The partogram was not created for the convenience of doctors. It was in
fact created as a tool for all health professionals (by that read
midwives & traditional birth attendants too) who care for the birthing
women. The aim of the partogram was to provide a precise overview of the
labouring women's situation and progress. It was introduced by WHO in
1993, as part of a program to decrease the very real and very tragic
number of mothers and babies that die as a result of labour
mismanagement and obstructed labour. To the best of my knowledge
Indonesia was one of the major designated trial sites for the partogram
and midwives were extensively involved in this process. (1994).
The partogram was based on the work of Philpott & Castle (1972). I was
introduced to and worked with the original version "The Philpott Chart"
as a midwifery student 20 years ago. The chart is well research and
based on normal labour. Research shows that a "fifth of primigravida
crossed the action line and 10- 11% the alert line."
In other words a great many women in established labour conform to the
pattern predicted by the partogram. The purpose of the partogram as we
now know it is to enable the person caring for the birthing women to
critically analyse the situation and care for the women accordingly. It
does not mean you HAVE to do 4 hourly vaginal exams. If you are able to
judge the progress of labour by decent of head pelvically (is that not
what we are all supposed to do before a vag exam) and by other means
that's great and very women centred. It merely gives you a framework
that can be used to confirm the normal or warn the midwife/ doctor of
deviations. It is an evaluation and analysis tool.
This may be vital in certain situations. As a homebirth midwife who may
have been awake for over 20 hrs with a labouring women the ability to
use a decision making tool might crucially aid the midwife to correctly
assess the situation Certainly if one is a rural midwife 4 - 6 hrs by
road away from any assistance the difference could be life or death.
I do not believe that the use of a partogram impacts on our ability to
give women centred midwifery care. The difference is in how you
interpret and act on that information not on the tool used. If you
assess that a women's contractions are the problem that definitely
requires attention: in the medical model you use pitocin in the
midwifery model you do other things, like reassuring the women,
assisting her with natural methods of pain control, support, maybe even
herbs before the pitocin.
Yes, birth is a natural and physiological process and I absolutely vote
for the midwifery model. But with that comes accountability and evidence
based practice. As we all know that when things go wrong they can go
very wrong. In this profession there are "guns and roses" and I am quite
happy to use the partogram as a tool if it enables me to think
critically regarding the care of a birthing women. In hospital or out.
As a matter of interest I wonder how many of you are using the actual
WHO partogram which has action and alert lines demarcated on it.
Regards
Mandy O'Reilly
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