RE-Audit Report Cover Sheet
Your Name THOMSON HW CHIRWA
STUDENT NUMBER 0025
Date of ReAUGUST AND SEPTEMBER 2012
audit
Location
where reaudit took
place
CHITIPA DISTRICT HOSPITAL LABOURWARD
RE-Audit Title
MANAGEMENT OF LABOUR USING A LABOUR GRAPH IN MATERNITY WARD AT CHITIPA DISTRICT
HOSPITAL.
RE-Audit Aims
List clearly and concisely the aims of your re- audit (100 words)
To make sure Chitipa manages labour using the labour graph following the set standards in the
management of labour using the labour graph. All labour graphs should have; patients identification,
number of actual hours in labour, fetal heart filled every 30 minutes and colour of liquor every 30
minutes moulding every 4 hours, cervical dilatation 4 hours descent one hour, contraction 30minutes
and maternal vitals every 4 hours by the end of September 2012. This will eventually translate into
quality care and quality management of labour to improve fetal and maternal outcome of labour
RE-Audit Overview Summary
Briefly state how you conducted your re-audit. What went well and what went less well? What were
the problems and how would you overcome these in the future? (200 words)
We conducted the re-audit using a team of two clinical officers, two state registered nurse
midwives(nurse midwife in-charge of labour ward and his deputy ) and two nurse midwives
technicians and conducted sport interviews to ten midwives on the use of the labour graph,
observation of the deliveries in the labour ward and re-auditi team member mentored the midwives
on how to use the labour graph following the standards and we evaluated 60 labour charts from
august and September2012. The re-audit process went well because all team members were well
oriented on what was supposed to be done and because four of the members are the same who
participated in the initial audit process, the data was readily available and well packed according to
monthly and this was made possible by the statistic department who were very cooperative in the
release of the case files. Despite having the above mentioned positives the re audit process was
affected by time constraints due to tight schedule. It was difficult to assemble the members. The
charts on the audit had examination documented once before delivery because the patients arrived
late in the labour ward, so it was difficult to assess the frequency of the examinations according to
standards.
Summary of Findings
Summarise the main findings of your re- audit. (200 words)
All the 60(100%) charts examined had patients identification details, all 60(100%) patients charts had
actual hours spent in labour ,fetal heart rate was checked every 30mins in 57(95%) charts and 3(5%)
charts had fetal heart rate at more than 30minutes interval , amniotic fluid color check 32(53.3%)
checked every 30minutes and 27(45%) were checked more than 30minutes apart, moulding
55(91.7%) were checked 4hourly and 4(6.6%) had it checked at more than 4houly interval, cervical
dilation 59(98.3%) were checked 4hourly and 1(1.6%) was checked at more than 4houly interval,
descent 32(55.3%) were checked every hour and 28(46.7%) were checked more than an hour apart,
contractions 29(48.3%) were checked every 30minutes and 31(51.7%) were checked more than
30minutes apart, oxytocin for management of third stage of labour was given in all 60(100%) women,
emptying the bladder and urine check was documented in 28(46.7%) women, maternal vital signs
pulse 44(73.3%),Bp48(80%),temperature 50(83.3%). The other strength in the re-audit every
parameter was being monitored and documented but what was not perfect was the sequencing of
the monitoring unlike in the audit where some parameters were not monitored at all.
Relevance to Clinical Guidelines
State which guidelines are relevant to this re-audit. Include version number and/or date of guideline
Were guidelines followed in whole or in part in your chosen audit area?
Describe any problems encountered in implementing guidelines in your audit area, including how you
would overcome these problems (200 words)
The re-audit is very relevant to our Malawi national reproductive health guide lines and the
recommended labour graph. we also noted some difficulties in the standards where the examination
can either be done by vaginal examination like color of liquor which is supposed to be monitored
hourly but most midwives said they only check the colour of liquor after a vaginal examination which
is 4hourly so there was some contradictions with the standards against the practical experience and
similar to this is the monitoring of descent which some midwives raised a concern that it’s difficult to
monitor when the head is in the pelvis where a vaginal examination is required to give actual descent
to assist in bringing in interventions like vacuum or forceps deliveries because by abdominal palpation
it is very difficult to estimate the descent in the pelvis.
Recommendations
What are your recommendations for improvement in care and re-audit area? (200 words)
There is a great improvement on the adherence to the standard in the management of labour
following the cascading and mentoring of midwives and clinicians in the labour ward. There is a big
difference in terms of the audit result and the re-audit result in the way the labour graph was used to
manage labour for example in audit fetal heart 8(19%) and re-audit 95%, audit colour of amniotic
fluid 5(12%) and re-audit 53.3%, audit moulding 5(12%) and re-audit 91.7% ,audit cervical dilation
10(24%) and re-audit 98.3%, descent 9(22.4%) audit contractions4(9.5%) and re-audit 48.5% . We
have observed some challenges in the adherence to the standards because some patients come in
labour ward in second stage of labour and just after a single examination they have delivered and in
some instances many women come at once against few midwives or even one midwife and this
affects the standards monitoring of labour. we also noted some difficulties in the standards where the
examination can either be done by vaginal examination like color of liquor which is supposed to be
monitored hourly but most midwives said they only check the colour of liquor after a vaginal
examination which is 4hourly so there was some contradictions with the standards against the
practical experience and similar to this is the monitoring of descent which some midwives raised a
concern to say it’s difficult to monitor when the head is in the pelvis where a vaginal examination is
required to give actual descent to assist in bringing in interventions like vacuum or forceps deliveries
because by abdominal palpation it is very difficult to estimate the head is fully engaged in the pelvis.
Personal Reflection
What did you learn about the re- audit process, and what will you do differently next time? How will
this affect your clinical practice? (200 words)
I have learn that with proper mentoring the standards of patient care can greatly improve and I give
an example of the issue of my audit findings against my re-audit findings which has actually showed a
great improvement in the standards after cascading ,mentoring colleagues in the use of the labor
graph in our labour ward .if people Cleary understand why you are doing the audit and they see an
improvement in the quality of service they become motivate and they gain a drive that makes them
to own the audit process even without finical benefits and become very supportive.
signature Thomson HW Chirwa ETATMBA 0025
Date:18 October 2012
WARWICK UNIVERSITY ETATMBA
STUDENT NUMBER 00025
Re-audit team members :1. Thomson HW chirwa, clinical officer re-audit team leader Email:thomsonchirwa@gmail.com,
2.Boss Mwafulirwa, nursing officer. Nurse midwife in-charge chitipa maternity ward
Email:bmwafulirwa@yahoo.com,,3. Grace Mkandawire nurse midwife officer chitipa district hospital labour ward (Deputy ward in
charge) gracemovete@gmail.com,4. Given Chilimira, internee clinical officer working in labour ward during re-audit period
Email:givenchilimira@yahoo.com,5. Greshyne Mataya nurse midwife technician working in chitipa district hospital labour ward
Email:gmataya@yahoo.com, 6. Wellington Dube nurse midwife technician working in maternity
RE-AUDIT REPORT
TITTLE
MANAGEMENT OF LABOUR USING A LABOUR GRAPH IN MATERNITY WARD AT CHITIPA DISTRICT
HOSPITAL.
AIM
To make sure Chitipa manages labour using the labour graph following the set standards in the
management of labour using the labour graph. All labour graphs should have; patients
identification, number of actual hours in labour, fetal heart filled every 30 minutes and colour of
liquor every 30 minutes moulding every 4 hours, cervical dilatation 4 hours descent one hour,
contraction 30minutes and maternal vitals every 4 hours by the end of September 2012. This will
eventually translate into quality care and quality management of labour to improve fetal and
maternal outcome of labour.
OBJECTIVES
1. To have all labour graphs with Patients identification details
2. To have all labour graphs with Actual number of hours in labour recorded
3. To have all labour graphs with Fetal heart rate filled every 30minutes
4. To have all laqbour graphs recorded Color of liquor every 30 minutes
5. To have all labour graphs recorded Moulding every 4 hours
6. To have all labour graphs with Cervical dilation recorded every 4 hours
7. To have all labour graphs with uterine Contractions recorded every 30minutes
8. To have all labour graphs with Maternal vitals recorded every 4 hours
9. To have all labour graphs with descent recorded every one hour
STANDARDS
All labour graphs should by the end of September 2012 have:
10.
11.
12.
13.
14.
15.
16.
17.
18.
Patients identification details
Actual number of hours in labour
Fetal heart rate filled every 30minutes
Color of liquor every 30 minutes
Moulding every 4 hours
Cervical dilation every 4 hours
Contractions every 30minutes
Maternal vitals every 4 hours
Descent recorded every one hour
INTRODUCTION
The partograph has been in use since 1960s and was invented in Africa and some have labeled it as
an east African gift to the world and is used extensively in many centers and so many countries
world wide. It has been found to be inexpensive, effective and pragmatic in a variety of different
settings including developed and developing counties. A partogram is one of the valuable
appropriate technologies in use for improved monitoring of labour progress, maternal and foetal
wellbeing. It is an important tool for managing labour. This is through enabling clinicians (midwives
and clinicians) to plot examination findings from their assessments on the partogram. The belief that
its use was applicable in developed and developing settings led to its introduction worldwide. A
number of common partograph designs incorporate an alert and action line. The development of the
partogram provided health professionals with a pictorial overview of labour progress, maternal and
foetal condition to allow early identification and diagnosis of pathological labour.
Its use is critical in preventing maternal and perinatal morbidity and mortality. The World Health
Organization (WHO) recommends partograms with a 4-hour action line from alert line, denoting the
timing of intervention for prolonged labour; others recommend earlier intervention to allow for
referral. This tool is now widely used across African Countries including Malawi to monitor labour
progress, foetal and maternal wellbeing. The core issue is to prevent obstructed labour through early
detection of abnormal progress of labour, and appropriate clinical responses rendered in accessible,
equipped and staffed health units. Appropriate use of a partogram requires adequate number of
skilled health workers with a positive attitude towards its use especially midwives at various levels of
health care facilities and actual availability of the partogram tools at all times. Chitipa district
hospitals use a partogram to monitor labour progress and conditions of the mother and foetus.
However, the District Hospital in my initial audit showed substandard (we did not follow the set
standards) use of the labour graph. The reasons for this state were unavailability of the labour
graphs, people’s altitude, many patients arriving in labour ward at once, some arriving in labour in
second stage delivering on arrival and shortage of staff. The use of a partogram for intrapartum
monitoring was expected to be fully carried out at Chitipa district hospital labour ward. This re audit
will help as to compare the findings with the audit findings.
MATERIALS AND METHODS
We conducted the re-audit using a team of two clinical officers, two state registered nurse midwives
(midwife in charge of labour ward and his deputy) and two nurse midwives technicians. we
conducted sport interviews on the use of the labour graph, observation of the deliveries in the
labour ward and re-auditi team member mentored the midwives on how to use the labour graph
following the standards and we evaluated 60 labour charts from august and September2012. The
re-audit process went well because all team members were well oriented on what was supposed to
be done and because four of the members are the same who participated in the initial audit process,
the data was readily available and well packed according to monthly and this was made possible by
the statistic department who were very cooperative in the release of the case files. Despite have the
mentioned positives the re audit process was affected by the tight schedules of audit member who it
was difficult to assemble them at once. Some of the charts on the audit had only one
documentation then delivery of baby because the patients arrived late in the labour ward so it was
difficult to assess such case notes considering the frequency of the examinations which were difficult
to follow
RESULTS
The results have been summarized in the table below which is comparative of the audit
findings against re-audit findings.
Table below showing the findings of the re-audit and the initial audit findings with attached
percentages(Only showing findings on all parameters done according to standards.)
Patie
nt
Detail
s
Actua
l Hrs
in
Labor
Fetal
Heart
Rate
Colour
Of
amnioti
c Fluid
Mould
ing
Cervi
cal
Dilat
ation
Desce
nt
Contra
ctions
Oxytoc
in
When
Protein In
Urine/Uri
ne
Volume
Maternal Vital
Signs
Used
Pul
se
BP
Tem
p
ReAudit
Findin
gs
60(10
0%)
60(10
0%)
57(9
5%)
32(95%
)
55(91.
7%)
59(9 32(55.
8.3%) 3%)
29(48.
3%)
60(100
%)
28(46.7%)
44(
73.
3%)
48(8
0%)
50(8
3.3
%)
Audit
Findin
gs
-
-
8(19
%)
5(12%0
5(12%)
10(2
4%)
4(9.5%
)
-
5(12%)
14(
33.
3%)
19(4
5.3%
)
14(3
3.3
%)
9(22.4
%)
NOTE: The denominator used in the initial audit was 42 and in the re-audit was 60
The re-audit added the following parameters which were not audited in the initial audit patient’s
details, actual hours in labour and Pitocin administration in management of third stage of labour. All
the 60(100%) charts examined had patients identification details, all 60(100%) patients charts had
actual hours spent in labour ,fetal heart rate was checked every 30mins in 57(95%) charts and 3(5%)
charts had fetal heart rate at more than 30minutes interval ,amniotic fluid color check 32(53.3%)
checked every 30minutes and 27(45%) were checked more than 30minutes apart, moulding
55(91.7%) were checked 4hourly and 4(6.6%) had it checked at more than 4houly interval, cervical
dilation 59(98.3%) were checked 4hourly and 1(1.6%) was checked at more than 4houly interval,
descent 32(55.3%) were checked every hour and 28(46.7%) were checked more than an hour apart,
contractions 29(48.3%) were checked every 30minutes and 31(51.7%) were checked more than
30minutes apart, oxytocin for management of third stage of labour was given in all 60(100%)
women, emptying the bladder and urine check was documented in 28(46.7%) women, maternal vital
signs pulse 44(73.3%),Blood pressure 48(80%),temperature 50(83.3%).
The re-audit great improvement in all the parameters from the audit result but some parameters did
not show much improvement in percentages.
These are a summary of the audit findings on parameters which were monitored according to
standards.
The following were findings from the audit done in November and December 2011 where we
analyzed 42 labour graphs , fetal heart 8(19%), colour of amniotic fluid 5(12%) moulding
5(12%),cervical dilation 10(24%) descent 9(22.4%) contractions4(9.5%) pulse
14(33.3%)Bp19(45.2%)temperature 14(33.3%)
Percentage Of Standard Adherance
Coperative Graph Showing Results Of ReAudit & Initial Audit Findings
120%
100%
80%
60%
40%
20%
0%
Re-Audit Findings
Initial Audit Findings
Labour Monitoring Parameters
This gives us a pictorial reflection on the findings.
DISCUSSION
The midwives and clinicians in this re-audit process understood this well as quality improvement
process that seeks to improve patient care and outcomes through a systemic review of care against
explicit criteria and the implementation of change and as a result there is a great improvement on
the adherence to the standard in the management of labour following the standards following the
cascading, mentoring and direct observations of midwives in the labour ward. There is a big
difference in terms of the audit result and the re-audit result in the way the labour graph was used
to manage labour. We have observed some challenges in the adherence to the standards because
some patients come in labour ward in second stage of labour and just after a single examination
they have delivered and in some instances many women come at once against few nurse midwives
and this affects the standard monitoring of labour .we also noted some difficulties in the standards
where the examination can either done by vaginal examination like color of liquor which is supposed
to be monitored hourly but most midwives said they only check the color of liquor after a vaginal
examination which is 4hourly so there was some contradictions with the standards against the
practical experience and similar to this is the monitoring of descent which some midwives raised a
concern to say it’s difficult to monitor when the head is in the pelvis where a vaginal examination is
required to give actual descent to assist in bringing in interventions like vacuum or forceps deliveries
because by abdominal palpation it is very difficult to estimate the descent in the pelvis.
CONCLUSION AND RECOMMENDATIONS
There was some improvement in some parameters audited and there were decrease in
percentages in some parameters as compared to the initial audit findings in December 2011. There
was greater team work in the re-audit because members understood the purpose of the re-audit
and the mentality of it being a fault finding exercise completely changed and they were all very
supportive. The parameters re-audited have all showed positive improvement except in some
parameters like descent which all midwives complained that it was difficult to assess when baby’s
head is in the pelvis, colour of liquor which is supposed to be monitored every 30 minutes but is
better assed on gloved fingers after a vaginal examination which is supposed to be done every four
hours.
Strengths in the re-audit







Patient identification was 100%
Actual hours in labour was 100%
oxytocin administration 100%
Improved documentation no labour graphs with(sss)meaning seen in second stage of labour
Improved monitoring in all parameters ie Fetal heart rate 95%,colour of amniotic fluid
53.3%,moulding 91.7%,cervical dilations 98.3%, descent53.3%,contraction 48.3%,urine
output 46.7%
Improved maternal condition monitoring like pulse 73.3%, Bp 80% and temperature 83.3%
Every file had all the parameters were examined and documented despite that in some
cases the standard frequency was not followed
Limitations





Confusion in some parameters like colour of liquor which is supposed to be monitored every
30 minutes but practically midwives prefers doing it 4 hourly together with vaginal
examination.
More women coming in labour at once against one midwife and some women coming late in
labour ward when the baby is just to be delivered
Under staffing in labour ward
Inadequate resources like urine dipsticks not available, few thermometers and blood
pressure machines
The hospital has no ultra sound machine which makes monitoring difficult
Recommendations





To maintain standards and improve and continue mentoring each other on the need to
maintain the standards
Lobby with management for availability of diagnostic materials like urine sticks, blood
pressure machines, thermometers.
Lobby with management to buy an ultrasound machine
Peer mentoring to influence positive altitudes
To lobby with the head of nursing section to increase nursing staff allocation in the labour
ward
REFFERENCE
1.Nyamtema AS, Urassa D P, Massawe S, Massawe A,Lindmark G and Van Roosmalen J
2008).Partogram use in the Dar es Salaam perinatal care study. International Journal of Gynaecolgy
and Obstetrics. 100, 37- 40.
2.Fatusi, O. A., Makinde, N. O., Adeyemi, B. A., Orji, O. E.,Onwudiegwu, U., (2007). Evaluation
of healthworkers’ training in use of the partogram. International Journal of Gynecology and Obstetrics
pp3
3. Philpott RH, Castle WM. (1972). Cervicographs in the management of labour in
primigravidae. II. The action line and treatment of abnormal labour. Journal of
Obstetrics Gynaecology British Commonwealth;79: 599–602.
4. Int J Gynaecol Obstet. 2008 Jan;100(1):41-4. Epub 2007 Sep 27.Evaluation of health
workers' training in use of the partogram. Fatusi AO, Makinde ON, Adeyemi AB, Orji
EO, Onwudiegwu U.Department of Community Health, Faculty of Clinical Sciences,
Obafemi Awolowo University, Ile-Ife, Nigeria.
5.Int J Gynaecol Obstet. 2008 Jan;100(1):37-40. Epub 2007 Sep 27.Partogram use in
the Dar es Salaam perinatal care study.Nyamtema AS, Urassa DP, Massawe S, Massawe
A, Lindmark G, van Roosmalen J.Tanzanian Training Centre for International Health,
Ifakara, Tanzania.angelo.nyamtema@healthtrainingifakara.org
6.SoniBL.Effects of partogram use on outcomes for women in spontaneous labour at
term:RHL commentary(last revised: 1June 2009).The WHO Reproductive Health
library;Geveva:world Health organisation