Proforma for Registration of Subjects for Dissertation s2

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

DISSERTATION PROPOSAL

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED

TEACHING PROGRAMME REGARDING KNOWLEDGE ON OBSTETRICAL

EMERGENCIES DURING LABOUR AMONG THE STAFF NURSES IN

SELECTED HOSPITALS AT TUMKUR.

SUBMITTED BY

Mrs. N.GAYATHIRI I YEAR M.SC NURSING OBSTETRICS AND GYNECOLOGICAL NURSING SHRIDEVI COLLEGE OF NURSING TUMKUR-06 2007-2008 1

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA.

ANNEXURE – II

Synopsis proforma for registration of subjects for dissertation.

1. Name of the Candidate : Mrs.N.Gayathiri I year M.sc (Nursing) Shridevi college of Nursing Lingapura, Sira road, Tumkur.

2. Name of the Institution : Shridevi college of Nursing

3. Course of study and subject : I year M.sc Nursing Obstetrics and Gynecological Nursing.

4. Date of admission to course : 21.05.2007

5. Title of the topic : A study to assess the effectiveness of Structured Teaching Programme Regarding knowledge on obstetrical Emergencies during labour among the Staff nurses in selected hospital at Tumkur. 2

6.Brief Resume of Intended Work Introduction :

Obstetrical emergencies are life-threatening medical conditions that occur in pregnancy or during or after labour and delivery1. Babies are wonderful additions to our lives. Their arrival is both tense and beautiful. Learning how to recognize and react to emergencies involving childbirth or pregnancy is very essential to save the life of mother and child. There are number of illnesses and disorders of pregnancy that can threaten the wellbeing of both mother and child. Obstetrical emergencies may also occur during active labour and delivery are amniotic fluid embolism, inversion or rupture of uterus, placenta accreta, prolapsed umbilical cord and shoulder dystocia1.A basic understanding of management of obstetrical emergencies during labour will help the professional nurse to save the life of mother and child. Considering the high maternal deaths in the developing countries, WHO in 1987 conceived the idea of “Safe Motherhood Initiative” at a conference in Nairobi, Kenya. It is a global effort to reduce the maternal deaths by at least left by 2000 A.D, now extended to 20102. Dr.Paul Van look, Director of WHO’s Department of Reproductive Health and Research, said more research into health systems was needed to test, adapt and refine, evaluate and scale up effective interventions to find ways to make these accessible to the people who need them3. Reducing high levels of maternal mortality is widely recognized as vital for development and economic prosperity but, while treatment for childbirth complications exists, not enough is known about what is stopping life-saving treatment from reaching the millions of women who need it3. Maternal mortality rate indicates the number of maternal deaths divided by the number of women of reproductive age (15-49). It is expressed per 100, 000 women of reproductive age per year. In India it is about 120 as compared to 0.5 of U.S2. Hospital Obstetric services can be improved and Government can be mobilized to contribute. Treatment delay and obstetric case finding rate can be reduced. Deteriorating economic conditions, however, may diminish utilization by services despite improvements6. 3 6.1.Need for the study: “Every minute a woman dies from pregnancy-and-childbirth- related causes, and at least 20 more women each minute suffer injury or disease as a result of childbirth, often with long-term consequences”3. - Anna Coates.

Worldwide, every year approximately eight million women suffer from pregnancy related complications. Over half a million of them, die as a result. The problems of maternal mortality and morbidity are greatest (99%) for the poor women in the developing countries. One woman in 11 may die of pregnancy related complications in developing countries, compared to one in 5000 in developed countries1.

Maternal death is a tragedy for individual women, for families and for their communities. In developed countries, the maternal mortality ratio is around 27 per 100,000 live births and in the developing countries the ratio is 20 times higher. It varies between 480 and 1000 per 100,000 live births depending on the region. Majority 80% of these deaths are preventable by nursing care1.

More study is required into what the barriers are in healthcare delivery systems and what stops women, particularly those who are poor, from assessing them. While clinical research into maternal mortality is vital, its findings do not address the problem of millions of mothers who are not receiving the health care they need.

Anna coates said 99% of maternal deaths occur in developing countries: women in northern Europe have a 1 in 4000 chance of dying from pregnancy related causes, while for women in Africa the risk is 1 in 163.

World wide causes of maternal death are obstructed labour 8%, severe bleeding 24%, and one of other dissect causes embolism 8%3.

Poverty & lack of resources contribute to this, but the main reasons for such high maternal mortality are policy barriers and management problems that impede access to good-quality emergency obstetric care in rural areas. The doctors, nurses and other hospital staff in managerial positions are not trained in modern management skills, which contribute to poor quality services. The situation can be improved by training existing 4 medical staff to provide emergency obstetric services in rural areas and training hospital mangers in management skills5.

More women die in India during childbirth than anywhere else in the world. Of the 5.36 lakh women who died during pregnancy or after childbirth in 2005 globally. India accounted for 1.17 lakh.

Midwives everywhere are concerned at the loss of a woman’s life at or near the time of giving birth. Each midwife needs to be aware of local circumstances and seek to apply best practice to the utmost of her ability. This may include initiating research and applying available evidence to ensure that appropriate care is given4.

As a staff nurse, I had experience in the hospital to witness the mother dying due to amniotic fluid embolism in the labor room soon after delivery of the newborn with in 5 minutes before the separation of placenta.

Providing knowledge to the professional nurse with obstetrical emergencies during labour is the best means for reducing the number of maternal mortality rate and neonatal mortality rate. Nurses must therefore have adequate knowledge of the obstetrical emergencies during labour that they can identify the emergency situation and provide immediate care.

Thus overall aim of this study is to provide information about obstetrical emergencies during labour like cord prolapse, shoulder dystocia, placenta previa, rupture of uterus and amniotic fluid embolism and to mange the condition to the staff nurse.

5 6.2. Review of Literature: Review of literature is defined as broad comprehensive, in depth systematic and critical view of scholarly publications, unpublished scholarly print materials, audio-visual material and personal communication. The purpose of this study is to identify the effectiveness of structured teaching program on obstetrical emergencies during labor among staff nurses through structured questioners. Also the purpose of review of literature is to obtain comprehensive knowledge base and in-depth of information from previous studies. 1. Otchere SA et al, (Sep 2007) conducted a study on strengthening emergency obstetric care in Vietnam. The objective was save the children and the ministry of health of Vietnam undertook a project between 2001 & 2004 to improve the availability of access to, quality and utilization of emergency obstetric care services at district and provincial hospitals in Vietnam. Study concluded that improvements in the capacity of existing health facilities to treat complications in pregnancy and childbirth can be realized in a relatively short period of time and is an essential element in reducing maternal mortality7. 2. Islam MT et al, (May 2006) conducted a study on implementation of emergency obstetric care training in Bangladesh. This paper describes the project in 2000-2004 and lessons learned. A 17 weeks competency based training course for team of medical officers and nurses was introduced in 2003. The scaling up of competency based training course for team of medical officers and nurses was introduced in 2003. The scaling up of competency based training, innovative incentives to retain trained staff, evidenced- based protocols to standardize practice and improve quality of care and the continuing involvement of key stakeholders, especially trainees, will all be needed to reach training targets in future8. 3. Skupski DW et al, (May 2006) conducted a study on improving hospital systems for the care of women with major obstetric haemorrhage. The study concluded that despite of significant increase in major obstetric haemorrhagic cases, found improved outcomes and fewer maternal deaths after implementing systematic approaches to improve patient safety. Attention to improve the hospital systems necessary for the care of women at risk for major obstetric haemorrhage is important in the effort to decrease maternal mortality from haemorrhage9. 6 4. Patricia A Janssen, et al, (Jan 2005) conducted a study to evaluate the success of a competency based nursing orientation programme for a single room maternity care unit by measuring improvement in self- reported competency after six months. The back ground of this study is single room maternity care has challenged obstetrical nurses to provide comprehensive nursing care during all phases of hospital birth experience. In this model, nurses provide intrapartum, post partum and new born cell in one room. Methods used were learning methods like classroom lectures, self-paced learning packages and preceptor ships in the clinical area. The study concluded that an education programme tailored to the learning needs of experienced clinical nurses contributes to improvements in nursing competencies and patient care10.

5. Kumari Ibha et al, (Nov 2003) conducted a study to evaluate the risk factors, clinical presentation, management and maternal and fetal outcome of uterine rupture. Methods used were the clinical details of 25 cases of uterine rupture managed in the last 5 years were reviewed. Result of this study was the incidence of uterine rupture was 1.4/1000 deliveries. Uterine rupture occurred ante partum in four cases during labor in the remaining 21. Study concluded that in majority of cases uterine rupture and its consequences are preventable with proper antenatal and intranatal care, identification of high-risk cases and education of the people about the benefits of supervised pregnancy and delivery11.

6. Sylvia D.Rinker, (Jan 2000) conducted a study on the real challenge; lessons from obstetric nursing history. Study concluded that the successes, failures, and ongoing dilemmas within nursing derive directly from the earliest nursing practices. This historical challenge, relevant to current practice, is that nurses not become so focused on techniques and routines that they forget the patient’s needs for comfort and support12.

7. Pittrof.R.,(Jan 1997) conducted a study to evaluate access to obstetric care in a rural districts using easily collected and evaluated data and avoiding expensive field surveys, complicated study design or statistical methods. A complete set of data was collected for 2147 (98.5%) of the 2178 total births. Compared to the total number of expected obstetrical conditions in the district, less than 25% of breech, 45% twin deliveries, 10% placental abruption and 5% placenta previa. Overall, these findings indicate that 5-10% of women in need of essential emergency care13.

8. Sharon P.Hall, (Jan 1997) conducted a study on the nurse’s role in identification of risks and treatment of shoulder dystocia. This study concluded that shoulder dystocia is a clinical emergency that requires immediate recognition and prompt treatment to minimize maternal and neonatal sequelae. The nurse’s calm demeanor, knowledge of treatment modalities and prepared response are valuable assets in this clinical dilemma14. Statement of the problem: “A study to assess the effectiveness of Structured Teaching Programme regarding knowledge on Obstetrical emergencies during labour among the staff nurses in selected hospitals at Tumkur.”

6.3. Objectives of the study: 6.3.1. To assess the knowledge of staff nurses regarding obstetrical emergencies during labor. 6.3.2. To deliver planned teaching programme on obstetrical emergencies among staff nurses. 6.3.3. To assess the effectiveness of planned teaching programme on obstetrical emergencies among staff nurses by comparing pre and post test knowledge. 6.3.4. To associate the knowledge of obstetrical emergencies during labor with selected demographic variables.

6.4. Operational Definitions:

* Assessment : Refers to the organized systematic variable process of collecting information about pretest and post test knowledge from staff nurses regarding obstetrical emergencies during labour.

*Effectiveness: Refers to the extend to which the planned teaching program on obstetrical emergencies during labour achieves desired effect in improving the knowledge of staff nurses as evident from gain in knowledge scores.

*Structured Teaching Programme: Refers to the systematically developed institutional method and teaching aids designed for staff nurses to provide information on obstetrical emergencies during labour.

*Obstetrical emergencies: Obstetrical emergencies are life-threatening medical conditions that occur in pregnancy during or after labour and delivery like cord prolapse, placenta accreta, shoulder dystocia, inversion or rupture of uterus and amniotic fluid embolism. 9 *Staff nurses: An individual who is qualified in Diploma nursing and registered as a nurse and who is involving in professional practice irrespective of their sex.

6.5. Hypothesis of the study: Research Hypothesis: There will be significant difference between the pre and post test knowledge scores of staff nurses regarding obstetrical emergencies during labor.

6.6. Assumptions: 1. Obstetrical emergencies are common during labour which may lead to life threatening condition. 2. Obstetrical emergencies are challenging phase for every staff nurses. 3. Though staff nurses are having rich exposure to clinicals, but the skill to perform and tackle the situation effectively is still lacking. 4. Enhancement of knowledge regarding obstetrical emergencies through a light for staff nurse to act promptly at the time of emergencies and prevent mortality rate due to obstetrical emergencies.

6.7. Delimitations: 1. This study is limited to the staff nurses who are working in the selected hospitals at Tumkur. 2. This study is limited to the staff nurses who are qualified in Diploma nursing in selected hospitals at Tumkur. 3. Sample size is limited to 100 staff nurses both male and female.

6.8. Pilot study: Pilot study will be conducted with 10 samples. The purpose of pilot study is to find out the feasibility of conducting study and design on plan of statistical analysis.

10 6.9. Variables: Research variables are the concepts at various levels of abstraction that are entered manipulated and collected in a study. * Independent variable - Structured teaching programme. * Dependent variable – knowledge of staff nurses.

7.0. Material and Methods (Methodology): The study is designed to determine the effectiveness of Structured Teaching Programme on obstetrical emergencies during labor among staff nurses of selected hospitals at Tumkur.

7.1. Source of data: Staff nurses in selected hospitals at Tumkur.

7.1.1. Research design: One group pretest – post test, quasi experimental design.

7.1.2. Research approach: An evaluative research approach.

7.1.3. Setting of the study: Selected hospitals at Tumkur.

7.1.4. Population: The population of present study comprise of all staff nurses who are qualified in Diploma Nursing and working in selected settings.

7.2. Method of collection of Data: (including sampling procedure) Self administered questionnaire and structured teaching programme on obstetrical emergencies during labor.

7.2.1. Sampling technique: Non probability convenient sampling technique.

7.2.2. Sample size: The sample of the study consists of 100 staff nurses in selected settings. 11 7.2.3. Sampling criteria: Inclusion criteria: 1. Staff nurses who are willing to participate in the study. 2. Staff nurses who are available during the period of data collection. 3. Staff nurses who are qualified in diploma nursing.

7.2.4. Exclusion criteria: 1. Staff nurses who are not willing to participate in study. 2. Staff nurses who are not available during the study. 3. Student nurses who are posted for clinical experience.

7.2.5. Tool for data collection: Self administered questionnaire. It consists of two parts,part I and II Part I – Items on demographic variables like age, sex, educational Qualification, total years of experience. Part II – Knowledge items on obstetrical emergencies during labor.

Procedure for data collection: The data will be collected with the prescribed time period, some selected hospital will be taken for study. The objective of a study will be explained to the head of the hospitals and responsible persons of each hospital before starting the data collection.

7.2.6. Data analysis method: The data analysis through descriptive and inferential statistics. Descriptive Statistics: Frequency, mean, median, mode of described demographic Variables. Inferential Statistics: - Paired‘t’ test to compare pre and post test knowledge test. - Chi square test will be used to find out the association between Selected variables with knowledge scores.

7.3.Does the study require any interventions to be conducted on patients or other humans or animals? Yes, the planned teaching programme will be delivered to staff nurse regarding obstetrical emergencies during labour.

7.4. Ethical clearance: The main study will be conducted after the approval of research committee. Permission will be obtained from the concerned head of the institution. The purpose & other details will be explained to the study subjects and an informed consent will be obtained from them. Assurance will be given to the study subjects on the confidentiality of the data collected from them. Information consent will also be taken from the staff nurses who are willing to participate in the study.

8. List of References: [Vancouver Style followed]

1. Chamberlain , Geoffery, Philip Steer., Obstetric emergencies. British Medical Journal.1999 May;318,no7194:1342.

2. D.C.Dutta. Textbook of Obstetrics. 6th edition,Calcuta:New central book agency (P) Ltd;2004.P.599-602.

3. Bulletin of the World Health Organisation.2005 Feb;83(2).

4. Myles.Textbook for Midwives.13th edition,United Kingdom: Churchill Livingston;1999.P.936.

5. Mavalankar DV., Policy and Management constraints on access to and use of life-saving emergency obstetric care in India. Journal of American Medical Women’s Association.2002 summer;57(3):165-6,168.

6. I Fenne D, Essien E, Golji N, Sabitu K, Alti-Mu’azu M, Musa A et al., Improving the quality of obstetric care at the teaching hospital. International Journal of Gynecology and Obstetrics.1997 Nov;59 suppl 2:s 37-46.

7. Otchere SA, Binh Ht., Strengthening emergency obstetric care training in Vietnam. Journal of Gynecology and Obstetrics.2007 Sep;26

8. Islam MT, Haque YA, Waxman R, Bhuiyan AB., Implementation of emergency obstetric care training in Bangladesh: lessons learned. Reproductive Health Matters. 2006 May;14(27):61-72.

9. Skupski DW, Lowenwirt IP, Weinbaum FI, Brodsky D, Danek M, Eglinton GS, Michael C Klien et al., Improving hospital systems for the care of women with major obstetric hemorrhage. Obstetrics and Gynecology.2006 May;107(5):977-83. 14

10.Patricia A Janssen, Lois Keen, Jetty Soolsma, Laurie C Seymour, Susan J Haris., Perinatal nursing education for single room maternity care: an evaluation of a competency- based model. Journal of clinical nursing. 2005 Jan;14(1):95-101.

11.Kumari Ibha et al., Rupture of the Gravid uterus. Journal of obstetrics and gynecology in India.2003 Nov.

12.Sylvia D.Rinker., The Real challenge: Lessons from obstetric nursing history. Journal of Obstetric, Gynecologic and Neonatal nursing.2000 Jan;29(1):100-106.

13.Pittrof R., Observed versus expected obstetric complications: an assessment of coverage of obstetric care in developing countries. Trop Doct.1997 Jan; 27(1):25-9.

14.Sharon P Hall., the nurse’s role in the Identification of risks and treatment of shoulder dystocia. Journal of Obstetric, Gynecologic and Neonatal nursing.1997 Jan;26(1):25-32. 15

9 Signature of the Candidate N.Gayathiri

10 Remarks of the Guide

11 Name and Designation

11.1 Guide Prof.Mrs.DANASU.R Professor Shridevi College of Nursing

11.2 Signautre

11.3 Co.Guide

11.4 Signature

11.5 HOD Prof.Mrs.DANASU.R Professor Shridevi College of Nursing

11.6 Signature

12.1 Remarks of the Principal

12.2 Signature