal

thigh of the corresponding side to which it originally lay.

h. External rotation- It is the movement of the head visible externally due to internal rotation of

the shoulders. As the anterior shoulder rotates towards the symphyisis pubis from the oblique

diameter through one-eighth of a circle in the same direction as restitution. The shoulders

now lie in the anterior-posterior diameter.

i. Expulsion- This is the complete expulsion or delivery of the foetus out of the birth canal.

2.5 ABNORMAL PROGRESS OF LABOUR

This is also called dysfunctional labour, labour dystocia, failure of progress or cephalopelvic

disproportion. It is described as difficulty in labour characterized by slow progress as a result of

the problem with any of the “3 P’s”- the abnormality involving the passenger (the foetal size or

foetal presentation), abnormalities involving the passage (pelvis) and abnormalities in the power

(uterine contractility). These factors may occur singly or more often in combination. Dystocia

reflects an abnormality in first stage of labour which is usually in 3 forms; prolonged latent

phase, protraction disorder and arrest disorder.59

2.5.1 Prolonged latent phase

Friedman defined prolonged latent phase as when the latent phase is greater than 20 hours in

nullipara and 14 hours in the multipara from the onset of regular painful contraction. However,

according to the WHO partograph, a prolonged latent phase of labour is when the cervix has not

dilated beyond 4cm after 8 hours from the time of admission. Most time this may be difficult to

39
ascertain as it is affected by some factors such as excessive sedation, uterine dysfunction and

false labour.60, 61

2.5.2 Arrest disorders

This diagnosis is made when women in active phase of labour, with adequate uterine contraction

(3 contractions in 10 minutes, each lasting greater than 40 seconds) fail to make progress in

labour. Arrest in labour is represented in 3 patterns; prolonged deceleration (when the

deceleration phase lasts more than 3 hours or 1 hour in nullipara and multipara respectively);

secondary arrest (descent failing to progress for more than 1 hour) and failure of descent (descent

failing to occur during the deceleration or second stage).61-63

2.5.3 Protraction disorders

This is characterized by an abnormally slow rate of cervical dilatation or descent. In nullipara,

the rate of cervical dilatation or descent is less than 1.2 cm per hour or 1 cm descent per hour. In

multipara protraction is defined as less than 1.5 cm dilatation per hour or less than 2 cm descent

per hour. The WHO proposed a labour management partograph in 1994 in which protraction is

defined as less than 1 cm per hour cervical dilatation for a minimum of 4 hours.61-62

2.6 ACTIVE MANAGEMENT OF LABOUR

Active management of labour (AML) is a strategic approach to the management of labour

already established in the active phase, aimed at the prevention of prolonged labour.63-64 It is a

package of care which involves close supervision of labour, early identification of slower

cervical OS dilatation (rate less than 1 cm per hour) and timely treatment in appropriate cases to

40
reduce labour to within 12 hours. This was first proposed by O’driscoll in 1969.65 This package

is based on the following principles:56, 65

1. Active phase of labour is the more important aspect of first stage of labour.

2. Normal progress in active phase is cervical OS dilatation rate of 1cm per hour till delivery.

3. Uterine inertia and not cephalopelvic disproportion (CPD) is commonly the cause of failure

of the cervical OS to dilate at the rate of 1cm per hour in the active phase (especially in

primigravidae).

4. Uterine inertia responds well to oxytocin augmentation with improved cervical OS dilatation

in the active phase and head descent in the second stage.

5. Artificial rupture of membrane (ARM) in the active phase facilitates cervical OS dilatation

of 1 cm per hour.

6. Companion in labour and an assurance that active phase duration will not exceed 12 hours.

AML is an essential obstetric strategy for labour management in developing countries with a

high prevalence of prolonged labour. The modified AML protocol includes;66-67

a. Performing ARM (if membrane is still intact) as soon as active phase labour is confirmed.

b. Recording all findings on the partograph in which there is an alert line and the action line

sited at 4 hours to the right and parallel to the alert line.

c. Repeating vaginal examination at 4 hours (after the first vaginal examination at which active

phase was confirmed) and the descent and cervical OS dilatation plotted on the partograph.

Subsequent vaginal examinations are performed at 2 hourly intervals till delivery.

41
d. Allowing labour to progress till delivery without further intervention when the cervical OS

dilatation is on the alert line or to the left of it.

e. Oxytocin augmentation is begun when the graph of cervical OS dilatation crosses the action

line.

f. Oxytocin augmentation is only for duration of 6-8 hours during which period vaginal

examination is performed 2 hourly. When there is no progress after augmentation in 4- 6

hours, caesarean delivery is performed.

g. Management of third stage is done actively. Studies have shown that active management of

third stage of labour is superior to expectant management.65-67

2.7 THE WHO PARTOGRAPH MODEL

The WHO partograph is a simple tool recommended by WHO to be used in monitoring labour

worldwide. It represents in some ways a synthesized and simplified compromise, which includes

the best features of several partograph. It consists of four components: Patient information, foetal

condition, labour condition and maternal condition.68-71

2.7.1 Patient information

This is a section where patient’s information is recorded. Pieces of this information include

patient’s name, parity, hospital number, date and time of admission as well as the time of rupture

of the membrane.

2.7.2 Foetal condition

Foetal condition or foetal well being is recorded in this section.

2.7.2.1 Foetal heart rate- This is recorded every half hour.

42
2.7.2.2 Amniotic fluid- The colour of the amniotic fluid is recorded at every vaginal examination

and is indicated on the partograph as shown below:

 I: membrane intact;

 C: membranes ruptured, clear fluid;

 M: meconium-stained fluid;

 B: blood-stained fluid.

2.7.2.3 Moulding

 1: sutures apposed

 2: sutures overlapped but reducible

 3: sutures overlapped and not reducible

2.7.3 The labour condition – This is a component that records the progress of labour.

 Cervical dilatation- This is assessed at every vaginal examination and it is marked

with a cross (x). This is plotted on the partograph at 4 cm.

 Alert line- The line starts at 4 cm of cervical dilatation to the point of expected full

dilatation at the rate of 1 cm per hour.

 Action line- This is a parallel line drawn 4 hours to the right of the alert line.

 Descent- This refers to the part of the head (divided into 5 parts) above the

symphysis pubis. This is shown in figure 4 below. It is assessed by abdominal

43
 palpation. It is recorded as a circle (o) at every vaginal examination. At 0/5, the

sinciput (S) is at the level of the symphysis pubis.

Figure 4: Descent of presenting foetal head

 Hour- This is the time elapsed since the onset of active phase of labour.

 Time- Actual time

 Contraction- This is charted every half hour, by palpating the number of contractions in
10 minutes and their duration in seconds.

 Less than 20 seconds :

 Between 20 and 40 seconds:

 More than 40 seconds:

44
  Oxytocin- The amount of oxytocin per volume intravenous fluid in drops per minute

every 30 minutes when used.

 Drugs given: Records of any additional drugs given.

2.7.4 The maternal condition

 Pulse- This is recorded every 30 minutes and marked with a dot (•).

 Blood pressure- This is recorded every 4 hours and marked with arrows. (↕)

 Temperature: This is recorded every 2 hours.

 Protein, acetone and volume: These are recorded every time urine is passed.

2.8 THE PRINCIPLE OF PARTOGRAPH USE

The use of partograph in the monitoring of labour is based on the following principles:56, 68-71

1. The latent phase of labour should not be longer than 8 hours, however, in the new model the

latent phase has been removed and plotting on the partograph begins in the active phase

when the cervix is at least 4 cm dilated to make it simpler and easier to use.

2. The rate of cervical dilatation is 1cm per hour in active phase of labour.

3. A lag time of 4 hours between poor progress of labour and the need for intervention is

unlikely to compromise the foetus and the mother. This enables patients to be transferred

from peripheral clinics to the hospital in sufficient time to avoid risk to mother or foetus.

4. Vaginal examinations should be performed as infrequently as is compatible with safe practice

(once every 4 hours is recommended).

45
Figure 5: The old WHO Partograph

46
Figure 6: Modified WHO Partograph

47
2.9 PROBLEMS WITH THE WHO PARTOGRAPH

Although WHO partograph is excellent for use at primary health care level of which Family

Physicians are major stakeholders, there are some problems with its use which include the

following:56, 68-69

1. The action line is printed at 4 hours to the right and parallel to the alert line. The period of 4

hours may be too late for a meaningful intervention to reverse the causal factor viewing the

action line as the point of definite intervention to correct any slow in progress of labour.

2. The WHO partograph is not a complete record of all aspects of first stage of labour because

it does not provide enough space for documenting all findings in latent phase of labour.

3. Providing space for the record of latent phase of labour may encourage premature

intervention in the prodromal aspect of first stage of labour which requires only passive

management.

4. The use of the alert line in secondary and tertiary health care centres is not clear as

compared to primary health centre where transfer is required when it is crossed. There are

no uniform actions recommended for progress crossing the action line and those between

the alert and action lines.

5. The WHO partograph is not suitable for efficient management of induced labour.

6. It defines active phase of labour as cases touching or crossing action line located at 4 hours

from the alert line. This causes variability and confusion in the concept, diagnosis and

management of prolonged active phase labour.

48
7. It defines active phase only with reference to cervical OS dilatation. It made no reference to

effacement.

It is to be noted that most of these problems resulted from recommendation for the use of

partograph in secondary and tertiary health care centres rather than for the peripheral units where

it was designed for.

2.10 PARTOGRAPH USE AND MATERNAL AND PERINATAL OUTCOMES OF

LABOUR

The increasing maternal and perinatal mortality in developing countries, especially Nigeria, calls

for urgent attention. There is need to improve maternal health delivery in the country. Many of

the causes of these deaths take place in the hospital partly as a result of delay of treatment within

hospital settings.38 Prolonged and obstructed labour are major causes of maternal deaths in

Nigeria. However, these causes are preventable.

The partograph, when used acts as early warning system of obstruction in labour.7, 72
It also

assists in referral decisions in peripheral primary health centres, intervention decision in a

hospital and ongoing evaluation of the effect of intervention.7, 72

The focus of using the

partograph in developing countries is for the prevention of Maternal and Perinatal Mortality as

well as Morbidity related to prolonged labour, whereas in developed countries, it is on early

identification and management of dystocia in order to offer appropriate intervention.7, 73

The Saving Mothers Fourth Report on Confidential Enquiries into maternal deaths in South

Africa led to the development of 10 recommendations about the prevention of maternal and

49
perinatal mortality. Recommendation 8 stated that the correct use of the partograph should

become the norm in each institution conducting births.74

The use of partograph in labour is associated with good maternal and perinatal outcomes of

labour.54 Evidences had shown that correct application of partograph would remarkably reduce

the incidence and outcomes of prolonged and obstructed labour which are reported to be

associated with 8-10% of maternal death. 55-56, 75

A study by Fawole and Huyinbo on the knowledge and utilization of partograph among obstetric

care givers in South West Nigeria, reported that 32.3% used partograph to monitor labour.13 A

similar descriptive cross sectional study at peripheral maternity centres across Nigeria by

Oladapo and Daniel showed only 9.8% of all the personnel routinely used partograph for labour

management.14 These findings depict low utilization of partograph in Nigeria despite its proven

usefulness.

Another study on the impact of training on the use of partograph on maternal and perinatal

outcomes of labour in peripheral centres reported an increase in transfer in labour, reduction in

the duration of labour, incidence of obstructed labour, postpartum haemorrhage, genital sepsis

and perinatal mortality.76 There were also better Apgar scores at 1 and 5 minutes. The authors

concluded that introduction of partograph at peripheral health centres in developing countries

reduced labour complications with a resultant reduction in maternal and perinatal mortality.76

A cross sectional study to assess the knowledge and utilization of the partograph among

midwives in 2 tertiary health facilities in the Niger Delta region of Nigeria concluded that the

50
use of partograph reduces maternal and child mortality.2 The authors, however, identified factors

militating against the use of partograph as; non availability of the partograph (30.3%), shortage

of staff (11.4%), lack of sufficient knowledge in the use of the partograph (22.2%) and excess

time used in completing it (8.6%). These findings were also corroborated by a similar study

which revealed improved maternal and perinatal outcomes with the use of partograph in the

monitoring of labour.77

In an interventional study conducted in Ife Central Local Government Area owned maternity

centres, the use of partograph was associated with increased transfer in labour, reduction in

duration of labour and incidence of obstructed labour. There was also a reduction in perinatal

mortality and neonatal asphyxia. It was also observed that the Apgar scores at 1 and 5 minutes

improved after introduction of partograph. The authors noted an increase in the augmentation of

labour from 9.9% to 13.2%. The rate of vaginal delivery also improved from 1.7% to 4.9%.78

A similar interventional study on the impact of use of the modified WHO partograph on maternal

and perinatal outcomes of labour by Tayede and Jadhoa found a reduction in rate of caesarean

section from 44% to 21%, duration of labour from more than 16 hours to less than 12 hours,

neonatal intensive care admission from 17% to 6%, percentage of women requiring blood

transfusion from 13% to 7%. The WHO partograph was found to be a simple and efficient tool

used in labour management for preventing prolonged labour and its complications in Third

World countries with scarce resources.79

51
Javid et al reported in his work that there was a significant impact of partograph on the duration

of labour and mode of delivery with 94.4% of multigravida delivering within 12 hours when

partograph was used compared to 88.4% when partograph was not used.80 The authors

recommended its use in labour management.

In a descriptive cross sectional study on the implementation of partograph and its effects on the

outcomes of spontaneous labour at term, it was shown that with proper monitoring and

sustenance of partograph use in labour, prolonged labour or obstructed labour and their sequelae

were avoided. The study also showed a reduction in operative interventions and an improvement

in feto- maternal outcomes.81

However, in a Cochrane review of studies on the effect of the use of partograph on outcomes of

labour in women with spontaneous labour at term there was no significant association between

the use of partograph and outcomes in high resource setting. There was no evidence of any

difference between partograph and non-partograph groups in caesarean delivery (RR 64, 95% CI

0.85 to 1.17). The authors however, reported a low caesarean delivery in partograph group when

compared with non-partograph group in low resource setting (RR-0.38, 95% CI – 0.24 to 0.61).82

These findings were corroborated by Windrim et al in a randomised controlled trial of a bed side

partograph used in active management of primiparous labour.73 In 2 different randomised trials

with partograph of 2 hours action lines and partograph with 4 hours action lines, there was no

significant difference in the caesarean section rate (RR- 1.06, 95% CI- 0.85-1.32).83 A similar

study by Leanza et al in a data analysis involving 6 studies of partograph versus non-partograph

52
showed no evidence of significant difference between partograph and no partograph in caesarean

section rates.84

Basu and Buchmann in their work on the role of a second stage partograph in predicting the

outcome of normal labour showed a significant association between the second stage progress,

plotted to the right of the partograph line and non-spontaneous delivery.85 In a prospective non-

randomised study by WHO in South Asia, it was observed that prolonged labour reduced from

6.4% to 3.4% and the proportion of labour requiring augmentation also reduced from 9.9% to

8.3% and still birth from 0.5% to 0.3%.86

A clinical audit of intrapartum care at Delek Tibetan Hospital in North India led to the findings

of a sustained 50% reduced incidence of post-partum haemorrhage following the introduction of

the routine use of the partograph in the management of labour. It was also associated with a more

rational decision making process regarding transfers during labour.87

In an audit of the use of partograph in labour monitoring in University College Hospital, Ibadan,

it was shown that its use significantly influenced decision making and was also associated with

positive labour outcomes among low and high risk parturients.88 Also an interventional study to

evaluate WHO partograph implementation by midwives for maternity home birth in Medan City,

Indonesia showed that introduction of the partograph significantly increased referral rate and

reduced the number of vaginal examinations, oxytocin use and obstructed labour.89 The authors

concluded that WHO partograph should be promoted for use by midwives at maternity homes.

53
A population based case control study conducted in Brazil showed that non use of partograph

during labour was associated with perinatal deaths. The authors concluded that there was an

association between the use of partograph in labour and good foetal outcomes.90 Similar study in

Uganda found that good Apgar score was statistically and significantly associated with standard

foetal monitoring.91

54
 CHAPTER THREE

MATERIALS AND METHOD

3.1 STUDY SITE

The study was carried out in Gambo Sawaba General Hospital, one of the Kaduna State owned

secondary health care facility. It is located in Kofan Gaya in Zaria City, Zaria Local Government

Area, one of the highly populated indigenous settlements in Zaria. The inhabitants are mainly

Hausa and Fulani tribes as well as other minority tribes. The population of Zaria was put at

1,408,198 people as stated in the 2006 census report.27 Gambo Sawaba General Hospital is a

100- bed hospital that provides both primary and secondary health care services in the

following departments and units; Internal Medicine, Paediatrics, Surgery, Obstetrics &

Gynaecology, Dentistry, Ophthalmology and Accident/Emergency. Maternity healthcare service

is a major service that is being provided by the hospital. These included: antenatal care, labour

and delivery services, post-natal-care and family planning services. The hospital is equipped with

qualified doctors, midwives and other auxiliary staff. It is one of the outreach health facilities

under Ahmadu Bello University Teaching Hospital (ABUTH), Zaria providing community

services to the populace and skills for resident doctors. There was a record of 10-12 deliveries at

the hospital in a day with an average of 350 deliveries per month during the period of the study.

3.2 STUDY POPULATION

The study population comprised of all pregnant women who sought services at the hospital for

labour and delivery.

3.3 STUDY DESIGN

This is a non- randomised interventional (Quasi experimental) study in which the decision about

exposure and non exposure to a factor under consideration is made by the investigator but the

55
allocation of subjects into the intervention and control groups are done without randomization.15

Partograph was not in use in Gambo Sawaba General Hospital, Zaria. Partograph was introduced

to the intervention group and the maternal and perinatal outcomes of labour were compared with

those of the control group.

3.4 SAMPLE SIZE

The sample size was determined using the formula below which is used for comparing an

experimental group against a control group.15

n’=2Z2pq

d2

This is used for determining sample size when a test difference between two sub- sample

regarding a population with equal number of cases, is desired. (n’=n1=n2).15

Where n1- sample size for the control group

n2- sample size for the cases or intervention group.

z- The standard normal deviate usually set at 1.96 which corresponds to 95% confidence level.

p- The proportion in the population estimated to have a particular characteristic. A value of 9.8%

which represented the proportion of the use of partograph for labour management at peripheral

maternity centres in Nigeria was used in this study.14

q= 1- p

d- Degree of accuracy desired set at 0.05.15

n’= 2x1.96x1.96x0.098x0.902 = 0.67916415 =271.6 = 272.

0.05x0.05 0.0025

56
3.5 SAMPLING METHOD

Consecutive consenting women admitted into the labour room were screened and 272 women

who met the inclusion criteria were enrolled into each of the control (non- partograph group) and

the intervention group (partograph group) until the sample size was attained.

3.6 STUDY DURATION

The study duration was three months.

3.7 SELECTION CRITERIA

3.7.1 INCLUSION CRITERIA

The study included all consenting women with the following;

1. full term pregnancies

2. singleton pregnancies

3. cephalic presentation and

4. spontaneous labour in active phase of labour

3.7.2 EXCLUSION CRITERIA

1. Women with high risk pregnancies (women with severe anaemia, pre-eclamsia,

eclampsia, diabetes mellitus, immune compromised status (retroviral disease), preterm

labour, post-datism, ante-partum haemorrhage, intrauterine growth retardation,

premature ruptured of membrane and intrauterine foetal death.

2. Women with admission cervical dilatation above 8 cm (this was to allow for monitoring

of labour for at least 2 hours before delivery).

3. Women scheduled for elective caesarean delivery.

This was to ensure that extraneous and confounding factors were removed from the study.

57
3.8 TOOL FOR DATA COLLECTION

The content and consensual validity of this tool was done by giving it to two experts

independently (consultants Obstetricians at ABUTH, Zaria) to review and examine the

relevance, appropriateness and adequacy of the items in each of the subsections. The consensual

feedback from these experts was used to improve the first draft. The final form of the tool

reflected the expert judgement of the Obstetricians. The tool, interviewer-administered

questionnaire/data recording form, (Appendix-2-) was then used to collect information about the

participants after it has been pretested in a nearby primary health care centre to determine its

clarity, applicability and face validity. This instrument is divided into 2 sections. Section A

recorded information about the participants’ age, marital status, address, tribe, religion,

educational status, occupation, gravidarity, parity, pregnancy booking status, number of antenatal

visits, participant’s and her husband’s income. Section B consisted of four parts. The first part

recorded information about the socio-economic index scores of the participants. The second part

recorded information about the maternal outcomes; mode of delivery, perineal tear, duration of

first and second stages of labour, need for augmentation of labour, postpartum haemorrhage,

other maternal morbidity and maternal death. The third part recorded information about perinatal

outcomes; neonatal Apgar score (a score that evaluates newborn infants’ need for resuscitation or

monitor response to resuscitation immediately after birth), condition of baby, average foetal heart

rate and indication for neonatal intensive care unit (NICU). The fourth part recorded information

about maternal weight, height, blood pressure, symphysis-fundal height and urinalysis.

3.9 STUDY PROTOCOL

Doctors and midwives of the hospital were trained on the use of the modified WHO Partograph

(Apendix-3-) and an assessment of their competence on its use was done. This training was a

58
refresher to the one done by Society for Family Health in conjunction with Ahmadu Bello

University Teaching Hospital in year 2014. It was then used to monitor labour in the partograph

group while delivery was conducted in the control group without the use of partograph as it was

being done at the centre. The partograph was used on every alternate patient. In this study, the

socio-economic status described by Olusanya in his work was adopted.92 Socio-economic index

score was awarded to each patient based on her educational attainment and the occupation of her

husband. The family income was a derivative of both the woman’s educational level and her

husband’s occupation. For occupation, a score of 1 was allocated to senior public servants,

professionals, managers, large scale traders, businessmen and contractors: 2 to middle level

workers such as teachers, artisans and small scale traders: 3 to unskilled labourers and

unemployed. For educational level, a score of 0 was awarded to those with post secondary

education, 1 to those with post primary and 2 to those with primary school education or less.

From the above, a socioeconomic index score was obtained from the addition of the educational

score and the occupational score levels which ranged from 1 to 5. An index score of 1 and 2 was

classified as upper socioeconomic class. A score of 3 was classified as middle socio-economic

class while scores of 4 and 5 were classified as lower socio-economic class.92

The variables measured were those of immediate maternal and perinatal outcomes of labour. The

immediate maternal outcomes (and those up to 48 hours post-delivery) that were measured

included; duration of first and second stages of labour, need for augmentation of labour, mode of

delivery, post-partum haemorrhage, perineal laceration, episiotomy, ruptured uterus and maternal

death. The immediate perinatal outcomes (and those up to 48 hours post-delivery) that were

measured included; neonatal Apgar scores at 1 and 5 minutes, condition of birth (live birth and

immediate neonatal death), indications for admission in NICU (meconium stained liquor,

59
respiratory distress, delayed cry and low birth weight). The newborns were not followed up to 28

days post-partum because of the anticipated problems of neonatal follow up in the environment

where the study was carried out and also to exclude other extraneous or confounding factors that

may arise from that.

Maternal weight was measured to the nearest 0.1kg with a portable weighing scale (CAMIRY®

mechanical personal scale-Model: BR 9011) after it had been adjusted to point zero. The unit of

measurement was kilogram. The weight was taken with the participant wearing only the labour

room gown without shoes. It was taken three times and the average of the measurements was

taken as the weight of the participant.

The height was measured with a standiometer placed on a flat surface. The participants stood on

the basal part of the device with the feet together (without shoes), the shoulders, buttocks and the

heels torching the vertical measuring board. They were standing with their eyes in the Frankfort

horizontal plane and the height was measured to the nearest 0.1m.

The blood pressure was measured with a manual blood pressure cuff with a mercury

sphygmomanometer (Accoson®). The participants remained seated for at least 5 minutes. During

this time, they relaxed comfortably in a chair with back support, legs uncrossed, and feet rest

comfortably on the floor. Consumption of caffeinated products such as coffee, cola or tea was

avoided for at least 30 minutes prior to blood pressure measurement. An adequate cuff size of a

mercury sphygmomanometer based on the participant’s arm was chosen. The cuff was placed on

either the right or the left arm of the participant covering 75% of the arm between the acromion

and olecranon. While obtaining the blood pressure, neither the participants nor the person

obtaining the blood pressure talked. The bell of the stethoscope was placed lightly over the

60
brachial artery. The cuff was inflated 30 mmHg above the level at which the radial pulse was no

longer palpable. While slowly deflating the cuff (approximately 2-3 mmHg per heart beat), the

first and fifth Korotkoff sounds were taken as the systolic and diastolic blood pressure

respectively. A second blood pressure measurement was taken after 2 minutes and the average of

the 2 measurements was recorded as the participant’s blood pressure. The blood pressure was

measured at the other arm. Where a measurement discrepancy existed between the 2 arms, then

the arm with the highest measurement was used.

The symphysis-fundal height (SFH) was measured by first locating the upper boarder of the

uterine fundus by the ulnar side of the left hand and this point was marked. The distance between

the upper borders of the symphysis pubis up to the marked point was measured by a tape in

centimetres. The symphysis-fundal height measured in centimetres corresponds to the number of

weeks up till 36 weeks. A variation of +/- 2 cm was accepted as normal.

The foetal heart rate was measured with a Pinnard’s stethoscope. The participants were laid in

supine position and the uterus palpated to determine the position of the foetus. The wide end of

the Pinnard’s stethoscope was placed about half way between the umbilicus and the pubic

symphysis and about 2 cm to the left (when the foetus was in left occipito-posterior) or right

(when the foetus was in right occipito-posterior). This aimed at a point in between the shoulders

of the foetus. The examiner’s ear was placed on the other end (the flat side) of the stethoscope to

listen to and count the foetal heart rate while the maternal radial pulse was being palpated at the

same time to avoid mistaking the uterine vessels pulsation for foetal heart rate. The foetal heart

rate was counted for 1 minute and the value was recorded and charted on the partograph. These

measurements were done after uterine contractions had waned.

61
Capillary blood sample was taken for bed side random blood glucose measurement (Using

ACCU-CHEK® glucometer) and haemoglobin estimation (using haemocol 301®).

3.10 DATA ANALYSIS

The Statistical Package for Social Science (SPSS) version 20 was used to analyse the data.

Discrete variables were expressed as percentages and presented as frequency tables and bar

charts. Chi square test was used to test association between categorical variables. Statistical

significance was accepted at P-value of less than 5 (P= < 0.05).16

3.11 HYPOTHESIS TESTING

Hypothesis testing is a process undertaken to either accept or reject a null hypothesis. In this

study the P-value approach method was used for this process.15-16 The P value is computed and

decision on the type of test to use is taken (whether right tailed, left tailed or 2 tailed). The Null

hypothesis H0 is rejected in favour of the alternative hypothesis H1 at α X 100% level of

significance, if P-value is less than α. P-value is the smallest level of significance at which H0

would be rejected.16

3.11.1 STEPS IN TESTING HYPOTHESIS

1. Set the hypothesis- This consists of making a formal statement of the null hypothesis (H0) and

the alternative hypothesis (H1). In this study the null hypothesis (H0) stated that there was no

association between the use of modified WHO partograph and maternal as well as perinatal

outcomes of labour while the alternative hypothesis (H1) stated that there was an association

between the use of modified WHO partograph and maternal as well as perinatal outcomes of

labour. If H1 is of the type > or < type, a one tailed test (either the right or the left tailed) is used.

62
But when H1 is of the type “whether greater or smaller” then a 2 tailed test is used. In this case a

2 tailed test was used.

2. Select a significance level- These hypotheses are tested on a pre-determined level of

significance which was put at 5% level.

3. Decide on which test statistics to use- In this study, the test statistics used was the P value

approach. The P value was computed using SPSS version 20.16

4. Determine the critical value- The critical value used in this case was the level of significance α

which was 0.05.

5. Decide whether to reject or accept the null hypothesis- Comparing the value of the test

statistics and critical value, a decision is made. (a) The Null hypothesis is rejected when the

value of the test statistic is less than the lower critical value or value of test statistics is greater

than the upper critical value, in the case of a 2 tailed test. (b) when the test statistics is greater

than the critical value in case of the right tailed test and (C) when the values of the test statistics

is less than the critical value, in case of the left tailed test.16

3.12 ETHICAL CONSIDERATION

Ethical approval was obtained from the Ethical Review Committee of Kaduna State Ministry of

Health (Appendix-4- ) and Ethical Review Committee of Ahmadu Bello University Teaching

Hospital, Zaria (Appendix-5- ). A letter of permission was also obtained from Gambo Sawaba

General Hospital, Zaria (Appendix-6- ). Informed written consent (Appendix-1- ) was obtained

from the participants. The nature, purpose and procedure of the study were explained to the

participants. Only participants that consented by signing the written consent were recruited into

the study, while the management of the non-consenting patients was not compromised.

63
3.13 BUDGET

This study involved the use of instruments like weighing scale, sphygmomanometer and

urinalysis strips. These instruments were purchased by the researcher, with no financial

contributions from the participants. All finances required for the study was provided by the

researcher.

64
 CHAPTER FOUR

PRESENTATION OF RESULTS

Table 1: Distribution of Socio-demographic characteristics of the participants (n1=n2=272)

Variables Control (%) Intervention (%) X2 p-value
Age Interval
≤ 19 33(12.1) 33(12.1)
20-24 112(41.2) 112(41.2)
25-29 53(19.5) 54(19.9)
30-34 45(16.5) 45(16.5)
≥35 29(10.7) 28(10.3)

Marital Status
Single 11(4.0) 2(0.7) 0.513 1.00
Married 251(92.3) 266(97.8)
Divorced 1(0.4) 2(0.7)
Separated 8(2.9) 1(0.4)
Widowed 1(0.4) 1(0.4)

Level of Education
No formal Education 197(72.4) 186(68.4) 11.568 0.239
Primary 55(20.2) 63(23.2)
Secondary 14(5.2) 18(6.6)
Post secondary 6(2.2) 5(1.8)

Religion
Christianity 21(7.7) 58(21.3) 0.969 0.325
Islam 251(92.3) 214(78.7)
Tribe
Hausa/Fulani 232(85.3) 238(87.5) 2.048 0.563
Igbo 7(2.6) 10(3.7)
Yoruba 20(7.4) 15(5.5)
Others 13(4.8) 9(3.3)

Socio-economic Class
Upper class 11(4.0) 9(3.3)
Middle class 31(11.4) 27(9.9)
Lower class 236(84.6) 236(86.8)

65
Majority of the participants in both groups (the control and intervention) were within the age

group of 20-24 years (41.2%). Majority of the participants were married in both groups (92.3%

and 97.8% in control and intervention groups respectively) while an insignificant percentage of

them were widows (0.4% in the intervention and nil in control groups).

Also, majority of the participants had no formal education (72.4% and 68.4% in the control and

intervention groups). However, a small percentage of the participants have secondary education

5.2% and 6.6% in both groups (control and intervention groups). Most of the participants were

Muslims (92.3% and 78.7% in both control and intervention groups). A large proportion of the

participants were of the Hausa/Fulani tribe (85.3% in control and 87.5% in intervention groups)

whereas 15.1% of the participants in the control group and 12.4% of the participants in the

intervention group were Yoruba and other tribes.

Majority of the participants were of lower socio-economic class (84.6% and 86.8% in the control

and intervention groups) whereas less than two-fifth of the participants was in the upper and

middle socio-economic classes (15.4% and 13.2% in the control and intervention groups).

The details of the socio-demographic characteristics of the participants are shown in table 1.

66
 200

188
180

176

160

140

120

100 CONTROL
INTERVENTION

80

73
60 66

40

20 23
18

0
GROUP 1 GROUP 2 GROUP 3

Figure 7: Showing distribution of occupation among the participants (n1=n2=272)

Group 1-Upper level worker Group 2 – Middle level worker Group 3 – Lower level worker

Majority of the participants were lower level workers, group 3 (64.7% and 69.1% in the control

and intervention groups). Meanwhile, an insignificant percentage of the participants were upper

67
level workers’ group in both the control and intervention groups (8.5% and 6.6% respectively).

The details of the occupation of the participants are shown in figure 7.

68
 Table 2a: Distribution of maternal outcomes of labour among the participants (n1 = n2 =
272).

Outcomes Control (%) Intervention x2-value p-value

(%)
Mode of delivery 9.354 0.009

Spontaneous vaginal
204(75) 232(85.3)
delivery
Instrumental delivery 24(8.8) 12(4.4)
Caesarean section 44(16.2) 28(10.3)

Perineal laceration
(degree) 30.306 0.0001
1st 56(20.6) 20(7.4)
2nd 26(9.6) 11(4.0)
3rd 26(9.6) 11(4.0)
4th 5(1.8) 3(1.1)
None 159(58.5) 227(83.5)
Duration of first stage of
19.063 0.0001
labour (in hours)
<8 104(38.2) 154(56.6)
8-12 115(42.3) 86(31.6)
13-16 30(11.0) 18(6.6)
>16 23(8.5) 14(5.2)
Duration of second stage of
40.945 0.0001
labour (in hours)
<1 86(31.6) 157(57.7)
1-2 109(40.1) 80(29.4)
>2 77(28.3) 35(12.9)
n1= sample size in control n2= sample size in intervention

69
Majority of the participants had spontaneous vaginal delivery (SVD) in the intervention group

(85.3%) and about three-fourth of the participants (75%) in the control group. Also, 16.2% of the

participants had caesarean delivery in the control group and 10.3% in the intervention group.

A significant proportion of the participants had no perineal laceration (58.5% in control and

83.5% in the intervention groups). Whereas less than a quarter of the participants in the control

group (20.6%) and 7.4% in the intervention group had 1st degree laceration. More than half of

the participants in the intervention group (56.6%) had duration of first stage of labour less than 8

hours and 42.3% of the participants in the control group had their duration of first stage of labour

between 8-12 hours. Majority of the participants in the intervention group (57.7%) had their

duration of second stage of labour less than 1 hour while almost one-third of the participants

(28.3%) in the control group had their duration of second stage of labour greater than 2 hours.

70
 Table 2b: Distribution of maternal outcomes of labour among the participants (n1 = n2 =
272)
Outcomes Intervention
Control (%) x2-value p-value
(%)

Episiotomy 5.962 0.015

Yes 63(23.2) 41(15.1)
No 209(76.8) 231(84.9)

Need for augmentation of

labour 17.467 0.0001
Yes 88(32.4) 46(16.9)
No 184(67.7) 226(83.1)

Post-partum haemorrhage 3.931 0.047

Yes 68(25.0) 49(18.0)
No 204(75.0) 223(82.0)

Ruptured uterus
Yes 0(0.0) 0(0.0)
No 272(100.0) 272(0.0)

Maternal death
Yes 0(0.0) 0(0.0)
No 272(100.0) 272(100.0)
n1= sample size in control n2= sample size in intervention

About a quarter of the participants in the control group had episiotomy (23.2%) while majority

(84.9%) had no episiotomy in the intervention group. Majority of the participants (83.1%) in the

intervention group had no need for augmentation of labour. About one-third of the participants in

the control group (32.4%) had need for augmentation of labour.

71
Less than a quarter of the participants (18%) had post-partum haemorrhage in the intervention

group while 82% had no post-partum haemorrhage in the same group. There was no incidence of

ruptured uterus or maternal death. The details of the findings on maternal outcomes of labour of

the study are shown in tables 2a and b.

72
 Table 3: Distribution of perinatal outcomes of labour among the participants in both
groups (control & intervention). n1 = n2 = 272

Control Intervention
Outcomes X2-value p-value
(%) (%)

Neonatal Apgar score in 33.56 0.003

1 minute
<7 73(26.8) 39(14.3)
≥7 199(73.2) 233(85.7)

Neonatal Apgar score in 11.371 0.001

5minutes
<7 50(18.4) 31(11.4)
≥7 222(81.6) 241(88.6)

Condition of baby 5.422 0.020

live birth 252(92.7) 264(97.1)
Immediate neonatal death 20(7.4) 8(2.9)

Indication for admission in

23.221 0.0001
NICU
Meconium aspiration 12(4.4) 4(1.5)
delayed cry 10(3.7) 3(1.1)
Respiratory distress 13(4.8) 5(1.8)
Low birth weight 5(1.8) 1(0.4)
n1= sample size in control n2= sample size in intervention

Majority of the participants in the intervention group (85.7%) had babies with Apgar score of

greater than or equal to 7 in 1 minute. Less than a quarter (18.4%) of the participants had babies

with Apgar score of less than 7 in 5 minutes in the control group. Also, majority of the

participants in both groups had live births (92.7% in the control and 97.1% in the intervention

73
groups). Respiratory distress (4.8% in the control and 1.8% in the intervention groups) accounted

for the commonest indication for admission into the NICU. The average foetal heart rate in the

control and intervention groups were 141 and 143 beats per minute respectively.

The details of the perinatal outcomes of labour in this study are shown in table 3.

74
Comparison of maternal outcomes of labour of participants in both groups (control and
intervention)

There was a significant reduction in the participants who had episiotomy in the intervention

group as compared to the control group (X2=5.962, P=0.015). The need for augmentation of

labour in the control group was more than that of the intervention group (X2= 17.467, P

=0.0001).

A greater percentage of the participants (82.0%) had no post-partum haemorrhage in the

intervention group when compared with the control group (75%) (X2= 3.931, P= 0.047). There

was no incidence of uterine rupture or maternal death in both groups.

There was a significant improvement in the mode of delivery in the intervention group as

compared to the control group (P=0.009, X2=9.354). There was a reduction in the rate of

caesarean delivery and instrumental delivery in the intervention group (10.3%, 4.4%) as

compared to 16.2% and 8.8% in the control group. There was also a reduction in the perineal

laceration in the intervention group (16.5%) compared to the control group 41.6% (X2=30.306,

P=0.0001).

The duration of first stage of labour in the control group was more than that of the intervention

(X2=19.063, P=0.0001) while that of the second stage of labour was lesser in the intervention

group as compared to the control group (X2=40.945, P=0.0001).

The details of the comparison of the maternal outcomes of labour in both groups are shown in

tables 2a and 2b.

75
Comparison of perinatal outcomes of labour of participants in both groups (control &
intervention)

There was a significant improvement in the Apgar scores of babies (of the participants) in 1

minute in the intervention group as compared to the control group (X2=33.56 P=0.003). A lower

percentage (81.6%) of babies (of the participants) in the control group had Apgar score (in 5

minutes) of greater than or equal to 7 compared to the 88.6% in the intervention group

(X2=11.371, P=0.001).

There were better outcomes in the condition of the babies of the participants in the intervention

group compared to the control group (x2=5.422, P=0.020). Also there were lesser indications for

admission in NICU in the intervention group as compared to the control group (X2=23.221,

P=0.0001). The details of the comparison of perinatal outcomes of labour in both groups are

shown in table 3.

RESULT OF HYPOTHESIS TESTING

The P-value approach was used to test the hypothesis in this study. The hypotheses (the null and

alternative) were set as stated earlier. A significant level α which is 0.05 was chosen. The P-

value was computed for the variables as shown in tables 3a, 3b and 4. These were; mode of

delivery (P=0.009), perineal laceration (P=0.0001), duration of first stage of labour (P=0.0001),

duration of second stage of labour (P=0.0001), episiotomy (P=0.015), need for augmentation of

labour (P=0.0001); post-partum haemorrhage (P=0.047), Apgar score in 1 minute (P=0.003),

Apgar score in 5 minutes (P=0.001), condition of baby (P=0.020), indication for admission in

NICU (P=0.0001).

76
The P values stated above were less than the level of significance α (0.05). Therefore, the Null

hypothesis which stated that there was no association between the use of modified WHO

partograph and maternal as well as perinatal outcomes of labour was rejected in favour of the

alternative hypothesis.

77
 CHAPTER FIVE

DISCUSSION

Maternal Mortality and Morbidity are on the increase in Nigeria particularly in the Northern part

of the country even though nearly all the causes are preventable.5 Every maternal death is an

28
event that could have been avoided and should never have been allowed to happen. The

partograph is a simple and efficient tool designed for intrapartum management of labour. This

tool was found to have significantly improved the maternal and perinatal outcomes of labour

among the participants.

The findings in this study provided evidence that the use of the modified WHO partograph

improved both the maternal and perinatal outcomes of labour. The age distribution, socio-

economic status and obstetric characteristics in both the control and intervention groups were

similar, providing a more robust basis for comparison and demonstration of the effect of the use

of partograph in labour.

Majority of the participants in this study (both groups) were in the age group of 20-24 years

(41.2%). This is similar to the finding of 21-25 years as the modal age in a previous study done

in Ife.78 Also majority of the participants in a study done in Bangladash fell into the age group of

21-30.81 In a similar study on the role of partograph on the outcomes of spontaneous labour by

Sanyal and Goswami, majority of the participants were in the age group of 21-29 years.93

78
The findings in this study might be due to the facts that majority of the people in the study

within that age group were already married and had started their family. This reflected the

cultural and religious beliefs of the people in the study area in early marriage.

A low percentage of the participants (12.1%) fell into the age group of <19 years and between

10.3% to 10.7% of the participants were ≥ 35 years age group (in both the intervention and

control groups). These low percentages might be as a result of the teenage participants and the

older ones delivering at home or patronizing traditional birth attendants rather than using the

health care institutions. This might have resulted from the inability of the teenage participants to

take independent decision or the older ones relying on the experiences of their previous delivery.

It was also noted in this study that less than a quarter of the participants (20.2% and 23.2%) in

both the control and intervention groups had primary school education as compared to a large

proportion with no formal education (72.4% and 68.4%) in both groups even though the

minimum expected educational qualification stipulated by the Millennium Development Goal is

a primary school education. This finding is contrary to that of 4% and 12% in a previous study.78

A low percentage of the participants had secondary school education in this study (5.2% and

6.6% in control and intervention groups) as against 49% and 56% in the intervention and control

group according to Tayade and Jadhoa and 38.5% in a study on the use of partograph in labour:

analysis of its application in different care models by Agulav et al.79, 94

79
The findings of the educational distribution of the participants in this study might be due to the

religious and cultural beliefs of the people where female hardly go to school as compared to

those in the similar studies referenced above in which the culture of the study population

permitted more women education. The lower socio-economic class of a large percentage of

participants (84.6% and 86.8% in both the control and intervention groups) might have also

accounted for these educational findings.

The use of partograph had been shown in this study to improve the mode of delivery. Among the

participants in this study, the spontaneous vaginal delivery increased from 75% to 85.3% with a

commensurate reduction in operative delivery (from 8.8% and 16.2% for instrumental and

caesarean delivery to 4.4% and 10.3% respectively). This was statistically significant (P=0.009).

This is similar to an interventional study conducted in Ife where the rate of vaginal delivery

improved from 1.7% to 4.9% and the rate of caesarean delivery also decreased from 6.6% to

4.5%.78 Tayade and Jadhao reported a reduction in caesarean delivery from 44% to 21%.79 These

findings were also corroborated in a descriptive cross sectional study on the implementation of

partograph and its effects on the outcomes of spontaneous labour at term where a reduction in

operative delivery was recorded.81 This similarity may be attributed to the consistency of the

effectiveness of the use of partograph on labour care.

Meanwhile, a Cochrane review on the studies of partograph use on outcomes of labour in women

in spontaneous labour at term by Levander et al reported no significant difference between the

partograph and non-partograh groups in caesarean delivery rate.82 Also, in a study on two

80
different randomised trials with partograph, there was no difference in the caesarean delivery

rate.83 These findings were also similar to those found by Leanza et al in a data analysis

involving 6 different studies of partograph versus non-partograph group.84

The difference in their findings and that of this research work might be due to the difference in

the study settings where the studies were conducted. This study was conducted in a low resource

setting compared to those of other studies which were conducted in high resource settings. This

deduction further buttressed the finding in the Cochrane study quoted earlier where a low

caesarean delivery was reported as compared to that of the non-partograph group.82

The improvement or reduction in the operative delivery with a corresponding increase in the

spontaneous vaginal delivery in this study might be due to the use of partograph which helped in

close monitoring of labour, hence a reduction or prevention of likely causes or indications for

operative delivery in the participants. It also prevented unnecessary caesarean delivery that

would have been done in the partograph group. The implication of this finding is the reduction in

the financial and psychological burden on patient, length of hospital stay and other complications

of surgery.

It was also noticed that there was a reduction in the duration of labour with the use of partograph

in this study, from 19.5% to 11.8% in the duration of first stage of labour greater than 12 hours

(P=0.0001). Those of second stage of labour (less than 1 hour) also improved from 31.6% to

57.7% (P=0.0001). The duration of second stage of labour (greater than 1 hour) reduced from

81
68.4% to 42.3% (P=0.0001). An earlier study reported a reduction in the duration of labour (for

labour lasting > 12 hours from 18.6% to 3.7%).76 Another study conducted in Ife reported a

decrease in the duration of labour.78 A similar study revealed a reduction in duration of labour

from more than 16 hours to less than 12 hours.79 A study by Javid et al also reported a significant

reduction in the duration of labour with the use of partograph with a reduction from 94.4% to

88.4% of people whom partograph was used to monitor their labour as compared to those whom

partograph was not used.80 Prolonged labour was also found to be reduced with the use of

partograph in a descriptive cross sectional study in the implementation of partograph on

outcomes of spontaneous labour at term.81 A reduction from 6.4% to 3.4% in prolonged labour

was recorded by Busu and Buchmann.85

Findings in this study could be due to the use of partograph that permitted immediate

intervention where the needs arose which in turn helped to shorten the duration of labour. It is

important to note that, the effect of partograph on the duration of labour will further bring about

a reduction in maternal and neonatal mortality as well as morbidity. It is also important to note

that there was no study found (within the limit of the literature search) that reported a contrary

findings.

The need for augmentation of labour decreased from 32.4% to 16.9% with the use of modified

WHO partograph (P=0.0001). This was similar to the finding of a study by Basu and Buchmann

who found a reduction from 9.9% to 8.3%.85 Also a reduction in augmentation of labour was

reported in an interventional study to evaluate WHO partograph implementation by midwives for

82
maternity homes.89 However, a previous study conducted in Ife reported an increase in the need

for augmentation of labour from 9.9% to 13.2% with the use of partograph.78 This difference

noted may be as result of the difference in the methodology of the two studies. The study (in Ife)

was a retrospective cohort while this study was a quasi experimental design. The findings in this

study might be related to the indiscriminate use of oxytocin for labour in the study centre when

partograph was not being used. Many of the maternity care-givers see oxytocin as a catalyst for

delivery, hence its frequent use even when there were no indications for its use.

The percentage of participants who had post-partum haemorrhage reduced from 25% to 18%

(P=0.047) with the use of partograph in the study. A reduction in the incidence of post-partum

haemorrhage was also reported in an observational study on the impact of training in the use of

partograph on maternal and perinatal outcomes of labour.76 There was a reduction from 13% to

7% of participants with post-partum harmorrhage after the use of partograph in a previous

study.79 Also, in a clinical audit of intrapartum care in India, a sustained 50% reduction in post-

partum haemorrhage was recorded after introducing partograph in the management of labour.87

This finding was not unconnected with the efficacy of the partograph use in decreasing the

incidence of instrumental delivery, episiotomy and perineal laceration, hence a reduction in the

incidence of post-partum haemorrhage that could have resulted from such procedures.

There was a significant reduction in the percentage of the participants who had perineal

laceration and episiotomy from 41.6% and 23.2% in the control and intervention groups to

16.5% and 15.1% (P=0.0001 and 0.015 respectively). Although studies on the effect of

83
partograph on labour that measured such variables were not obtained in the course of this study,

these findings were not surprising as the use of partograph had demonstrated a reduction in the

incidence of instrumental delivery which invariably might have contributed to the decrease in the

incidence of episiotomy and perineal laceration. Also, the adequate monitoring of labour when

partograph was used might have also helped in preventing or reducing the incidence of

participants bearing down before full cervical dilatation. The incidence of prolonged labour was

also reduced in this study, hence a reduction in the percentages of the participants that would

have had episiotomy and perineal laceration.

In this study, there was no maternal death recorded despite the significant number of participants

with post-partum haemorrhage (21.5%) recorded. However, this can be explained by the fact that

all cases of post-partum haemorrhage were detected early and managed before significant

haemodynamic instability sets in. This is contrary to situations where parturients deliver at home,

develop post-partum haemorrhage and got delayed before presentation at the hospital. Secondly,

many of these patients in the study area do come with many relations (many of whom readily

donate blood when the need arises) hence making an effective blood transfusion service in the

centre very effective. In this study there was a significant improvement in the neonatal Apgar

score of ≥7 from 73.2% to 85.7% in 1 minute when partograph was used (P=0.033). Also a

significant reduction was seen in the Apgar score of ˂7 in 5 minutes from 18.4% to 11.4%. A

previous study reported a better Apgar score at 1 and 5 minutes.76 This was similar to a study in

Ife which reported an improvement in Apgar score at 1 and 5 minutes after introduction of

84
partograph (from 17.4% to 1.7% in babies with Apgar score <7 and from 82.6% to 98.3% in

those with Apgar score ≥7).78 A population based study also corroborated this finding.91 An

earlier study also found a reduction in the percentage of participants whose babies had Apgar

score of ˂7 in 1 and 5 minutes when partograph was used.79 The use of partograph enabled

effective intrapartum foetal monitoring thereby serving as a tool in decision making in the hand

of the maternal health care providers to intervene appropriately. Hence, an improvement in the

neonatal Apgar scores of babies of the participants in whom partograph was used.

There was a significant decrease in the percentage of the babies that required NICU admission

for participants whom partograph was used (from 14.7% to 4.8%). This finding was also

corroborated by similar finding in previous study where the incidence of admission of babies into

NICU decreased from 17% to 6%.79

The percentage of live birth in this study was also observed to have improved from 92.7% to

97.1% with the use of partograph (P=0.020) leaving 2.9% and 7.4% accounting for perinatal

mortality in both the intervention and control group. A reduction in perinatal mortality was

reported in two previous studies.2, 78 Basu and Buchmann in their study reported a reduction in

early (immediate) neonatal death from 0.5% to 0.3%.85 Similar studies in Brazil and Uganda also

reported significant improvements in foetal outcomes with the use of partograph.90, 91

85
 CHAPTER SIX

CONCLUSION AND RECOMMENDATIONS

6.1 CONCLUSION

Obstetric care is an important way of improving the health indices of a nation. The word

Obstetrics, coined from the Latin words ‘Ob stare” which means “I stand by,” demonstrates one

of the role of obstetricians/maternal health providers which is standing by pregnant women

watchfully and with the expectation of appropriate intervention in the course of labour.35

An ideal tool for such monitoring is the partograph which is a pictorial representation of labour.

It is important to note that, a picture is worth a thousand word, so when a partograph is

adequately utilised, it provides comprehensive information about the progress of labour when

compared with a detailed hand written review as seen in this study. It has helped in identification

of the abnormal labour and also acted as a tool for prompt decision-making in averting untoward

events in the participants it was used in monitoring their labour.

In this study, the use of modified WHO partograph was shown to be effective in improving the

outcomes of labour (by reducing the incidence of prolonged labour, augmentation of labour,

operative delivery, post-partum haemorrhage, neonatal mortality/morbidity and the incidence of

admission in NICU). The use of partograph needs to be introduced and sustained to reduce the

unabating incidence of maternal and perinatal mortality/morbidity in the study area. This will

also help to increase the quality and regularity of foetal and maternal monitoring of well-being

during labour.

86
6.2 RECOMMENDATIONS

6.2.1 GAMBO SAWABA GENERAL HOSPITAL, ZARIA

1. The hospital management of Gambo Sawaba General Hospital should incorporate the use

of the modified WHO partograph to the labour management protocol of the hospital.

2. There should be regular in-house-training and re-training of the maternity health care

providers on the use of partograph in labour management.

3. The hospital management should appeal to the State Ministry of Health to post or employ

more maternal health care providers (Midwives/ Doctors) to the maternity ward for more

efficient labour management especially with the modified WHO partograph.

4. There should be adequate provision of partograph forms in addition to those donated by

the researcher on a regular basis.

5. There should be routine partograph auditing to provide for improvement and sustained

usage of the partograph.

6.2.2 STATE GOVERNMENT AND POLICY MAKERS

1. Government should recommend the use of modified WHO partograph in labour

management to all hospitals in the state.

2. Training and re-training of maternal health care providers in all the public hospitals

across the state on the use of partograph in labour monitoring.

3. The principle of the use of partograph should be emphasised in Medical and Midwifery

schools.

87
 4. Government should invest more in research on the evaluation of the use of partograph in

labour management across the state to further strengthen the evidences in support of its

use.

5. Government should strengthen, empower and ensure an enabling environment for the

growth and practice of Family Medicine, a specialty that provides, among other things,

first contact care. When the Family Physicians are adequately engaged, they can

significantly contribute to the improvement of maternal health and national health of the

nation.

6.3 LIMITATIONS

1. This research work was done in one hospital. Hence its findings might have limited

generability.

2. The study, though an interventional one, was not a randomised study, therefore, limiting

its strength of evidence.

3. Obtaining information via interviewer’s administered questionnaire is subject to human

bias.

6.4 RELEVANCE OF THE STUDY TO FAMILY MEDICINE

Primary care is one of the domains of family medicine. Partograph is primarily designed to be

used at primary health care level of health to prevent or reduce the burden of maternal and

perinatal mortality which is still a problem in Nigeria especially in the North West zone, where

the study site was located. Family Physicians play a vital role in the prevention of maternal and

perinatal mortality and morbidity in a nation. This research helped to evaluate the effects of this

88
tool (partograph) on maternal and perinatal mortality as well as morbidity thereby providing an

opportunity for the Family Physicians to advocate for measures to reduce maternal and perinatal

mortality in Nigeria.

6.5 FURTHER RESEARCH

1. A multi-centre study involving both private and public hospitals to evaluate the effects of

the modified WHO partograph on maternal and perinatal outcomes of labour.

2. A randomised case/control study could also be done to increase the strength of the study.

3. A study to assess the problems associated with the use of partograph.

89
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59. Zhang J, Troendle JF, Yancy MK. Re assessing the labour curve in nulliparous women.

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64. El-Sayed YY. Diagnosis and management of arrest disorders: Duration to wait. Sermin

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66. Smyth RM, Alldred SK, Markhan C. Amniotomy for shortening spontaneous labour.

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 APPENDIX-1- CONSENT FORM

My name is Dr Olorunmowaju Oluwafemi Magnus. I am a member of staff of Ahmadu Bello

University Teaching Hospital, Zaria, Kaduna State. I am carrying out a study bordering on the

outcomes of pregnancy in women. Some general questions will be asked about your health,

family and your pregnancy. Please note that your answers will be kept confidential. Doctors and

the government will use the information given to formulate better health policy. During this

exercise, medical examination will be carried out on you. Necessary investigations will also be

done which will include urine and blood tests. Also partograph (a sheet of paper for recording

the activities of labour) may or may not be used in the course of the study depending on the

group you fall into.

Your honest answers to the questions and co-operation will help us to make appropriate

management of all pregnant women during labour and delivery. You are free to refuse to take

part in this programme. You have the right to withdraw at any given time if you choose to.

Withdrawal from this study will not in any way affect your management. Kindly give accurate

response to the questions. Thank you. Phone: 08037303271

CONSENT: Now that the study has been well explained to me and I fully understand the content

of this study process, I will be willing to be a part of this programme.

…………………………………………… ……………………………….

Signature/ Thumb print of participant/Date Signature of interviewer/Date.

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 APPENDIX- 1- CONSENT FORM (HAUSA VERSION)

TAKARDAN YARJEJENIYA

Suna na Dr. Olorunmowaju Oluwafemi Magnus. Ina daya daga cikin ma’aikatan asibitin

koyarwa na Jamiar Ahmadu Bello dake- Zaria a jahar, Kaduna. Ina nazarine akan abubuwan da

suka shafi cikin, yaya mata. Wasu tambayoyi daza ayi muna maku tabbaci da cewa amsoshinku

shine abun dogaro. Likitoci da gwabnati za suyi amfani da bayanin ku domin gudanar da harkar

lafiya mai inganci. Sannan a lokacin wannan darasi, za’ayi jarabawa akan abun da yashifi lafiya

ku. Kuma za’ayi wasu gwaje-gwaje na fitsari da jini. Amsoshim dakuka bayar na gaskiya shine

zai taimaka mana wajen nakuda da harkar lafiyar mata masu ciki a wajen nakuda da haihuwa.

Kuna da dama wajen kin halartan wannan shiri, kuma kuna da dama idan ana cikin taro ku fita

zuwa wani waje kowani lokaci. Fita daga darasin da’akeyi bazai shafi abun da akeyi ba. A

tabbatar ambada kyawawan amsa ga tambayar da akayi.

Na gode ma ku. Numba waya: 08037303271

Yarjejeniya: Yanzu darasin anyi mani bayanai yadda yaka mata, kuma na sami cikakken

ganewa so sai. Zan kasance a cikin wannan shiri nan gaba.

Sa hannun mai ciwon……………………… Sa hannun likita…………………..

Rana…………………………… Rana …………………………

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 APPENDIX-2- QUESTIONNAIRE/DATA RECORDING FORM

SECTION A: DEMOGRAPHY

1.0. Age in years 1.1 15-19 ( ) 1.2 20- 24 ( ) 1.3 25- 29 ( ) 1.4 30-34 ( ) 1.5 ≥ 35 ( )

2.0. Marital status 2.1 Single ( ) 2.2 Married ( ) 2.3 Divorced ( ) 2.4Separated ( ) Widowed ( )

3.0. Level of education of mother 3.1 No formal education ( ) 3.2 Primary ( ) 3.3 Secondary ( )

3.4 Post. Secondary school ( )

4.0. Patient’s Occupation ……………………. Husband’s occupation ………………

5.0. Gravidarity 5.1 1 ( ) 5.2 2-4 ( ) 5.3 ≥5

6.0. Parity 6.1 0 ( ) 6.2 1 ( ) 6.3 2-4 ( ) 6.4 ≥5 ( )

7.0. Pregnancy booking 7.1 Yes ( ) 7.2. No ( )

8.0. Number of Antenatal visit 8.1 None ( ) 8.2 1-3 ( ) 8.3 4-6 ( ) 8.3 7-9 ( ) 8.5 >10 ( )

9.0. Patient’s income (in naira) 9.1 < 10,000 ( ) 9.2 10,000- 50,000 ( ) 9.3 > 50,000 ( )

10.0. Husband’s income (in naira) 10.1< 10,000 ( ) 10.2 10,000- 50,000 ( ) 10.3>

50,000 ( )

11.0. Socio-economic index of the patient 1.1 class 1 ( ) 1.2 class2 ( ) 1.3 class3 ( )

1.4 class 4 ( ) 1.5 class 5 ( )

SECTION B: MATERNAL OUTCOME

1.0 Mode of delivery 1.1 Spontaneous vaginal delivery ( ) 1.2 Forceps ( )

1.3 Vacuum ( ) 1.4 Embryotomy ( )

1.5 Caesarean Section ( ) 1.6 Other abdominal delivery ( )

2.0 Perineal Laceration 2.1 none ( ) 2.2 1st degree ( ) 2.3 2nd degree ( ) 2.4 3rd degree ( )

. 2.5 4th degree ( )

3.0. Duration of first stage of labour (hours) 3.1 ˂ 8 hours ( ) 3.2 8-12 ( ) 3.3 13-16 ( )

102
 3.4 ˃16 ( )

4.0 Duration of second stage of labour (hours) 4.1 < 1 ( ) 4.2 1-2 ( ) 4.3 > 2 ( )

5.0 Need for Augmentation of labour 5.1 Yes ( ) 5.2 No ( )

6.0 Post-partum Haemorrhage 6.1 Yes ( ) 6.2 No ( )

7.0 Other maternal morbidities ………………………………………….

8.0. Maternal death 8.1 Yes ( ) 8.2 No ( )

SECTION C: PERINATAL OUTCOME

9.0 Neonatal Apgar score 1st minute 5 minutes

9.1 < 7( ) > 7 ( ) 9.2 <7 ( ) > 7 ( )

10.0 Condition of baby 10.1 Live birth ( ) 10.2 Fresh still birth ( )

10.3 Macerated still birth ( )

10.4 Immediate neonatal death ( )

11.0 Indication for admission in NICU 11.1 meconium aspiration ( )

11.2 delayed cry ( )

11.3 Respiratory distress ( )

11.4 Low birth weight ( )

11.4 No indication for admission in NICU

12.0 Average foetal heart rate ...........................................................

SECTION D: PHYSICAL EXAMINATION/ LABORATORY

13.0 Weight of Mother (Kg) ……………………………………………..

14.0 Height (m) ……………………………………………..

15.0 SFH (Cm) ………………………………………………

16.0 Maternal blood pressure (mmHg) ……………………………………………

103
17.0 Urinalysis

17.1 Protein present ( ) Absent ( )

17.2 Glucose present ( ) Absent ( )

104
105
APPENDIX 3: MODIFIED WHO PARTOGRAPH

106
107
APPENDIX-4-KADUNA STATE MINISTRY OF HEALTH ETHICAL APPROVAL

108
APPENDIX-5-ABUTH HREC FULL ETHICAL CLEARANCE CERTIFICATE

109
Appendix-6- letter of permission

110
111