|Year : 2013 | Volume
| Issue : 3 | Page : 157-161
Feasibility of use of color-coded rings by nurse midwives: An appropriate technology based on partographic principles
Asha K Pratinidhi1, Shubhada Suresh Javadekar2, Aparna Nishikant Shrotri3, Sudesh Vijay Gandham4, Archana Patil5, Krishna S Patil5
1 Krishna Inst. of Med. Sciences Deemed University, Karad, India
2 Department of Preventive and Social Medicine, B.J.M.C., Pune, India
3 Department of Ob/Gyn, B.J.M.C., Pune, India
4 Department of Preventive and Social Medicine, RCSM GMC, Kolhapur, India
5 Directorate of Health Services, Government of Maharashtra, Mumbai, India
|Date of Submission||04-Jun-2011|
|Date of Acceptance||03-Jul-2012|
|Date of Web Publication||8-Aug-2013|
Asha K Pratinidhi
Research Director, KIMSD University, Karad, Maharashtra
Source of Support: MOHFW, New Delhi, Conflict of Interest: None
| Abstract|| |
Objectives: To study the feasibility of use of color-coded rings as a proxy for partograph for early identification of slow progress of labor. Materials and Methods: Color-coded rings were devised as a tool using appropriate technology to translate the partographic principles into simpler, easy to understand methodology. The rings were in pairs of 4 colors i.e., red, blue, yellow, and green, ranging from 3 cm to 10 cm in diameter with a difference of 4 cm between rings of the same color. The midwife performed p/v examination of the woman in labor to assess the initial cervical dilatation and identify corresponding ring. P/V was to be repeated after 4 hours to reassess the cervical dilatation and compare it with the bigger ring of the same color indicating expected cervical dilatation. If existing cervical dilatation measured lesser, it was interpreted as slow progress of labor indicating referral. Results: 44 women [23 (22.1%) primis and 21 (13%) multis] showed delayed progress of labor as judged by use of color-coded rings. 20 women (4 primis and 16 multis) showed satisfactory progress or delivered by the time arrangements for referral were made. Conclusion: Use of color-coded rings may serve as a valuable tool based on appropriate technology to assess slow progress of labor not only in the hands of nurse midwives but it also can serve as a training tool for TBAs to help facilitate timely referral of such cases.
Keywords: Appropriate technology, color-coded rings, partographic principles
|How to cite this article:|
Pratinidhi AK, Javadekar SS, Shrotri AN, Gandham SV, Patil A, Patil KS. Feasibility of use of color-coded rings by nurse midwives: An appropriate technology based on partographic principles. Indian J Community Med 2013;38:157-61
|How to cite this URL:|
Pratinidhi AK, Javadekar SS, Shrotri AN, Gandham SV, Patil A, Patil KS. Feasibility of use of color-coded rings by nurse midwives: An appropriate technology based on partographic principles. Indian J Community Med [serial online] 2013 [cited 2022 May 16];38:157-61. Available from: https://www.ijcm.org.in/text.asp?2013/38/3/157/116352
| Introduction|| |
Prolonged and obstructed labor is an important cause of birth asphyxia with resultant high perinatal mortality and morbidity. ,
There is increasing awareness among the population and policy makers about the risks associated with childbirth. Under the national program for Child Survival and Safe Motherhood, which was launched in 1992, a component for promotion of institutional deliveries for reduction of perinatal and maternal mortality has been included. 
Majority of women from rural areas avail the obstetrical care facility at the Primary Health Centers (PHCs) and Sub Centers (SCs) where the facilities are limited and Nurse Midwives (NMs) or Auxiliary Nurse Midwives (ANM) conduct most of the deliveries. The decision for referral where facilities for emergency obstetrical care are available is often based on subjective impression of the TBA, nurse, or relatives.
Prolonged and obstructed labor may not always be prevented but can be predicted. Antenatal care and risk screening can identify mothers in need of extra care. Assessment of progress of labor by graphic record i.e., partography has been recommended by WHO, and it is included in the primary health center manual of Govt. of Maharashtra  as a tool for identification of prolonged labor. Maintenance of graphic record for each delivery is often found difficult by NMs and ANMs, but they are well- versed with assessment of cervical dilatation. A feasibility study sponsored by Government of India was, therefore, planned to find out if TBAs and nursing staff could use the color-coded rings  as a proxy for graphic presentation of progress of labor (partography) for identification of slow progress of labor. Only the experience of nurse midwives in using color-coded rings is presented in this paper.
| Materials and Methods|| |
Eight primary health centers from 3 randomly selected Talukas and 2 randomly selected rural hospitals (RH) from Pune District were included in the study [Figure 1].
All 36 nurses working at these 8 PHCs and 2 RH were given training of 2 days in a group of 8 to 12. A questionnaire was given to know their knowledge and practices in relation to obstetrical case management before training. Their ability to judge cervical dilatation was tested on a simulation-training device [Photo 1] [Additional file 1] specially designed for this purpose.
This simulation training device consisted of a rotating drum, on which 8 holes corresponding to 3 cm to 10 cm diameter were prepared, in which rubber rings used in the color-coded device were fitted. With use of handle, (II) desired ring size could be brought in the center of orifice of the simulation model. The palpation of the ring could be done by inserting the fingers through the orifice (I).
Color-coded rings [Photo 2] [Additional file 2] were devised as a tool using appropriate technology to translate the partographic principles into simpler, easy to understand methodology.  A set of color-coded rings was prepared [Photo 2]. The rings were in pairs of 4 colors i.e., red, blue, yellow, and green, ranging from 3 cm to 10 cm in diameter with a difference of 4 cm between rings of the same color e.g., ring of 3 cm and 7 cm - red color, 4 cm and 8 cm - blue color etc.
The midwife was expected to perform an aseptic vaginal examination of the woman in labor to assess the initial cervical dilatation and identify corresponding ring. The vaginal examination was to be repeated after 4 hours to reassess the cervical dilatation and compare it with the bigger ring of the same color indicating expected cervical dilatation. Should the existing cervical dilatation measure lesser, it should be interpreted as slow progress of labor needing closer observation and arrangements for referral.
At the end of the training, it was ensured that all the ANMs/NMs had mastered recognition of onset of labor, asepsis during vaginal examination, concept of stages of labor, cervical dilatation and progress of labor, use of color-coded rings to assess the cervical dilatation, interpretation of the findings at 2 examinations indicating satisfactory/unsatisfactory progress of labor, causes and consequences of slow progress resulting in prolonged labor, and the need for referral for those with unsatisfactory progress.
All the ANMs/NMs were given a set of color-coded rings and pretested proforma for monitoring and recording progress of labor of each woman delivered by them.
The data were collected for a period of 1 year from July 2004 to June 2005 and analyzed using 't' test, X 2 test, ANOVA test, and Kappa statistics.
A focus group session was arranged 1 year after use of color-coded rings to get a feedback of midwives.
| Results and Discussion|| |
It was observed that all the ANMs as well as NMs were routinely doing vaginal examinations with hygienic precautions. Most of them were able to judge the cervical dilatation but were expressing it in fingers and not in centimeters. They had no clear concept of optimum duration between 2 vaginal examinations but were knowing that too many vaginal examinations can result in infection during perinatal period and with too few examinations, they would not be able to judge the progress of labor satisfactorily. Their practice was to perform vaginal examination after every 2 hours. There were occasions when internal examinations were done more frequently if relatives insisted or if there were signs of maternal or fetal distress.
They had some concept of partography following training under Reproductive and Child Health Program (RCH program).  Hence, it was not difficult to train them with color-coded rings. The partographic principle used being that after active stage of labor i.e. cervical dilatation of 3 cms, cervix should dilate at a rate of at least 1 cm per hour. A difference of minimum of 4 cm is expected between initial cervical dilatation and the dilatation at the end of 4 hours. The person during vaginal examination has his/her own impression about cervical dilation in terms of fingers and the distance between the fingers, which is mentally converted into centimeters before using partogram, whereas color-coded rings are more objective in giving visual impression of existing and expected size of the cervix reducing inter observer variation.
The nurses could convert 2 finger dilatation in to 3 cm. dilatation and identify the corresponding small red ring with some practice. It was not difficult to tell them to do another vaginal examination at the end of 4 hours and to identify bigger ring of the same color corresponding with the expected minimum cervical dilatation at the end of 4 hours [Photo 3].
During the period of 1 year, the trained NMs/ANMs attended 484 deliveries. Since parity is the most important determinant of rate of cervical dilatation and duration of labor, comparison was made between primiparous (35%) and multiparous women (65%).
There was a significant difference in the mean age of primiparous and multiparous women. There was no significant difference in the mean age at marriage or the mean age at first delivery [Table 1]. There was no significant difference in the availing of ANC services between primis and multis.
Comparison of some important parameters among primis and multis revealed that primis had longer duration of I st and II nd stage of labor, more number of referrals and assisted deliveries. They had lesser number of preterm births [Table 2].
|Table 2: Comparison of some important parameters among primis and multis |
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Out of 484 deliveries, 50 (17 primis and 33 multis) were in second stage of labor at the time of admission and delivered soon after arrival before use of color-coded rings. Initial dilatation of cervix on admission of 434 (89.7) women is given in [Table 3].
It was observed that 86 (56.2%) primis and 189 (67.3%) multis had initial dilatation of 7 cm or more at initial assessment [Table 3], and if 4 hours interval was taken for second assessment, these 225 (51.8%) women would have been beyond the scope of using color-coded rings.
Although it is desirable to conduct second vaginal examination 4 hours after initial examination, in practice, the nurses carried out internal examination after 2 hours or less of initial examination, hence color-coded rings could be used in 265 (61.1%) women.
It was also observed that it was not difficult to grasp the concept that every hour there was an increase in 1 cm. cervical dilatation i.e., next ring. When the vaginal examination was done earlier than prescribed period of 4 hours, it was not difficult for midwives to assess delayed cervical dilatation by this concept, even when color-coding was not applicable.
Analysis by Kappa statistics revealed [Table 4]a-b that in primiparous women, there was no significant difference between the proportions of agreement (48/104) and disagreement (56/104) indicating that the cervical dilatation and duration in hours were associated with each other. In multis, however, there was a significant difference between these 2 variables (the proportion of agreement and disagreement being 67/161 and 94/161, respectively.) This difference was due to rapid rate of cervical dilatation in multis, which is a known obstetrical fact.
Thus, the use of partographic principles and, therefore, color-coded rings is more applicable in primis than in multis. However, if the minimum cervical dilatation for given duration is not reached in multiparous women, it should be taken more seriously. There is a possibility of development of partograph and color-coded rings separately for multis, which would give better judgment about delayed progress of labor in them.
There were 44 women [23 (22.1%) primis and 21 (13%) multis], in whom the progress of labor was delayed as judged by use of color-coded rings. Enema was given and/or oxytocin drip was started. Twenty women (4 primis and 16 multis) showed satisfactory progress or delivered by the time arrangements for referrals were made.
Out of remaining 24 (19 primis and 5 multis) women availing referral, 15 had some other reason for referral. Four had leaking membranes (>24 hours), 6 had meconium-stained liquor (2 of them had in addition PIH), 2 had antepartum hemorrhage, 1 had history of stillbirth, and 2 had severe anemia.
Remaining 9 (37.5%) women did not have any other reason other than slow progress of labor as judged by color-coded rings and progress of labor not improving by enema or oxytocin drip. All of them required interventions: 7 required cesarean section and 2 instrumental deliveries. All 44 women, identified as slow progress of labor, needed intervention-labor augmentation at PHC/S.C. or instrumental delivery/cesarean section at referral hospital. Thus, 100% specificity of the color-coded rings in identifying cases in need of intervention due to slow progress of labor was observed.
Focus group discussions were arranged to know the experience and opinions of nursing staff using color-coded rings. They thought that color-coded rings were excellent, effective, and easy method, for judging slow progress of labor unlike partogram, which they thought was complicated. It was thought to be more useful in primis. They felt that this device was useful for training of TBAs/ANMS/NMS/Interns and explaining delayed labor to relatives. All nursing staff using it gave a positive feedback.
| Conclusions|| |
Use of color-coded rings, an appropriate technology, may become a valuable tool in the hands of nurse midwives for identification of slow progress of labor like partogram. The "color-coded rings" device is easier to understand and use due to readily available objective visual impression about existing and expected size of the cervix, overcoming limitation of subjective mental impression during use of partogram. They can also use this tool for training TBAs under their jurisdiction to facilitate timely referrals to the rural health center.
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[Table 1], [Table 2], [Table 3], [Table 4]