Completeness of national partogram documentation and intrapartum monitoring at Base Hospital Muthur, Sri Lanka: a retrospective clinical audit

Abstract

Background: Accurate intrapartum documentation supports continuity of care, recognition of abnormal labour, and timely clinical decision-making. This clinical audit assessed the completeness of partogram documentation and selected maternal and fetal monitoring parameters in a base hospital in Sri Lanka.

Methods: A retrospective clinical audit was conducted using 48 bed-head tickets of women managed in the labour ward of Base Hospital Muthur. Twenty documentation and monitoring criteria were assessed using a structured data-extraction checklist. A tick was coded as documented and an X as not documented. We calculated descriptive statistics at the item and record levels and examined exploratory associations.

Results: The mean maternal age was 25.85 years (standard deviation 5.69; range 17-38). Across 960 item-record observations, 904 were documented, giving an overall completeness of 94.2%. Complete documentation was observed for 10 of the 20 assessed criteria. The main gaps were caput and moulding, each documented in 28/48 records (58.3%), commencement of pushing in 42/48 (87.5%), and vaginal examination at the specified interval in 44/48 (91.7%). Twenty-seven records (56.3%) were complete for all 20 criteria, and 41/48 (85.4%) achieved at least 90% completeness. Caput and moulding accounted for 40/56 (71.4%) of all missing entries.

Conclusions: Partogram-related documentation was generally high, but deficiencies were concentrated in a small number of labour-assessment components, particularly caput and moulding. Targeted reinforcement of these elements, clarification of clinically conditional criteria, and re-audit after corrective measures are recommended.