RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1) / NAME OF THE CANDIDATE AND ADDRESS / : / Mrs.TINTU.R.B
1ST YEAR M.Sc NURSING.
PRAGATHI COLLEGE OF NURSING
#33 BYRATHI EXTN, NEAR EBENEZER HOSPITAL, HENNUR BAGALUR MAIN ROAD, KOTHANUR POST, BANGALORE:560077
2) / NAME OF THE INSTITUTION / : / PRAGATHI COLLEGE OF NURSING
#33 BYRATHI EXTN, NEAR EBENEZER HOSPITAL, HENNUR BAGALUR MAIN ROAD, KOTHANUR POST, BANGALORE:560077
3) / COURSE OF STUDY AND SUBJECT / : / DEGREE OF MASTERS IN NURSING
OBSTETRIC AND GYNAECOLOGICAL NURSING
4) / DATE OF ADMISSION TO THE COURSE /
08/06/2010
5) / TITLE OF THE STUDY / : / EFFECTIVENESS OF VIDEO ASSISTED TEACHING ON KNOWLEDGE REGARDING PARTOGRAM AMONG NURSES WORKING IN SELECTED MATERNITY HOSPITALS, BANGALORE

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

Pregnancy and child birth are generally times of joy for parents and families. Pregnancy, birth and motherhood, in an environment that respects women can powerfully affirm women’s right and social status without jeopardizing their health. The enabling environment for safe motherhood and childbirth depends on the care and attention provided to pregnant women and new born by communities and families, the acumen of skilled health personnel and the availability of adequate health care facilities, equipment and medicines and emergency care need. Many women in the developing world and most women in the world’s least developed countries- give birth at home without skilled attendants. The health risk associated with pregnancy and child birth are far greater in developing countries than in industrialised ones1.

According to the world health report in 2004, bad maternal conditions account for the fourth leading cause of death for women after HIV, malaria and tuberculosis. 99% of these deaths occur in developing countries; while only one of 4000 women a chance of dying in pregnancy or child birth in a developed nation. Further more, maternal problems cause almost 20% of the total burden of disease for women in developing countries. Almost 50% of the births in developing countries take place without a medically skilled attendant to aid the mother and the ratio is even higher in South Asia2.

In many developing countries, complications of pregnancy and child birth are the leading causes of death among women of reproductive age. A women dies from complications from child birth approximately every minute. Most maternal deaths and injuries are caused by biological process and can be prevented, not from disease, and have been largely eradicated in the developed world such as post partum haemorrhaging which causes 34% of maternal death in the developing world and only 13% of maternal death in developed countries2.

Globally, efforts to reduce deaths among women from complications related to pregnancy and childbirth have been less successful than other areas of human development- with the result that having a child remains among the most serious health risks for women. On average, each day around 1,500 women die from complications related to pregnancy and child birth, most of them in Sub- Saharan Africa and South Asia1.

Maternal health problems in developing countries also include complications from child birth that do not result in death. For every woman that dies during child birth approximately 20 suffer from infection, injury, or disability. Improving access and affordability of health care is a major factor in improving maternal health. In India the government started paying for prenatal care and skilled delivery and new technologies to prevent complications during delivery, so successes in reducing maternal mortality so that India is cited as the major reason for the decreasing global rates of maternal mortality3.

Maternal mortality ratios strongly reflect the overall effectiveness of health systems, which in many low income developing countries suffer from weak administrative, technical and logistical capacity, inadequate financial investment and a lack of skilled health personnel. Scaling up key investigations could sharply reduce both maternal and neonatal deaths. Maternal mortality ratio is estimated globally at 402 maternal deaths per 100,000 live births resulting in over 500,000 deaths annually. In India Maternal mortality ratio is 254 deaths per 1, 00,000 live births. Major causes for maternal mortality are pre- eclampsia/ eclampsia (26%), haemorrhage (21%) obstructed labour (13%) and sepsis (7.7%). Causes of deaths can be divided into direct causes that are related to obstetric complications, during pregnancy, labour, or post partum period and indirect causes. There are five direct causes; haemorrhage, sepsis, eclampsia, obstructed labour and complications of abortion. Indirect obstetric deaths occur from either previously existing condition or from condition arising in pregnancy which are not related to direct causes but may be aggravated by the physiological effects of pregnancy1.

Pregnancy is a seemingly a long journey that is best travelled with support. Labour is almost an overwhelming experience because it involves sensations and emotions at such an intence level. Women need supportive persons with them to cope with their experience of labour. Labour and birth need all psychological and physical coping methods available for a woman, no matter, how many child birth preparations she had nor how many times she had already gone through the experience4.

Labour has been termed the most dangerous journey a human ever undertakes. The reason being that although it is a natural process but complications can arise at any time during its course. Maternal mortality remains between 500 and 1000 deaths for 100,000 live births in developing countries. A major cause of these deaths is prolonged obstructed labour primarily because of cephalopelvic disproportion. In those who survive, morbidity is significant due to complications like sepsis, post partum haemorrhage, ruptured uterus and urinary fistula. Obstructed labour is also a major precedent of perinatal deaths, birth asphyxia and neonatal sepsis5.

The majority of the deaths and complications could be prevented by cost effective and affordable health interventions like the partograph and indeed the measures that would prevent maternal deaths would also prevent morbidity and improve neonatal outcome. The partograph is an effective tool for monitoring labour, and when used effectively, will prevent prolonged labour, which accounts for about 8% of maternal deaths. The partogram, thus serves as an early warning system and assist in early decision on transfer, intervention decision in hospitals and ongoing evaluation of the effect of interventions6.

Increasing the effectiveness and efficiency of health services is important every where but particularly so in developing countries with limited resources. It is estimated that 97% of reported still births and 98% of reported neonatal deaths occur in less developed countries. In Sub Saharan Africa, women face a 1 in 22 chance of dying during child birth where as corresponding deaths in industrialised countries is 1 in 8000. Continuous monitoring of labour and provision of rapid care to deal with problems are most crucial for preventing adverse Obstetrics outcomes related to child birth7.

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 doctors) to plot examination findings from their assessment on the partogram. The belief that its use was applicable in developed settings led to its introduction worldwide. A number of common partogram 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 mortality and mortality8.

The WHO recommends partogram 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 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 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 times9.

According to the recommendation of the Indian Nursing Council, the trained birth attendants should maintain a partogram when the woman reaches active labour. The partogram should contain foetal condition, labour process, maternal conditions and interventions2.

6.1 NEED FOR THE STUDY

Based on 2005 data, the average life time risk of a woman in a least developed country dying from complications related to pregnancy or childbirth is more than 300 times greater than for a woman living in an industrialised country. Millions of women who survive childbirth suffer from pregnancy related injuries, infections, diseases and disabilities, often with lifelong consequences. The truth is that most of these deaths and conditions are preventable- research has shown that approximately 80% of maternal deaths could be averted if women had access to essential maternity and basic health care services1.

The tragedies of obstructed labour and rupture of the uterus comprise one of the five major causes of maternal mortality and morbidity in developing countries. The partograph serves as an “early warning system” and assists in early decision on transfer augmentation and termination of labour. WHO has modified to make it simpler and easier to use. The latent phase has been removed and plotting on the partograph begins in the active phase when the cervix is 4 cm dilated. Although a considerable amount of experience and information on the use of the partograph has been accumulated in the past 15-20 years, it is not in use in many great countries and there are significant gaps in our knowledge. Studies have shown that using partograph can be highly effective in reducing complications from prolonged labour for the mother and for the newborn10.

A study was conducted with an objective to assess the effectiveness of competency based training among 60 nurse midwife in Medical college hospital, Rajasthan through a structured questionnaire method for three months and the results revealed that there was an improvement in the use of WHO partogram to monitor labour and take decisions about prolonged labour, detect maternal- neonatal emergency and manage or refer cases and the author concluded that appropriate training made partogram an easy and uncomplicated tool for trained nurse- midwives to use11.

A cross sectional study was conducted with an aim to assess the improvement in knowledge and skills amongst trainees of the workshop on labour and partograph among 100 trainees in Hamdard University Hospital, Karachi through feed back forms, pre and post test questionnaire and pre and post training assessment of skills and the results revealed that 80% of the trainees strongly agreed that workshop had improved their knowledge and skills and overall results showed significant improvement in both knowledge and skills of the trainee after the workshop. The author concluded that training workshops should be done on a larger scale to train the staff in order to achieve the targets set under millennium development goals12.

A cross sectional descriptive study was conducted with an objective to find out with the status of Maternal Child Health Services after the induction of the indigenous system of medicine among lady doctors and general nurse midwives in 10 blocks of 5 selected districts in Uttar Pradesh through a structured interview schedule and the results revealed that knowledge of the indigenous system of medicines and general nurse midwives was lacking in many essential components of Maternal Child Health including high risk pregnancy, high risk newborn for urgent and timely referral. 36% could identify high risk pregnancy and only 18% used partograph during labour. The author concluded that in service training, timely monitoring and supervision can help in identifying high risk pregnancy and high risk newborn13.

The midwife who cares for a woman during labour is responsible for recognizing information on the progress of labour. This progress of labour needs to be charted on a partogram. It is a graphic record of progress of labour that helps caregivers to detect whether labour is progressing normally or not, indicates when augmentation of labour is appropriate and assist in recognising cephalopelvic disproportion long before labour becomes obstructed. The partogram assist nursing staff in early decision on transfer and termination of labour. It also increases the quality and regularity of all observation on the foetus and the mother during labour and aids in early recognition of problems with other14.

While recent trends move nursing and health care out of the hospital and into the community, some areas of nursing remain predominately in the hospital setting. One of these areas is labour and delivery nursing. Labour and delivery registered nurses use professional judgement, critical thinking and fast decision making skills. They care for women who are labouring, having complications of pregnancy or having recently delivered. They work closely with patients, families, and other health care professionals. Labour and delivery registered nurse provide care to women and their newborns during the antepartum, intrapartum, postpartum, and neonatal stages of this important life event. They implement the plan of care by monitoring the mother and baby and by teaching patients about their care and topics related to women’s health and newborn care15.

The above facts and studies created an insight in the investigator’s mind that by improving the knowledge regarding partogram among nurses who is working in maternity hospital will reduce the maternal complications during labour. It may enhance the changes in health care delivery system. The overall aim of the present study is to assess the effectiveness of video assisted teaching on knowledge regarding partogram among nurses.

6.2 REVIEW OF LITERATURE

The related literature of the present study has been collected and organised under the following sections

Section I: Literature related to general information on partograph

A cross sectional study was conducted with an objective to analyse the use of Obstetrical intervention, type of delivery and perinatal outcomes according to zones I, II, III of the partogram among 233 low risk pregnant women at public maternity hospital, Saopaulo over a period of four months and results revealed that the practice used in the different partogram zones with statistical significance of (p = 0.005) were: bath, movement and walking(zone III);artificial rupture of membranes (zone II) and oxytocin (zone 1). Caesarean sections were performed of 24% of women in zone III and the author concluded that partogram is an instrument that can be used as a guide when adopting interventions during labour16.