prasavGraph: Android based Labour Monitoring

Shalini Singh

, Kolin Paul

, Geeta Yadav

and Sanjiva Prasad

Department of Computer Science and Engineering, IIT Delhi, New Delhi, India

ICMR, New Delhi, India

Keywords:

Partograph, Smart Phone, Labour, Maternal Health.

Abstract:

The simpliﬁed Partograph is a concise charting mechanism used by skilled birth attendants for recording and

communicating the important parameters and developments during the labour process. Compliance and cor-

rect plotting of partographs may be signiﬁcantly improved with the use of technology. This paper reports the

development of an Android-based smart phone/tablet application to plot the partograph. To date such a com-

plete application is not available. We envisage that over a period of time, systematic plotting of partographs

will encourage providers to use it as a decision-making tool and thereby reduce morbidity and mortality both

of mother and foetus/newborn arising out of complications during labour and its sequelae.

1 INTRODUCTION

The Millennial Development Goal 5 (MDG 5) tar-

geted a 75% reduction in maternal mortality and a

two-thirds reduction in child mortality. MDG 5 was

formulated following a 1987 WHO conference where

the Safe Motherhood Initiative was announced, of

which the adoption of the partograph was an integral

part (Hogan et al., 2010). An outcome of this Initia-

tive was a comprehensive manual on preventing ma-

ternal deaths (Royston and Armstrong, 1989). A re-

view in 2000 (Raleigh, 2000) cited areas for improve-

ment such as increased use of manual vacuum aspi-

ration for the management of incomplete abortion, as

well as the education of midwives in the use of the

partograph, and training traditional birth attendants.

Maternal mortality worldwide stood at about

343,000 in 2008. Studies showed that the main causes

of maternal death were anaemia, post-partum haem-

orrhage (PPH), sepsis, malaria, delay, and eclampsia.

“Delay” was cited as a primary cause relating to ob-

structed labour, i.e., the failure of fetal descent de-

spite healthy uterine contractions, which accounted

for 8% of maternal deaths worldwide (though of-

ten misreported as PPH or merely as “delay”). Ob-

structed labour is also the major cause of mater-

nal morbidities such as obstetric ﬁstulae which are

thought to afﬂict an estimated 10-20 million women

worldwide. It can be prevented by better trained atten-

dants, timely monitoring and emergency intervention.

The simpliﬁed partograph is a concise chart-

ing mechanism used by skilled birth attendants

for recording and communicating the important pa-

rameters and developments during the labour pro-

cess (WHO, 2015). This single page sheet is prepared

for collecting and recording all important information

over a 12-hour period starting with the onset of labour

through to delivery. It acts as a decision-making aid in

that it indicates when labour is proceeding at a normal

rate and when doctors should prepare for carrying out

interventions.

Compliance and correct plotting of the partograph

has been a major issue in its widespread use and in

research based on the data collected. The adoption

and accuracy of partographs may be signiﬁcantly im-

proved with the use of technology. The ubiquity of

relatively inexpensive smart phones/tablets provides

an opportunity, with a well designed electronic Parto-

graph signiﬁcantly increasing use and correct record-

ing of the labour processes. This paper reports the

design and development of an electronic version of

the simpliﬁed partograph. This mobile/smart phone

application – prasavGraph (Figure 1) enhances the

simpliﬁed Partograph by recording events at the time

of admission and during the active phase of labour up

to 30 minutes after delivery.

The partograph may be considered to consist of

three sections, each of which has different inputs

• the fetal record

• the progress of labour record

• the maternal record

458

Singh, S., Paul, K., Yadav, G. and Prasad, S.

prasavGraph: Android based Labour Monitoring.

DOI: 10.5220/0005820504580466

In Proceedings of the 9th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2016) - Volume 5: HEALTHINF, pages 458-466

ISBN: 978-989-758-170-0

Figure 1: prasavGraph.

The fetal record tracks fetal heart rate and the condi-

tion of amniotic membranes and colour of liquor. The

labour record tracks cervical dilation against time,

charting it with pre-printed alert and action lines. The

maternal record captures contractions, blood pres-

sure, pulse, urine output, temperature, and drugs ad-

ministered including those used to help uterine con-

tractions. This information is a concise summary of

the birth process and indicates when further interven-

tions are necessary.

The Android-based application prasavGraph em-

ulates the simpliﬁed paper Partograph and also pro-

vides additional features. The digitization of the

record keeping process during labour can help build

applications for decision support to reduce morbid-

ity and mortality both of mother and foetus/newborn

arising out of complications of labour and its seque-

lae. To the best of the authors’ knowledge, this is

the ﬁrst such application that is based on the Android

platform, and which has been developed using a de-

lay tolerant 3-tier architecture. The Partopen is the

closest electronic aid that is available for recording

labour. However, the Partopen is not as comprehen-

sive as this effort (Underwood, 2013), although its

design goals were to work with the paper partograph

without changing the workﬂow processes.

The broad objectives of the prasavGraph applica-

tion are

1. Reducing data entry errors, achieved by stream-

lining and simplifying the data recording process.

2. Compliance with mandated/suggested procedures

during childbirth, ensured by making the applica-

tion run in real time with the option of recording

data “ofﬂine” too. However all such entries are

logged and colour coded.

3. Providing a Delay-tolerant Infrastructure, to en-

able the application to work in low network con-

nectivity areas.

4. Analytics, enabled by the availability of data in

digital form. A server database is integrated to

manage records of various devices in the same fa-

cility for better record sharing and visualization.

5. To act as a training aid.

In the next section, we describe the high level design

of the prasavGraph application.

2 RELATED WORK

ICT has been seen as an enabler for better provision

of healthcare. In particular, with the widespread use

of mobile phones, mHealth technologies are seen as

a means for low-cost and effective delivery of mater-

nal health care, in particular by providing better train-

ing to caregivers, better access to specialist support

and remote diagnosis, increased information about re-

productive health, and greater awareness of diseases

and their prevention and treatment. The deployment

of ICT does not automatically lead to improved out-

comes. This was seen in the case of the ClaimMo-

bile project (Densmore, 2012), where the smartphone

application did not replace the existing paper-based

ﬂows, but suffered from additional limitations of un-

reliable connectivity and power. The e-IMCI project

in Tanzania achieved success in replacing bulky pa-

per protocols with PDA-based IMCI workﬂow mod-

els (DeRenzi et al., 2008). Open Data Kit (ODK),

an extensible set of phone based tools, supports the

collection of data using smartphones, thereby reduc-

ing errors in data and providing timely feedback and

decision support. While health-related ODK-based

applications have reported a degree of success, ma-

jor limiting factors include small screen size and con-

cerns related to the security of data (Anokwa et al.,

2012). CommCare is an open-source phone-based

platform that has been used by community health

workers in Tanzania for the care of pregnant women.

Since CHWs could now be monitored, this interven-

tion unfortunately resulted in a signiﬁcant decrease

in the number of CHW submissions (Svoronos et al.,

). The MoTeCh project in Ghana (MoTeCH, 2011)

also faced resistance in its use from CHWs. Both

these experiences suggest that a greater participatory

role involving users is essential for successful adop-

tion. The Swasthya Slate (Swasthya, 2015) is a tablet-

based platform interfaced with a collection of med-

ical/diagnostic sensors that has been developed for

CHWs and medical professionals in rural India. The

most relevant work in addressing the labour process

is the PartoPen (Underwood et al., 2013), where a

pen-like device is used on specially printed parto-

graph forms, while also digitally recording the inputs

and providing timely audio reminders and feedback

prasavGraph: Android based Labour Monitoring

459

on a tiny screen on the device. The PartoPen ap-

proach is not to supplant the existing paper-based pro-

tocols, but to automatically extract information from

the forms and supplement the process with feedback

and reminders. The PartoPen has been used in teach-

ing and clinical studies in Kenya, showing the de-

vice’s robustness but also the limitations of such a

hardware-software solution in that it is oriented to-

wards successful ﬁlling of the partograph rather than

on the quality of care (Underwood et al., 2014).

3 SYSTEM DESCRIPTION

As mentioned above, a key motivation for this ac-

tivity is to enable the faithful recording of data dur-

ing labour. Despite government and WHO initia-

tives, compliance in this aspect is low across the

world (Ollerhead and Barriers, 2014). The paper-

based approach is often prone to errors during data

entry, both in relation to the time and also in the ﬁ-

delity of the data being entered. The fact that in many

settings the medical staff are overworked often causes

data to be entered retrospectively. Most importantly,

the data has to be manually (and often painstakingly)

digitized for any sort of data analysis.

Android-based smart phones, which are ubiqui-

tous today, are very good data acquisition devices.

The portability of applications across different hand-

sets and tablets is also very good. The design of the

electronic Partograph has been targeted at such de-

vices. The smart phone is used as the primary data

acquisition device. The application residing on it es-

sentially uses form-based entry with client-side data

validation on each data entry ﬁeld. Colour-coded text

boxes and out-of-bounds warnings are built into each

such ﬁeld. The application is built assuming an op-

portunistic communication framework (Pelusi et al.,

2006). It works as a standalone device but whenever

it is in the vicinity of a laptop in the premises, it repli-

cates the data that have been collected so far.

Figure 2: Architecture Diagram.

As shown in Figure 2, the tablet and laptop are

connected via WiFi or USB. The data is maintained

in a standard format (openMRS), and can be oppor-

tunistically uploaded to the central server (cloud) for

analysis. The design architecture resembles a Client-

Server model. The laptop containing the database and

web-server is used for backup and background pro-

cessing of the data. The laptop also provides the fa-

cility for making paper copies of the partograph.

The different modules of the Android application

are:

• Static User Interface Module: This module is used

for creating various user interfaces of the Android

Application. Static UIs in Android are created in

XML.

• Network Module: This module is responsible for

interacting with the network either as a service or

otherwise. APIs used herein are:

– Network Android API

– Network Service API

– Web Connection API

• Database Manager Module: This module is use-

ful for carrying out database-related functions, in-

cluding backup and logging. APIs used herein

are:

– Database API

– Database Connection API

– Database Functionalities API

• Notiﬁcation Module: Notiﬁcations play an impor-

tant role in this Android application whereby it

notiﬁes users (using an alarm / colour changes)

about the validity/correctness of the input data etc.

The partograph records the progress of labour.

The key parameters that are tracked are cervical di-

lation, and the vital parameters of the foetus and the

mother. The onset of active labour is indicated when

the cervical dilation is measured to be 4cm and con-

tinues up to 10cm, after which delivery occurs. Med-

ically, progress is normal if the rate of dilation is

1cm per hour. Partograph zones are colour coded, as

shown in Figure 3, to indicate different monitoring

modes for the birth attendant. Any time the cervix

Figure 3: Partograph Zones.

dilation is in the red zone, action has to be taken. Pro-

vision for alerting the attending physician is (option-

ally) present in the system. The yellow zone indicates

HEALTHINF 2016 - 9th International Conference on Health Informatics

460

that labour is sluggish and alerts the attending staff for

closer monitoring and/or augmentation of labour.

In the second and third stages a complete record

of the medication as well as other physiological con-

ditions of the mother is also maintained. On deliv-

ery, the details of the child(ren) need to be entered.

This feature, coupled with opportunistic communica-

tion with the cloud/hospital, can be used effectively

to automatically record births with municipal authori-

ties. Popups and/or beeps are built into the application

to serve as reminders to the attendant for recording the

data. The use of the web server helps in making these

data available on the central monitoring station.

4 DETAILED DESIGN

A signiﬁcant part of the design activity is concen-

trated on the User Interface (UI). The UI is essentially

composed of multiple forms which have been care-

fully designed to minimize the number of keystrokes.

Multiple versions of the application have been val-

idated by professionals, students, trainee doctors to

evaluate and report on the ease of using the applica-

tion. Figure 4 diagrams the application ﬂow.

Figure 4: Flow Diagram of the Android application.

The application starts with the Home Screen,

which has options to either add a new patient and to

go to a pre-existing partograph, given a patient id or

a patient name. Clicking on the add new patient but-

ton takes the user to a screen which records the pa-

tient’s name and other attributes. The next form, in

Figure 5, allows the user to input the patient’s medi-

cal history and examination details at the time of ad-

mission. Some of the ﬁelds are mandatory while oth-

ers may be left blank. This is an important feature

because the state in which the patient is admitted is

not always completely known, e.g., all the test results

may not be known at that time. Many of the ﬁeld

values (e.g., date and time of entry) are either set au-

tomatically from the machine settings or set to default

values. The right side of Figure 5 shows some of the

Figure 5: Form Based Entry.

physiological parameters of the patient that need to

be entered at admission. All these ﬁelds are checked

for validity and bounds, with alerts popping up on in-

correct or out-of-range values. The attending medical

staff has the option to override the ﬂagged exceptional

values (e.g., a very high systolic BP value) but any

such value is (colour) coded and stored.

After the user inputs these data, the main parto-

graph screen is displayed. The cervical dilation value

is noted and the partograph “starts” recording in real

time only if the value is greater than or equal to 4 cm.

Once the details at admission have been entered, the

partograph is presented as shown in Figure 6. All

subsequent entries are made in this page. Note that

the top of the partograph continues to display admis-

sion time entries.

This screen has three different input modes: 1

and 2

stages and the 3

stage with delivery de-

tails. The 1

stage requires recording cervical dilation

values periodically and the cervical dilation value vs

time graph gets updated automatically. During 1

and

stages, the recording of data such as foetal heart

rate, duration and frequency of uterine contractions,

pulse, BP etc. is done at predeﬁned intervals (30 or

prasavGraph: Android based Labour Monitoring

461

Figure 6: Cervical Dilation.

15 minutes). The tabular display gets automatically

time-stamped and hence only the actual time at which

data are entered gets noted. The ﬁrst column of left

half of the ﬁgure shows a partial list of the parameters

that are monitored at regular intervals of 30/15 min-

utes depending on the stage of labour. The values are

displayed in the table below the graph aligned with

the time axis of the cervical dilation graph (CDG). As

mentioned earlier, this application is used for mon-

itoring all the 3 stages of labour. In Figure 7, we

show one of the forms that needs to be ﬁlled in the

stage. The right side presents the data regarding

the neonate(s) post delivery.

In case the data input from the 2

stage in the

CDG shows some abnormality, the application noti-

ﬁes the user by an alarm. Similarly during a 3

stage

Figure 7: Third Stage.

input procedure, if any parameter is found to be ab-

normal, the user is immediately notiﬁed about it. The

application also suggests possible precautionary mea-

sures that can be undertaken. Delivery details of the

patient such as number of babies born, date and time

of birth, sex etc. are fed in the third part of the par-

tograph. The data collected are periodically synced

with the mysqlite database residing on the tablet and

the laptop.

To increase the reliability of the software and to

avert data loss due to malfunctioning of the device,

two approaches have been developed. First, the data

are replicated on an external SD card on the tablet.

Second, data are replicated over a network to the

server after a ﬁxed time or done manually by the user.

In case of device failure, the SD Card is removed from

the tablet and inserted in another tablet and all the Par-

tograph data captured by previous device are restored.

Also, data captured at the server end can be copied to

an SD card and inserted in another tablet to restart

operations in case of device failure. Thus, the Par-

tograph can be seamlessly migrated from one tablet

to another (Figure 8). The use of this application

Figure 8: Restoring Partograph data from one device to an-

other.

in a ﬁeld setting required making the application ro-

bust, and the tablet safe from accidental mishandling.

Accordingly, the tablet where the application runs is

kept in a casing that has been made using Rapid Pro-

totyping. As shown in Figure 9, the device can be

screwed to the nurses’ trolley conveniently to prevent

it from being misplaced/mishandled in a ﬁeld setting.

At the control station, doctors can view the parto-

graph(s) of the currently admitted patients arranged

in a grid pattern according to current cervix dilation

of the patient(s). On clicking any partograph, com-

plete details of patient are displayed. The criticality of

various patients can be assessed remotely and simul-

taneously priorities to attend to cases can be decided

HEALTHINF 2016 - 9th International Conference on Health Informatics

462

Figure 10: Information Flow from attending technician to Clinician.

Figure 9: Rapid Prototype Model of the device holder.

as illustrated in Figure 10. This application paves

the way for timely delivery of medical services in re-

mote/rural areas. A paper record of the partograph

can be obtained at any time from a browser, as a web-

server running on the laptop serves the page. As

shown in Figure 11, the webpage has been designed

to print on an A4 size printer and shows all the data

captured during labour.

The partograph has been tested initially by a resi-

dent doctor at Safdarjung Hospital, New Delhi. This

phase helped us identify crucial gaps in the imple-

mentation with respect to actual ﬁeld use. A version

of this application underwent ﬁeld testing in the Dis-

trict Hospital, Panchkula. Currently the application

is being used by student nurses and resident doctors

at two tertiary care centers in Chandigarh and New

Delhi. Additional trials are planned at primary, sec-

ondary and tertiary facilities including 23 district hos-

pitals across 13 states of India to understand scala-

bility and other system issues. Data collected from

these studies will be analyzed for reporting in a med-

ical journal.

5 OBSERVATIONS

In this section, we report some of the ﬁndings that

prasavGraph as a Data Collection and Reporting ap-

plication can provide. We would like to inform the

reader that, in this paper, we do not attempt any anal-

ysis or even comment on the data that have been col-

lected – only the potential of such an infrastructure for

ofﬁcials planning healthcare activities and for people

working in health care analytics is illustrated.

The preliminary data collected on prasavGraph

from hospitals give an insight into trends in cases of

pregnancy and its potential complications. The in-

terface of prasavGraph is user friendly and feeding

data in various columns of the app are kept simple

so that medical staff attending patients can send re-

ports without any glitches. Data obtained on prasav-

Graph from various hospitals were centrally recorded

and analyzed to study patterns among patients. The

medical/pathological evaluation of the patients blood

sample takes some time and the medical condition of

the patient may not allow the medical staff to ﬁll all

the details on the prasavGraph. In this situation, the

staff has to rely only on the readily available reports.

Recording cervical dilation is a reliable option for the

prasavGraph: Android based Labour Monitoring

463

Figure 11: Partograph.

medical staff in determining the stage of labour, espe-

cially in cases with very little reaction time.

Figure 12 displays some of the admission time

parameters of patients admitted in this particular hos-

pital during the period of survey. Green and red por-

tions of the bar represent normal and “out of nor-

mal” ranges of medical/pathological parameters re-

Figure 12: Data Captured at Admission time.

spectively. The data were analyzed for about 200 en-

tries available on prasavGraph. The haemoglobin bar

shows that 46.55% of patients had lower than normal

blood haemoglobin value. The number of patients

who were detected HIV positive can also be seen.

10.61% patients had abnormal urine sugar levels and

25.95% patients had abnormal urine albumin. The

patients history of pregnancies also helps the doctor

to prudently scrutinize the case. In prasavGraph we

take values of gravida (number of times a patient got

pregnant), para (number of times a patient give birth

to a premature baby of gestation age greater than six

months) and number of live child(ren). Clearly these

data can identify potential areas where intervention is

required.

Figure 14 shows some of the medical parameters

whose values can potentially ﬂuctuate during active

labour. The ﬁgure shows the number of patients with

HEALTHINF 2016 - 9th International Conference on Health Informatics

464

Figure 13: Previous Pregnancy Data.

Figure 14: Parameters during Active Labor.

normal and “abnormal” values. Light and dark por-

tions of the bar represent static and ”ﬂuctuating” med-

ical parameters respectively. For example, the FHR

bar shows the foetal heart rate varied signiﬁcantly in

56 patients out of 196. The Pulse Rate bar represents

that 30 patients out of 197 had a ﬂuctuating pulse rate.

Systolic blood pressure varied in 70 patients out of

196. The body temperature was found to change in

20 patients out of 190 compared with admission time

values.

The standard partograph is shown by the orange

line in Figure 15 which assumes that the rate of in-

crease in cervical dilation is 1cm/hour. The data ob-

tained from prasavGraph shows deviations from this.

It can be inferred that the observed rate of dilation

was faster than this for dilation values upto 9 cm af-

ter which it progressed at a slower pace to reach the

maximum level of 10 cm. In cases of prolonged deliv-

ery, the duration of full cervical dilation i.e. 10 cms

was reached even in the 11

and 12

hours. Table

1 displays the number of patients with each cervical

dilation value at the time of admission to the hospi-

tal. Analyzing data collected over 200 patients, it was

Figure 15: prasavGraph Summary of Patients.

Table 1: Cervical Dilation at Admission Time.

Cervix Dilation (in cm) No. Of Patients

4 86

5 32

6 19

7 15

8 22

9 3

10 23

Figure 16: Measurements at Each Hour.

found that 88.5 % patients were admitted in the ﬁrst

stage of labour, i.e., patients whose cervical dilation

is below 10cm. 11.5 % patients were admitted in the

second stage of labour i.e., cervical dilation is 10 cm.

This is essentially the percentage of patients admitted

to hospital at advanced stages of delivery/just after de-

livery. In 43.5 % cases, the data were properly ﬁlled

on the device from the start of active labour i.e., cer-

vical dilation 4 cm for the patient. Figure 16 shows

the number of points of data recorded from the start

of active labour, i.e., from hour 0 up to hour 12. In

11% cases, prasavGraph entered the red zone. A to-

tal of 1030 readings for each of the parameters (BP,

Fetal Heart rate, Temperature) were recorded during

patient examination. So, on an average, a patient was

examined 5 times during active labour. This illus-

trates some of the ways that statistical properties of

the data collected by the application can be analyzed

for developing decision support systems.

6 CONCLUSIONS

This paper reports the ﬁrst complete implementation

of an Android application which enhances the tradi-

tional partograph to record the developments in the

entire labour-to-childbirth process. The application

has been built in a delay-tolerant framework, which

enables it to be used in network deﬁcient or poor net-

work conditions.

Additional features like transferring the birth

record to municipal authorities can also be incorpo-

prasavGraph: Android based Labour Monitoring

465

rated into this application. A crucial feature that will

improve the adoption of this application will be the

integration of sensors to help semi automate the tak-

ing of readings. Another important feature that will be

tested in the next trials will be to alert the supervising

gynaecologist via sms.

With more trials being conducted successfully,

the application can be adopted by the Government

of India for monitoring labour especially in periph-

eral centres, for training providers and in promoting

self learning etc. It is expected that the easy-to-use

mobile/smart partograph will promote the practice of

plotting partograph during labour by peripheral health

workers which is currently very low. Over a period of

time, plotting of partographs will encourage providers

to use it as a decision-making tool and thereby reduce

morbidity and mortality, both of mother and newborn

arising out of complications of labour and its seque-

lae.

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