RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,BANGALORE
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION.
Ms. Iyrine Issac
First year Msc Nursing
Sushrutha College of Nursing
Bangalore- 85
1 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,BANGALORE
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1) NAME OF THE CANDIDATE AND Ms. IYRINE ISSAC ADDRESS First Year M.Sc Nursing, : Sushrutha College of Nursing, Bangalore -85
2) NAME OF THE INSTITUTION Sushrutha College of Nursing, : Bangalore -85
3) COURSE OF STUDY AND SUBJECT DEGREE OF MASTERS IN NURSING : OBSTETRIC AND GYNAECOLOGICAL NURSING
4) DATE OF ADMISSION TO THE 12-05-2012 COURSE
5) TITLE OF THE STUDY A STUDY TO ASSESS THE EFFECTIVENESS OF : STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING THE IMPORTANCE OF PARTOGRAPH AMONG STAFF NURSES DURING A LABOUR PROCESS IN A SELECTED HOSPITAL, BANGALORE.
2 6. BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
“ A man loves his sweetheart the most, his wife the best, but his mother the longest.”
-Irish Proverb.
Motherhood, the only act that manifests in human, forms the cosmic wonder of creation. Imagine a life growing within you, natured with your lifeblood. And then wonder of all, this vague motion within your womb turns into two tiny hands, reaching out for you. It’s like a moment of epiphany-a sacred communion when you look within and discover the
Godlike power of creation1.
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 ones2.
According to the world health report in 2010, 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
3 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 Asia3.
In many developing countries, complications of pregnancy and child birth are the leading causes of death among women of reproductive age. A woman 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 countries4.
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 Asia5.
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 mortality6.
4 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 pregnancy7.
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 intense 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 experience8.
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
5 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 sepsis9.
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 interventions10.
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 birth11.
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
6 foetal condition to allow early identification and diagnosis of pathological labour. Its use is critical in preventing maternal and perinatal mortality and mortality12.
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 times13.
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 interventions14.
6.1 NEED FOR THE STUDY
THE MOST DANGEROUS JOURNEY IS THE FIRST ONE WHICH WE ALL UNDERTAKE i.e. LAST TEN CMS OF GENITAL TRACT WHICH IS FULL OF EVENTS AND TWO MAIN HAZARDS- ASPHYXIA AND TRAUMA”
APSLEY- CHERNEY- GARRAD 1992.
Transition from being pregnant to becoming a mother brings enormous changes in the woman, both physically and psychologically. Many complications could develop during pregnancy and labour that could be fatal to both the mother and the baby15.
Each year of the 210 million women becoming pregnant, 20 million will experience pregnancy-related illnesses and 5, 00,000 will die due to complications of pregnancy or
7 childbirth2. The maternal mortality ratio in India is about 407 per 1, 00,000 term births and maternal mortality rate is 120 per 1, 00,000 women. The important causes of maternal deaths are haemorrhage, infection, pre-eclampsia, eclampsia, unsafe abortion, obstructed labour, anaemia, hepatitis etc. In this obstructed labour contribute about 8%.16
Obstructed labour is one where in spite of good uterine contractions the progressive descent of the presenting part is arrested due to mechanical obstruction. Antenatal detection of the factors likely to produce prolonged labour (big baby, small women, malpresentation and position), continuous vigilance during intranatal period, and use of partogram helps to prevent obstructed labour. The main proven intervention for obstructed labour is the use of partograph.17
Partograph is a tool graphically representing key events during labour. The partograph is used to plot the following parameters for progress of labour: cervical dilatation, descent of foetal head, uterine contractions, foetal heart rate, membranes, liquor and moulding of foetal skull. Additionally, the partograph can be used to monitor pulse, blood pressure, temperature, urine, drugs, IV fluids and oxytocin. This tool is recommended for routine monitoring of labour as an early warning system. It helps to diagnose slow progress of labour and thus helps to prevent obstructed labour.18
India tops the world with 26 million births every year, maternal mortality is alarming high (400-600/100,000 live births) with majority of deaths due to preventable causes like ante partum haemorrhage, puerperal sepsis, toxaemia, postpartum haemorrhage and obstructed labor.19
Pregnancy and labour are a normal physiological process, which are associated with certain risks. These risks can be prevented and managed if adequate ante partum and intra partum care is given to the pregnant and labouring women by skilled birth attendant. In developed countries, these risks have been largely overcome as every pregnant women have access to special care during pregnancy and child birth. And the maternal deaths resulting from pregnancy and child birth are estimated to be less than 1%. But in developing countries, pregnancy, childbirth and their consequences are still the leading causes of death, disease and disability among women of reproductive age. Over 300 million women in the developing world suffer from short term or long term illness brought by pregnancy and child birth and 5,29,000 die each year.20
8 The high rate of maternal and infant mortality in India has become a matter of concern. The maternal mortality rate in the country continues to be high at 540 per one lakh live births.
According to the government of India, maternal deaths related to pregnancy in Indian scenario are as follows. 21
9% 8% 29% Bleeding Anem ia
9% Sepsis Obstructe d Labor Abortion 10% Eclam psia Others 19% 16%
Prolonged and obstructed labour significantly contributes to maternal, fetal morbidity and mortality. Hence early detection and referral can not only reduce but prevent the occurrence of both these and their complications. 22
To prevent prolonged labour and its complications, we need a tool which not only prevents prolonged labour, but also identifies the deviation of labour process from normal at the earliest. The partograph is a simple, inexpensive tool to provide a continuous pictorial over view of labour, detect prolong labour and identify deviation of labour process from normal.23
Maternal mortality rate in Karnataka is 460 per 100,000 live births. Important contributing causes are anemia, poverty, ignorance, malnutrition, inter current infections, haemoglobinopathies. Haemorrhage(25.6%) ranks first as the cause of maternal death followed by sepsis(13%), Toxaemia of pregnancy (11.9%), abortion(8.5%), obstructed labor(6.2%) while other causes together total 35.3%.
9 Use of partograph during labour can prevent suffering and loss of life . The partograph records the progress of labour, especially the rate of cervical dilatation. Use of WHO partograph in eight hospitals in India , china and Malaysia reduced postpartum infection(59%) , the number of stillbirth, the amount of oxytocin augmentation and unnecessary caesarean section. Thus the WHO partograph was able differentiate labours requiring intervention from those not requiring intervention. WHO calls for health personnel to use its partograph and its management protocol, both in labour wards with the capabilities to manage labour complication and in health centres without these capabilities can refer women with labour complication to specialist. 24
A study conducted to assess the impact of breech labour management using the WHO partograph on foetal and maternal outcomes of labour in a larger multi-centre hospital- based study in Southeast Asia found reduction of caesarean section for multigravida from 27.1% to 19.3% after the introduction of the partograph. Prolonged labour (>18 hours) was reduced significantly among multigravida and primigravida (p<0.05) despite a reduced use of oxytocin.25
Hemant pandey Gijagi university, Madhya pradesh. (2009) A study was done in Dhule with the objective to assess the effectiveness of promoting the use of the World Health Organization (WHO) partograph by midwives for labor in a maternity home by comparing outcomes after birth. 20 midwives, who regularly conducted births in maternity homes, were randomly allocated into two equal groups. The design of the study was cluster randomized- control trial. Under supervision from a team of obstetricians, midwives in the intervention group were introduced to the WHO partograph, trained in its use and instructed to use it in subsequent labors. There were 304 eligible women with vertex presentations among 358 laboring women in the intervention group and 322 among 363 in the control group. Among the intervention group, 304 (92.4%) partographs were correctly completed. From 71 women with the graph beyond the alert line, 42 (65%) were referred to hospital. Introducing the partograph significantly increased referral rate, and reduced the number of vaginal examinations, oxytocin use and obstructed labor. The proportions of caesarean sections and prolonged labor were not significantly reduced. Apgar scores of less than 7 at 1min were reduced significantly, whereas Apgar scores at 5mins and requirement for neonatal resuscitation were not significantly different. Fetal death and early neonatal death rates were too low to compare. A training programme with follow-up supervision and monitoring may
10 be of use when introducing the WHO partograph in other similar settings, and the findings of this study suggest that the appropriate time of referral needs more emphasis in continuing education. The study concluded that the WHO partograph should be promoted for use by midwives who care for laboring women in a maternity home.26
Rukungiri district health facilities teams use a partogram to monitor progress of labor and condition of the mother and fetus. The district health officer reported that many maternal deaths actually occurred at hospital. The extent and quality of use of the partogram was a major concern to him and his team. DHO reported the partogram use was very low at various maternity units at heath centres and various hospitals.27
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 use28
. 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
11 monitoring and supervision can help in identifying high risk pregnancy and high risk newborn29.
WHO, UNICEF and non governmental institution announced that partogram is a most important procedure for the enhancement of the maternal and newborn well being. Cochrane review estimated that 97% of still birth reported and 98% of the neonatal death occur in less developed countries. Continuous monitoring of labor and provision of rapid care to deal with problems are most crucial for preventing adverse obstetric outcomes related to child birth.
On the basis of above literature, it is clear that knowledge of nurses regarding use of partograph during labor is inadequate. 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. Considering all the above factors the investigator felt that there is a need to assess the knowledge of staff nurses regarding use of partograph and to provide them with instructional module that will help them to give efficient care to women during labor.
6.2 REVIEW OF LITERATURE
Review of literature is an essential step in the research project. It provides basis for future investigation, justifies the need for study, throws light on the feasibility of the study, Reveals constrains of data collection and relates the findings from the study to another with a hope to establish a comprehensive study of scientific knowledge in a professional discipline, from which valid theories developed.
The related literature of the present study has been collected and organised under the following sections
1. Literature related to general information on partograph.
2. Literature related to knowledge regarding partogram among nurses.
3. Literature related to structured teaching programme among nurses.
Section I: Literature related to general information on partograph
12 WHO Maternal and safe Motherhood Programme issued a series of 4 inter related documents which are now updated as “Preventing Prolonged Labour: a practical guide- The Partograph.” The 4 documents are as follows:
First Document: Principles and Strategy”
Second Document: “User’s Manual”
Third Document: “Facilitator’s Guide”
Fourth Documents: “Guidelines for operational Research”
The above mentioned all the 4 documents provide useful resources for the introduction, the content and the making the tool and the analysis of the data collected.(WHO module, 2008)5
Jorge Thomas and Maria E Robin (2009). In their study on. “Increasing Compliance with Maternal and Child Care Quality Standards in Ecuador” they concluded that the care provider must check the fetal heart rate, maternal blood pressure and uterine activity every hour for every woman in labour. The second result was that in every delivery, a Partograph must be adequate completed. Both the results of the study helped the investigators to understand of Partograph for every woman in labour to prevent her from entering into the complications and thus help in reducing the maternal mortality and morbidity.30
Dr Julius sama DOHBIT in his study on “Study of Labour Partograph in Cama hospital, Jalandar”,(2009) he concluded that implementation of Partograph has greatly improved the Labour outcomes. This study helped the investigators a strong basis or foundation for conducting this particular study because it showed very impressive results which helped the investigators to move to move further in their own study.31
Ernest Oza, Albert Nima Baby,(2009) in their study on “Impact of Training on the Use of Partograph on Maternal and Perinatal Outcome in Peripheral Health Centres” they concluded that introduction of Partograph in peripheral health units in a developing country educed labour complications with resultant reduction in maternal and perinatal mortality and morbidity. This study helped study helped the investigator mainly during construction of the tool and during the analysis of data collected.32
13 Rahbar T, Atrkar Roshan Z. in their study on “Effect of Partograph on the First stage of Delivery” they concluded that using Partograph can decrease the number of Caesarean sectioned so it is very necessary to use Partograph for all the mothers at the time of delivery.
O.J. Daniel, A.O. Dadabhai ,New Delhi, 2010 In their study on “Knowledge and use of the Partograph among Health Care personnel at the peripheral Maternity Centres in Nigeria” they suggested that urgent referring of the cases which are found of having obstructed labour and providing effective training to care providers regarding the referral system.33
Diana and Margaret, (2009) in their study on “Study of Labour” they concluded that Partograph as a “GOLD” standard for assessing process in labour. This particular study helped the investigators in finding differences between the labours of multiparous and nulliparous women and induced labour and non induced labours. J.E. Mathews, A Rajaratnam, A George and M Mathai. In their study on “Comparison of the Two Who Partograph” they concluded that the simplified than the composite Partograph and was associated with better labour outcomes.34
Section II: Literature related to knowledge regarding partogram among nurses
Fawole A O, Robinson Albert James. (2010 June) A study was conducted with the objective to assess knowledge about the partograph and its utilization among maternity care providers in primary health care in Srinagar. Two hundred and seventy-five maternity care providers comprising of 64 CHEWS (23.3%), 74 Auxiliary midwives (26.9%), 123 Nurses/midwives (44.7%) and 14 medical doctors (5.1%) were interviewed in primary health centres and private hospitals in three states in Jammu Kashmir using a multi-stage sampling strategy. Knowledge about the partograph and assessment of labour were assessed with an interviewer-administered questionnaire. The study resulted that about a quarter of respondents, 75 (27.3%) had received prior training on the partograph. Only 25 (9.1%) reported that the partograph was available in their labour wards. Knowledge about the partograph was poor; only 18 (16.0%) of all respondents correctly mentioned at least one component part of the partograph, 21 (7.6%) correctly explained function of the alert line and 30 (10.9%) correctly explained function of the action line. Prior training significantly influenced knowledge about the partograph (gamma2 = 49.2; p < 0.05). Knowledge about assessment of labour was also poor: less than 50% of all respondents knew the normal
14 duration of labour and just about 50% understood assessment for progress of labour. The study concluded that the partograph is not utilized for labour management in Srinagar. Knowledge about partograph and assessment during labour is grossly deficient. Findings suggest poor quality intrapartum care. Effective interventions to improve labour supervision skills and partograph utilization are urgently required. 35
Orji E. (2009 Sep): The study was done in Kanpur with the objective to evaluate the progress of labor in nulliparous and multiparas using the modified World Health Organization (WHO) partograph. In a prospective study 259 nulliparous and 204 multiparas were compared for rates of normal labor progression in the active phase; of cervical dilatation plots crossing the alert line of the partograph; and of plots reaching or crossing the action line. Outcome measures were total duration of labor, mode of delivery, incidence of labor augmentation, and number of vaginal examinations. The study resulted that labor duration was similar in the 2 groups and cervical dilatation remained normal for most women. In both groups, the incidence of spontaneous vaginal delivery was highest among women with normal labor progress and the incidence of both labor augmentation and operative intervention increased when labor progress was delayed. The study concluded that Labor progress and duration were found similar for nulliparous and multiparas when monitored with the modified WHO partograph. Delay in labor progress increased the need for operative intervention and adversely affected fetal outcome.36
A study was conducted in Bangladesh with an aim to assess the impact of training on use of the partograph for labour monitoring among various categories of primary health care workers among 56 health workers over a period of 7 months in Bangladesh through hospital based survey and the result revealed that 242 partograph of women in labour were plotted and out of this 76.9% of them correctly plotted and 6.6% were inappropriate. The author concluded that effective training to use the partograph among primary health care workers can contribute towards improved maternal outcomes in developing countries37.
A cross sectional study was conducted to assess the knowledge ands utilization of the partograph among 719 health care workers from primary, secondary and tertiary levels of care over a period of one year in South Western Nigeria and the results revealed that only 32.3% used the partograph to monitor women in labour and partograph use was reported significantly more frequently by health care workers in tertiary level compared with health care workers from primary or secondary levels. The author concluded that the knowledge
15 about partograph is poor among the health workers and partograph is commonly not used to monitor the women in labour38.
A study was conducted with an objective to evaluate the knowledge and use of the partogram among 396 maternity care providers over a two month period in University Teaching Hospital, Nigeria through the questionnaire based survey and the results revealed that only 39 (9.8%) of all the personnel routinely employed the partogram for labour management and almost half of these individuals had a poor level of knowledge. The author concluded that training should be given to the care providers especially junior personnel for the effective use of the partogram39.
Section III: Literature related to structured Teaching programme among nurses
A study was conducted with an aim to evaluate effectiveness of structured Teaching programme for the nursing staff and students dealing with difficult and delicate patients in St. George’s maternity hospital, karad through self report questionnaire and the results revealed that nursing students and staff’s self efficacy increased noticeably over the course of the structured Teaching programme and the author suggests that using structured Teaching programme that shows students effectively coping with adverse situation and enhancing self efficacy and future research is needed to test the extent to which self efficacy measures relate with nursing performances40
A. O. Fatusi (2008 Jan) A study Swas done in gujarat with the objective to assess the impact of training on use of the partogram for labor monitoring among various categories of primary health care workers. Fifty-six health workers offering delivery services in primary health care facilities were trained to use the partogram and were evaluated after 7 months. The study resulted that total of 242 partograms of women in labor were plotted over a 1-year period; 76.9% of them were correctly plotted. Community health extension workers (CHEWs) plotted 193 (79.8%) partograms and nurse/midwives plotted 49 (20.2%). Inappropriate action based on the partogram occurred in 6.6%. No statistically significant difference was recorded in the rate of correct plotting and consequent decision-making between nurse/midwives and the CHEWs. The study concluded that Lower cadres of primary health care workers can be effectively trained to use the partogram with satisfactory results,
16 and thus contribute towards improved maternal outcomes in developing countries with scarcity of skilled attendants.41
Pettersson KO, Svensson ML, Christensson K. (2009 June) A study was done with the objective to evaluate the impact of an educational intervention of midwives' use of the Angolan model of the World Health Organization's (WHO) partograph. The setting used was a peripheral delivery unit with approximately 1500 deliveries per year, run by eleven midwives in south India. The quasi-experimental, One-Group Pre-test-Post-test design was used in this study. Fifty partographs plotted with an initial dilatation < 8 cm were randomly selected from the first period of six month to form sample I, and another fifty from the second six-month period to form sample II. In-service education (theory and practice) performed by a team of midwives and an obstetrician. The study reported that when comparing sample II with sample I, statistically significant improvements were found in seven of 10 measured variables. This indicates a positive effect of the educational intervention on a proper use of the partograph. Due to the small sample size, however, this study cannot evaluate action taken in relation to prolonged labor. The in-service educational programme may be of use when introducing the WHO partograph in similar settings and the findings of this study may indicate which parts of the programme need more emphasis. Conclusion of the study was that the midwives improved in general their documentation of the partograph. However, they tended to exceed established criteria for responsibilities at the peripheral delivery unit, a fact supported by an increased number of missed transfers. The study did not, however, answer the question why the midwives acted as they did in the referred cases.42
STATEMENT OF THE PROBLEM
A study to “assess the effectiveness of structured teaching programme on knowledge regarding the importance of partogram among staff nurses during a labour process” in selected maternity hospitals, Bangalore.
6.3 OBJECTIVES
6.3.1 To assess the knowledge of nurses regarding X of partogram in terms of pre test
17 6.3.2 To assess the knowledge of nurses regarding importance of partogram after conducting structured teaching programme in terms of post test.
6.3.3 To assess the effectiveness of structured teaching programme by comparing the pre and post knowledge scores of nurses.
6.3.4 To find out the association between the knowledge score with selected demographic variables of nurses like BSc nurses etc.
6.4 HYPOTHESES
H1: There will be significant difference between the mean pre test and post test knowledge scores among nurses regarding importance of partogram.
H2: There will be significant association between the mean post test knowledge scores regarding importance of partogram among staff nurses and the selected demographic variables like age, sex, professional qualification, total years of experience, total years of experience in labour ward, previous exposure to knowledge of partograph and source of information.
6.6 OPERATIONAL DEFINITION
Assess: refers to the procedure of judging the knowledge of nurses regarding
partogram.
Effectiveness: refers to the significant gain in knowledge scores of nurses regarding
partogram after conducting structured teaching programme.
Structured Teaching Programme: It refers to the systematically developed teaching
module designed for educating staff nurses on partogram.
18 Knowledge: refers to the correct response of the nurses to the structured knowledge
questionnaire method related to partogram.
Partogram: refers to a graphic recording of progress of labour and salient conditions
of mother and foetus and it is a tool to assess the progress of labour and recognize
need for action at the appropriate time and timely referral.
Nurse: refers to a person who is trained in both nursing and midwifery and focuses
on the management of women’s health care particularly pregnancy, child birth, the
post partum period, care of the new born and Gynaecology.
6.6 ASSUMPTIONS
1. Staff nurses will have poses some knowledge regarding X of partograph.
2. Level of knowledge and practical regarding X of partogram among nurses can be measured by structured teaching programme.
3. Staff nurses stress may get reduced by acquiring knowledge.
6.7 LIMITATION
The study is limited to:
1. Staff nurses present on duty
2. Staff nurses who are willing to participate in study.
3. Structured teaching programme will be provided only by the investigator.
7.0 MATERIAL AND METHODS
19 7.1 SOURCES OF DATA
Nurses who are working in selected maternity hospitals of Bangalore.
7.2 METHOD OF DATA COLLECTION
The data collection procedure will be carried out for a period of 6 weeks. The study will be conducted after obtaining permission from the concerned authorities. The data for this study will be collected using a structured teaching questionnaire to assess knowledge before and after structured teaching programme regarding importance partograph among nurses whose contents will be valuated by the experts and will be pretested and standardized through pilot study.
7.2.1 RESEARCH APPROACH
In the present study an evaluative approach will be used to assess the effectiveness of
Structured teaching programme regarding partogram among nurses.
7.2.2 RESEARCH DESIGN
Quasi- experimental design will be used to carry out the Study.
7.2.3 SETTINGS OF THE STUDY
Study will be conducted in selected maternity hospitals of Bangalore.
7.2.4 VARIABLES
Dependent variable- Knowledge of nurses regarding importance of partogram is the dependent variable.
20 Independent variable- Structured teaching programme on X of partogram is the independent variable.
7.2.5 POPULATION
The population of the present study comprise of nurses who are working in selected
Maternity hospitals of Bangalore.
7.2.6 SAMPLE SIZE
The sample size of the present study will be 50 nurses who are working in selected
Maternity hospitals of Bangalore.
7.2.7 SAMPLING TECHNIQUE
Purposive sampling technique will be used to select the sample. 7.2.8 SAMPLING CRITERIA
INCLUSIVE CRITERIA
Nurse who are willing to participate in the study.
Nurses who can read Kannada & English
Nurses who would be available during data collection
Staff mainly working in Labour room
Fourth year Bsc Nursing students posted in Obstetrics & Gynaecology
Ward.
EXCLUSIVE CRITERIA
Nurses who are not present at the time of data collection.
Nurse who are not willing to participate
Nurses age above 35 years
21 Nurses whose experience in less than 2 – 5 years
7.2.9 DATA COLLECTION TOOL
The data will be collected by using structured questionnaire method which consists of two parts.
Part 1: it includes demographic variables such as age, education, total experience, area of experience, any in-service education on partogram.
Part 11: it includes knowledge items related to partogram.
7.2.10 DATA ANALYSIS METHOD
The collected data will be analyzed through descriptive and inferential statistics.
Descriptive statistics: it includes mean, frequency, percentage, range and standard deviation to describe demographic variables and knowledge aspects.
Inferential statistics: it includes parametric paired‘t’ test and non parametric chi square test to assess the effectiveness of structured teaching programme and to find out the association between the knowledge scores with selected demographic variables.
7.3 DOES THE STUDY REQUIRE ANY INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS?
YES, the study will be conducted on staff nurses by imparting knowledge through structured teaching programme.
7.4 HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION?
YES, prior permission will be obtained from the research committees of the Sushrutha College of nursing, Bangalore.
22 8. LIST OF REFERENCES
1. Gittelsohn J et al. “Perception of motherhood in Listening to women talk about
their health”,(1994); 20,3-4
2. Moccia P, Anthony D, Brazier C, Marilia D, Egzlabher HG, Goodman E et al. The
state of the world’s children. United Nation Children’s Fund. 2009. Available from
http://www. Scribd.com.
3. Wikipedia, the free encyclopedia. Maternal health. 2010. Available from
http://en.wikipedia.org.
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9. SIGNATURE OF THE STUDENT :
10. REMARKS OF THE GUIDE :
11. NAME & DESIGNATION OF THE GUIDE : Mrs. Mahalakshmi, MSc (N), OBG
Assistant professor
11.1 GUIDE NAME & ADDRESS : Mrs. Mahalakshmi, MSc (N), OBG
Assistant professor
11.2 SIGNATURE OF THE GUIDE :
27 11.3 HEAD OF THE DEPARTMENT : Mrs. Mahalakshmi, MSc (N), OBG
Assistant Professor
11.4 SIGNATURE OF HOD :
12. REMARKS OF THE PRINCIPAL :
13. SIGNATURE OF THE PRINCIPAL :
28