Rajiv Gandhi University of Health Sciences s155

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

PERFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

MS. RENJINI.R 1ST YEAR M.SC NURSING OBSTETRICS AND GYNAECOLOGICAL NURSING SUSHRUTHA COLLEGE OF NURSING, BANGALORE-85.

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

MS.RENJINI.R 1 NAME OF THE CANDIDATE 1ST YEAR M.SC NURSING AND ADDRESS SUSHRUTHA COLLEGE OF NURSING, #23,PAPAIAH GARDEN, DIAGONAL ROAD, BANASHANKARI III STAGE, BANGALORE-560 085

2 NAME OF THE INSTITUTION SUSHRUTHA COLLEGE OF NURSING 3 COURSE OF THE STUDY AND MASTER DEGREE OF SCIENCE NURSING IN SUBJECT OBSTETRICS AND GYNAECOLOGICAL NURSING

4 DATE OF ADMISSION TO 18-05-2012 THE COURSE

“A STUDY TO ASSESS THE EFFECTIVENESS 5 TITLE OF THE TOPIC OF PLANNED TEACHING PROGRAMME ON KNOWLEDGE REGARDING RESUSCITATION OF PREGNANT WOMAN(MATERNAL CPR) AMONG STAFF NURSES WORKING IN OBG DEPARTMENT IN SELECTED HOSPITALS IN BANGALORE.”

BRIEF RESUME OF THE INTENDED WORK 6. INTRODUCTION

“Preparation through Education is Less Costly than Learning through Tragedy”. -Max Mayfield, Director, National Hurricane Center.

With one maternal death reported every ten minutes, India is likely to miss the Millennium Development Goal (MDG) related to maternal health, a latest United Nations report says. While there is an improvement from maternal death in every six minutes in 2010 to 10 minutes now, the MDG target in this respect is unlikely to be met; the report said. At present, the Maternal Mortality Rate (MMR) of India is 212 per one lakh live births, whereas the country’s target is 109 per one lakh live births by 2015. The MDG Report 2012 points out that an estimated 2, 87,000 maternal deaths occurred in 2010 worldwide.1

The Confidential Enquiries into Maternal and Child Health (CEMACH) data set constitutes the largest population-based data set on this target population. The overall maternal mortality rate was calculated at 13.95 deaths per 100 000 maternities. There were 8 cardiac arrests with a frequency calculated at 0.05 per 1000 maternities, or 1:20 000. The frequency of cardiac arrest in pregnancy is on the rise with previous reports estimating the frequency to be 1:30 000 maternities. Despite pregnant women being younger than the traditional cardiac arrest patient, the survival rates are poorer, with one case series reporting a survival rate of 6.9%. During attempted resuscitation of a pregnant woman, providers have two potential patients: the mother and the foetus. The best hope of foetal survival is maternal survival. For the critically ill pregnant patient, rescuers must provide appropriate resuscitation based on consideration of the physiological changes caused by pregnancy.2

Because of the increasing number of pregnancies with pre-existing conditions and maternal mortality, the healthcare team has a duty to respond when the pregnant woman's condition worsens, leading to the provision of advanced cardiopulmonary life support. In situations where deterioration of maternal status results in respiratory or cardiac arrest, healthcare providers need to provide basic and advanced life support that include the necessary pregnancy alterations taking into account physiologic changes induced by the pregnancy and the unique circumstances of both the mother and the foetus. The speed of resuscitation response in cardiac arrest in pregnancy is critical to the outcome of both the mother and the foetus. The management of the unresponsive pregnant woman differs from that of the traditional adult resuscitation. Care providers must be aware of the impact of physiologic and anatomic changes that occur during pregnancy and how these changes affect resuscitation techniques in the pregnant woman. Cause of the cardiopulmonary arrest should be considered to treat with the appropriate measures. Causes of cardiopulmonary arrest during pregnancy have been divided into obstetric, non- obstetric and iatrogenic etiologies. Obstetric etiologies may be Haemorrhage, Hypertension/Preeclampsia/Eclampsia or Amniotic fluid embolism. Non-obstetric etiologies can be Pulmonary embolism/ Venous thromboembolism (VTE), Cardiac disorders(Congenital Heart Disease, Atherosclerotic heart disease, Cardiomyopathy, Myocardial Infarction and Aortic Dissection in pregnancy), Sepsis(Common sources of obstetric infection are the reproductive tract, urinary tract, respiratory tract infection, wound, chorioamnionitis, and cholecystitis) or Stroke(Strong risk factors are hypertension, diabetes, heart disease, sickle-cell disease, thrombophilia, smoking, and drug use, particularly cocaine). Iatrogenic etiologies may be Magnesium sulphate toxicity (Administration errors or accidental magnesium sulphate overdose resulting in

3 cardiopulmonary arrest) or Anaesthetic complications (difficulty in obtaining an airway or systemic toxicity from an epidural or spinal anaesthesia).3

Cardiovascular changes that normally occur during pregnancy are important considerations in maternal resuscitation efforts. Cardiac output increases by 30% to 50%, reaching its peak at about 32 weeks gestation. This increase is caused by increases in heart rate and stroke volume, together with a decrease in systemic vascular resistance. Aortocaval compression by the gravid uterus occurs at approximately 20 weeks of gestation and is responsible for “supine hypotension syndrome,” reflecting a decrease in cardiac output by as much as 25%.4

The implications of managing CPR associated with pregnancy are significant. Chest compressions in a non pregnant individual produce approximately 30% of normal cardiac output, but only 10% in the later stages of pregnancy. In addition, the gravid uterus receives up to 30% of cardiac output as the result of markedly increased uteroplacental blood flow,

compared with the non‐gravid uterus, which receives less than 2% of cardiac output. Thus, the effectiveness of chest compressions may be attenuated by the obstructive effect of the gravid uterus on the great vessels together with the shunting of a large percentage of blood flow to the gravid uterus.5

If cardiac arrest occurs in the first half of gestation, the purpose of CPR is to resuscitate the mother. If she is resuscitated, it is likely that the pregnancy will proceed and the fetal viability will not be compromised. In this setting, emergency delivery of the fetus is not likely to improve the mother’s chances of survival and certainly the fetus will not survive. However, beyond the threshold of viability (24 weeks of gestation or greater) there are data to suggest that delivery may actually improve maternal survival. Delivery of the fetus will decrease aortocaval compressions and therefore improve venous return and cardiac output. In addition, the cardiac output will increase secondary to the 25-56% increase in intravascular volume that occurs when the uterus is emptied and auto transfusion occurs. An additional benefit is that chest compressions will be more effective once the gravid uterus is evacuated. The functional residual capacity will likewise increase, improving oxygenation during resuscitation efforts.6

Following recognition of cardiopulmonary arrest, rapid activation of the code response team should be accomplished to gain additional assistance and guidance to follow current American Heart Association (AHA) guidelines (2010) for Cardiac Arrest Associated With Pregnancy. In addition, to prepare for proper resuscitation in the pregnant woman, availability of ACLS equipment, Caesarean delivery instruments, and neonatal equipment should be brought immediately to the woman's bedside. Time is not taken to move the woman to an operating room for resuscitation, which may include perimortem caesarean delivery.7

6.1 NEED FOR THE STUDY The death of a woman during pregnancy is devastating. Although the incidence of maternal cardiac arrest is increasing, it continues to be a comparatively rare event. Obstetric healthcare providers may go through their entire career without participating in a maternal cardiac resuscitation. Concern has been raised that when an arrest occurs in the obstetric unit, providers who are trained in life support skills at 2-year intervals are ill equipped to provide the best possible care. The quality of resuscitation skills provided during cardiopulmonary arrest of inpatients often may be poor, and knowledge of critical steps to be followed during resuscitation may not be retained after life support training. The Obstetric Life Support (ObLS) training program is a method of obstetric nursing and medical staff training that is relevant, comprehensive, and cost-effective. It takes into consideration both the care needs of the obstetric patient and the adult learning needs of providers. The ObLS program brings obstetric nurses, obstetricians, and anesthesiologists together in multidisciplinary team training that is crucial to developing efficient emergency response.8

The Confidential Enquiries into Maternal and Child Health (CEMACH) data set constitutes the largest population-based data set on this target population. The overall maternal mortality rate was calculated at 13.95 deaths per 100 000 maternities. There were 8 cardiac arrests with a frequency calculated at 0.05 per 1000 maternities, or 1:20 000. The

5 frequency of cardiac arrest in pregnancy is on the rise with previous reports estimating the frequency to b 1:30 000 maternities.9 Furthermore, the 2003–2005 Confidential Enquiry into Maternal and Child Health (CEMACH) described deficiencies in knowledge and poor resuscitation skills among obstetrical caregivers and recommended that all clinical staff undergo regular training in basic and advanced CPR. The report also emphasised that changes in medical training and work patterns have reduced the exposure of junior medical staff to life-threatening illness and suggested the use of simulator trainingCardiopulmonary arrest during pregnancy presents a unique clinical scenario involving two patients: the mother and the fetus. Management of these patients demands a rapid multidisciplinary approach, including anesthesiology, medicine, obstetrics, neonatology and sometimes cardiothoracic surgery. Basic and advanced cardiac life support algorithms should be implemented; however, the physiological and anatomical changes of pregnancy require some modifications to these protocols. Randomized trials of approaches to management of pregnant women with cardiopulmonary arrest are lacking, so recommendations for these modifications are based on data from small case series and small cohort studies involving patients with cardiac arrest during cesarean delivery, and expert opinion.11

Lack of knowledge of resuscitation, (basic and advanced) is a problem long recognized, and recently reiterated. Resuscitation skills were judged to be poor in a significant number of cases in the two most recent reports on maternal mortality in the UK. Uptake of training opportunities is constrained by limited resources (both time and financial). In an attempt to address this, the Resuscitation Council in the UK has recently begun to develop e-learning materials to accompany hands-on training in order to shorten their courses.12

In 2005, a retrospective analysis study of 10 year data (1992 – 2001) pertaining to 928 critically ill obstetric patients from King Edward Memorial Hospital (KEMH),Mumbai being compared to a similar patient population at Houston county hospital, the mean age of Indian patients was 25.4 ± 4.6 years, only 60% of Indian patients presented for admission within 24 hours of onset of illness (vs. 90% for Western patients), the maternal mortality was much higher in Indian patients (25%) as compared to the Western patients (2.7%). In both ICUs about 70% of critically ill pregnant patients were admitted with Obstetric disorders. Cardiac arrest prior to ICU admission (2.8%) & Rheumatic heart disease (2.1%) were common in Indian patients. Factors leading to adverse outcomes in Indian subjects were lack of antenatal care, delayed presentation, higher severity of illness at presentation, and lack of an aggressive emergency obstetric approach.13

There are no randomized controlled trials evaluating the effect of specialized obstetric resuscitation versus standard care in pregnant patients in cardiac arrest. There are reports in the literature of patients not in arrest that describe the science behind important physiological changes that occur in pregnancy that may influence treatment recommendations and guidelines for resuscitation from cardiac arrest in pregnancy.14

Regular, multi-professional training sessions for all staff members is increasingly regarded in conditions to improve patient safety. A proficient staff makes all the difference when it comes to handling unexpected emergencies, especially when the more specialized assistance is located far away. The greater supply of resources found in hospitals has its advantages, but is not the sole key to patient safety. Early detection of complications and timely and accurate actions are equally important here when it comes to ensuring the safety of mother and child. Hence, the need for team training and enhancement of clinical skills is as relevant for hospitals as it is for rural maternity wards.15

Health Teaching is an integral part of nursing and it emphasis a scientific attitude towards health which is very important to modern healthy living. Planned health teaching of the masses is one of the most effective means of health promotion. Staff nurses working in OBG Department should be competent enough to identify maternal cardiac arrest and resuscitate the pregnant woman promptly according to maternal cardiac arrest algorithm given by American Heart Association in 2010. While working in clinical settings, it is observed by the researcher that no special training is provided for the staff nurses working in OBG Department regarding resuscitation of pregnant woman in most of the hospitals in India. Hence the researcher felt that it is essential to conduct a planned teaching programme regarding maternal CPR and to evaluate the effectiveness of the same.16

6.2 REVIEW OF LITERATURE

Review of literature is divided into three divisions.

7 1. Review of literature related to general information of CPR.

2. Review of literature related to general information about maternal CPR.

3. Review of literature related to planned teaching programme regarding maternal CPR.

1. REVIEW OF LITERATURE RELATED TO GENERAL INFORMATION OF CPR.

An interventional study was conducted in 2011 in Ahmadabad, Gujarat in which a workshop was conducted on basic skill of Cardio-Pulmonary Resuscitation (CPR) among doctors and nursing staff in medical college. First day 40 doctors, second day 26 nursing staff and third day 51 nursing staff participated in the training programme. Power point presentation was used for better visual impact on the participants. The results were analyzed by using an answer key prepared from BLS manual of American Heart Association (AHA). Out of 117 participants, only 3 participants secured 80-90% marks in pre test whereas the rest secured less than 50% marks. Post workshop assessment with same questionnaire showed 70% candidates securing more than 80%. Pair t test was used to establish statistical significant between pre and post training score. As per the result of Paired t – test, the P value for 1st group (doctors group),2nd and 3rd groups(Nursing staff) is less than 0.01 which is suggestive of the fact that the intervention (training) is highly effective for improvement of BLS knowledge and is highly significant statistically. They concluded that BLS and ACLS training programmes should be mandatory for all the medical and paramedical staff.17

A descriptive cross sectional study was carried out in 2012 in 3 medical college hospitals in coastal areas of Karnataka to assess the resuscitation knowledge among interns. 270 interns were included in the study. They were requested to answer the questionnaire, comprising of 20 questions covering various aspects of basic and advanced life support of child and adult. Statistical analysis was done by frequency, percentage, mean and mean percent. On an average 9.05 questions were rightly answered. Highest score of 16 was achieved by 3 and lowest of 2 was achieved by 2. Seven questions were rightly answered by more than 50%. They concluded that introduction of structured resuscitation program in the undergraduate curriculum is needed and effort should be made to determine an appropriate and efficient course design.18 A quasi- experimental study was conducted in January 2004 on knowledge and skill regarding CPR among staff nurses (n=40). The study was carried out in MD Oswal Cancer Hospital in Ludhiana. Random sampling was adopted to collect the data. The questionnaire consisted of 50 multiple- choice questions containing general information regarding CPR, causes of cardiac arrest, signs and symptoms of cardiac arrest, administration of CPR, CPR given during special circumstances, drugs used during CPR and interventions after initial recovery. Reliability of the tool was carried out by split-half technique and it came out to be 0.98 which concludes that the tool was highly reliable. The staff nurses aged 21-23 years and 24-26 years have highly significant difference in post-test knowledge scores at p <0.05 level and hence the structured teaching programme was highly significant in improving the knowledge of staff nurse regarding CPR. The staff nurses having work experience of 1-3 months, 10-12 months and more than 1 year have highly significant difference in post test knowledge scores at p<0.50 level and hence the structured teaching programme was highly significant in improving the knowledge of staff nurses regarding CPR.19

A study was conducted in 2010 on Assessing the need and effect of updating the knowledge about CPR in experts (n=35) in Golestun Medical University, Iran. Data collection was done by a questionnaire of 43 questions about knowledge which was completed by the participants before and after teaching and after two months duration. The data were analysed by the wilkoxon test. P-value less than -01 were considered to be significant. This result showed that the level of knowledge had improved to 85% after training and to 87% after two months. It was suggested that a periodic training can be scheduled for the staff.20

2. REVIEW OF LITERATURE RELATED TO GENERAL INFORMATION ABOUT MATERNAL CPR.

A study was conducted in 2008 by Intensive Care Unit, Shaare Zedek Medical Centre, Israel to assess the labour ward clinicians' knowledge of maternal cardiac arrest and resuscitation. Structured scenario questionnaire survey was conducted among relevant hospital clinicians. The overall response rate was 67% (30/45 questionnaires). Specialist obstetricians, midwives and anesthetists’ from 17 hospitals participated. The study hypothesis was that experienced medical clinicians who specialize in obstetric care would not follow current American Heart Association recommendations in this situation. Forty-three

9 percent (n=13) claimed broad experience, 50% (n=15) claimed some experience and 6.7% (n=2) claimed no experience in adult resuscitation. Participants were divided in their opinions regarding every choice of action like positioning, location of external chest compression. They concluded that Specialist clinicians who treat pregnant women in hospital on a daily basis possess a limited knowledge of the recommendations for treating maternal cardiac arrest.21

A study was conducted in 2010 in USA to assess the deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises. They evaluated 18 videotaped simulations of maternal amniotic fluid embolus and resultant cardiac arrest. A checklist containing 10 current American Heart Association recommendations for advanced cardiac life support (ACLS) in obstetric patients was utilized. They evaluated which tasks were completed correctly and the time required to perform key actions. Proper compressions were delivered by the teams 56% of the time and ventilations 50% of the time. Critical interventions such as left uterine displacement and placing a firm back support prior to compressions were frequently neglected (in 44% and 22% of cases, respectively). The mean +/- SD overall composite score for the tasks was 45 +/- 12% (range, 20-60%). The neonatal team was called in a median (interquartile range) of 1:42 (0:44-2:18) minutes: seconds; 15 of 18 (83%) teams called only after the patient was completely unresponsive. Multiple deficits were noted in the provision of CPR to parturients during simulated arrests, despite current ACLS certification for all participants. They recommended revision for ACLS certification and training of obstetric staff.22

A study was conducted in 2006 by the Department of Obstetrics and Gynaecology, UK to assess the competency of obstetric and gynaecology trainees in managing maternal cardiac arrests. A total of 71 questionnaires were collected which represents 62% of the 113 trainees in Yorkshire region. A total of 69% of trainees did not know that chin lift opens the airway in some 70 - 80% of patients; 50% of trainees were not aware why jaw thrust is preferred over chin lift; 76% of the trainees knew the most common cause of airway obstruction in a patient with an altered level of consciousness--the tongue falls back and obstructs the pharynx ('swallowing the tongue'). Knowledge of the main cause of airway obstruction was good among obstetrics and gynaecology trainees, but their understanding of how to manage this was found to be relatively poor. Attendance at a local Basic Life Support course should be compulsory for obstetric and gynaecology trainees early in their career.23 A systematic review of the literature that may contribute in defining the modifications to advance care life support resuscitation for the pregnant woman was done in UK in 2011. The objective of the study was to describe the consensus on science pertaining to resuscitation of the pregnant patient. Studies were selected through an independent review of titles, abstracts and full article. Two reviewers independently graded the methodological quality of selected articles. 1305 articles were identified and 5 were selected for further review. There were no randomized trials and overall the quality of the selected studies was good. Two studies examined chest compressions on a manikin in left lateral tilt from the horizontal and concluded that although feasible, with increasing degrees of tilt forcefulness of the chest compressions decreases. The third study observed the transthoracic impedance was not altered during pregnancy. One case series and one retrospective cohort study reviewed perimortem cesarean section. Both reports concluded that perimortem caesarean section is rarely done within the recommended time frame of 5 min after the onset of maternal cardiac arrest.24

3. REVIEW OF LITERATURE RELATED TO PLANNED TEACHING PROGRAMME REGARDING MATERNAL CPR.

A three day High Dependency, Obstetrics and Trauma management (HOT) training program had been conducted over a number of years to provide knowledge and skills to first responders at health centre and district hospital level. The course focuses on effective management of women with obstetric emergencies. The course has been run 16 times from 2005- 2010 and a total of 391 health care workers have successfully completed training. The objective of the study was to evaluate whether this training has impacted on care and maternal (MMR) mortality rates. It was also considered important to emphasise the importance of high dependency care, to maximize survival of patients who had been successfully resuscitated. The teaching faculty consisted mainly of Malawian instructors, who were medical anaesthesia trainees (MMeds), non-medical Anaesthesia Clinical Officers, midwives and intensive care nurses. The course material consisted of a combination of lectures and small practical resuscitation skills. Of the 391 delegates who had completed the course by November 2010, 386 passed initially and the other 5 passed after some

11 supplementary instruction.The MMR was reduced from 711 (in 2005) to 229 (in 2010) and the number of live births were increased from 26772 (in 2005) to 33495 (in 2010). All participants also recorded improvements in their work practice in obstetrics.25

A study was conducted in 2009 to evaluate the use of a structured training programme in emergency care in Pakistan through the completion of logbooks documenting actual resuscitation attempts. A Cross-sectional survey was conducted in which 120 health workers, trained in the skills for managing maternal, neonatal and childhood emergencies were participated. Participants were provided with logbooks to document the actual use of their newly acquired skills during the resuscitation of mothers. 1123 resuscitation attempts were documented and received from 63 of the 120 participants. 76% (858/1123) of documented cases were received from doctors and 24% (265) from nurses. The pregnant mothers receiving resuscitation were 21% (n=233). Skills used to secure the airway; breathing (use of oxygen and bag valve mask ventilation) and circulation were used in 58%, 82% and 73% of resuscitated patients. Oxygen was used in 62% of pregnant mothers. The overall survival rate in the cases reported was 89%. They concluded that resuscitation logbooks can be used to assess which skills are used in emergency care. Individually held and completed logbooks should continue to act as a feedback and audit mechanism to measure outcomes, in conjunction with other methods of evaluating the impact of the training component of this programme.26

A prospective observational cohort study was conducted in 2012 in Toronto, Canada to assess management of maternal cardiac arrest by anesthesia residents using high-fidelity simulation and compare subsequent performance following either didactic teaching or electronic learning (e-learning). Twenty anesthesia residents were randomized to receive either didactic teaching (Didactic group, n = 10) or e-learning (Electronic group, n = 10) on maternal cardiac arrest. Baseline management skills were tested using high-fidelity simulation, with repeat simulation testing one month after their teaching intervention. Even after teaching, only 65% of participants started Perimortem Cesarean delivery within four minutes. The technical and nontechnical skills scores between the two teaching groups were compared. Technical and nontechnical skills scores improved after teaching in both groups, and there were no differences between the groups. They concluded that there are gaps in the knowledge and implementation of resuscitation protocols and the recommended modifications for pregnancy among residents. Teaching can improve performance during management of maternal cardiac arrest. Electronic learning and didactic teaching offer similar benefits.27

An evaluative study was done in 2012 in India, at selected health centres of Udupi district in Karnataka to evaluate the effectiveness of maternal and child health educational intervention program which includes safe motherhood, neonatal resuscitation and emergency obstetric interventions. The sample size of 50 were drawn by convenient sampling technique which comprised of staff nurses, ANMs and lady health visitors who were currently working at the selected health centres. After analyzing the baseline knowledge, a pre-tested self learning educational material along with different methods of teaching like discussions, role play were introduced. Evaluation was done at 1 week interval after the intervention was introduced for final assessment. The mean knowledge of staff nurses was 4.7(SD:1.25) with a range of 3 to 7.After training, the mean knowledge score was7.9(SD:1.911),which showed that there was a difference in the depth of knowledge between subjects. This difference was statistically significant (p<0.05).The findings of the study suggests improvements in scores between pre-training and post training period, and demonstrated that the training has significantly increased scores on evaluation of knowledge in midwives despites their earlier advanced formal education and many years of experience. They concluded that maintaining midwives’ knowledge through retraining could be pivotal to prevent maternal and infant mortality.28

A study was conducted in 2009 in Atlanta to evaluate a simulation-based team training program called Obstetric Crisis Team Training Program (OBCTT) framed within a multilevel team theoretical model. 22 perinatal health care professionals (attending physicians, nurses, resident, and nurse midwives) volunteered to participate in this pretest-posttest study design. All participants were given an online module to study before attending a 4-hour training session. Team simulations were video recorded. Self-report measures of perinatal and team knowledge as well as several attitude surveys were given at the beginning and again at the end of the training session. A post simulation attitude survey was administered immediately after the first and last simulation, and a course reaction survey was administered at the end of the training program. There were significant (P<0.004) improvements in three of the outcome variables, attitudes toward competence in handling obstetric emergency (t=1.6), as well as

13 individual (t=4.2), and team performance (t=4.1). Overall task completion from the first to the last simulation (XF, df=3, n=3, 8.2, P=0.042) substantially improved (P<0.05). Trainees exhibit a positive change in attitude; perception of individual and team performance. The ability of individuals to accurately assess their performance improved as a result of training.29

6.3 STATEMENT OF THE PROBLEM

“ A STUDY TO ASSESS THE EFFECTIVENESS OF PLANNED TEACHING

PROGRAMME ON KNOWLEDGE REGARDING RESUSCITATION OF PREGNANT

WOMAN(MATERNAL CPR) AMONG STAFF NURSES WORKING IN OBG

DEPARTMENT IN SELECTED HOSPITALS IN BANGALORE”.

6.4 OBJECTIVES OF THE STUDY

1. To assess the existing level of knowledge of staff nurses regarding resuscitation of pregnant woman (Maternal CPR).

2. To determine the effectiveness of planned teaching programme of staff nurses regarding maternal CPR.

3. To compare the mean pre test and mean post test knowledge scores regarding maternal

CPR among the staff nurses.

4. To find out the association between mean post test knowledge scores of the staff nurses

with selected demographic variables like Age of the staff nurses, Education, Total years

of professional experience, Total experience in OBG department, Area of work, Source

of information on basic BLS/ACLS.

6.5 RESEARCH HYPOTHESIS:

H1: There is significant difference between mean pre-test knowledge scores and mean post test knowledge scores regarding maternal CPR among staff nurses. H2: There is a significant association between mean post test knowledge scores with selected demographic variables like Age of the staff nurses, Education, Total years of professional experience, Total experience in OBG department, Area of work, Source of information on basic BLS/ACLS.

6.6 VARIABLES

A) Independent variable:- Planned teaching programme on resuscitation of pregnant woman(Maternal CPR).

B) Dependent variable: - Knowledge of staff nurses working in OBG department regarding resuscitation of pregnant woman(Maternal CPR).

6.7 OPERATIONAL DEFINITIONS

1. ASSESS:- It refers to exploring information on knowledge of staff nurses working in OBG department regarding resuscitation of pregnant woman(Maternal CPR).

2. Effectiveness: It refers to producing an intended result. In this study, effectiveness refers to the extent to which the teaching programme helps to improve the knowledge on maternal CPR among staff nurses.

3. Planned teaching programme: In this study, it refers to systematically developed instructions designed to provide information on maternal resuscitation.

4. Knowledge: Knowledge is the theoretical or practical understanding of a subject. In this study, knowledge is defined as awareness of the staff nurses regarding the CPR as measured by structured knowledge questionnaire on CPR.

5. Maternal cardio pulmonary resuscitation: CPR combines compression of chest with rescue breathing to keep blood flowing through the body and brain while delivering oxygen to the bloodstream. In this study, ‘2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care- Part 12.3: Cardiac Arrest Associated with Pregnancy’ is followed. It includes BLS modifications and ACLS modifications, considering important physiological changes that occur in pregnancy.

15 6. Pregnant woman: Refers to woman in the state of carrying a developing embryo or foetus within the body.

7. Staff nurse: Refers to a qualified hospital nurse, a person who is trained in both nursing and midwifery, and who is certified under the midwives acts15. In this study, it refers to nurses who are registered as GNM or P.B.BSc or B.Sc nursing or ANM course and who are working in maternity units in selected hospitals at Bangalore.

8. OBG Department: In this study, OBG Department refers to the working areas related to Obstetrics and Gynaecology. That is; maternity wards, labour rooms and labour OT. 6.8 ASSUMPTIONS

The study assumes that;

1. Staff nurses need to have some knowledge on resuscitation of pregnant woman. 2. Knowledge of staff nurses regarding resuscitation of pregnant woman can be increased by Planned teaching programme. 3. Planned teaching programme is required for staff nurses to perform their role effectively in identifying the cardiac arrest in pregnancy and to perform resuscitation according to Maternal cardiac arrest algorithm.

6.9 LIMITATIONS

The study is limited to:

1. Registered nurse midwives who are working in OBG Department.

2. Staff nurses who are available during the period of study.

3. Staff nurses who are willing to participate in the study.

7. MATERIALS AND METHODS 7.1 SOURCE OF DATA COLLECTION Staff nurses who are working in maternity units in the selected hospitals at Bangalore.

7.2 METHODS Data will be collected through structured interview schedule 7.2.1 RESEARCH DESIGN The research design chosen for the study is Quasi Experimental design.One group pre-test post-test design will be adopted for this study.

E = O1 X O2

E = Experimental group

O1 = Pre-test of knowledge of maternal CPR

X = Planned teaching programme of maternal CPR

O2 = Post-test of knowledge of maternal CPR

7.2.2 RESEARCH APPROACH Evaluative Approach.

7.2.3 RESEARCH SETTINGS The study will be conducted in the maternity units of the selected hospitals in Bangalore.

7.2.4 POPULATION The population under the present study includes staff nurses working in the maternity units of the selected hospitals of Bangalore.

7.2.5 SAMPLE SIZE The sample size will be 60 staff nurses in the selected hospitals of Bangalore.

7.2.6 SAMPLING TECHNIQUE Non probability purposive sampling technique will be employed in the present study. 7.2.7 SAMPLING CRITERIA a) Inclusion Criteria Staff nurses who: 1. Have completed GNM or P.B.B.Sc or B.Sc nursing or ANM course. 2. Are available during the time of study. 3. Are willing to participate in the study.

17 4. Can understand & speak Kannada or English. 5. Who belongs to the age group between 20-35. b) Exclusion criteria Staff nurses are not eligible for randomization to the study if any of the following criteria are present: 1. Participated at a nationally accredited obstetric emergency management course within the 12 months prior to randomization. 2. Already booked to attend an accredited training course within the duration of the study. 3. If on maternity or long-term sick leave. 4. Staff nurses who cannot understand either Kannada or English.

7.2.8 TOOLS FOR DATA COLLECTION

1. Demographic Performa.

2. Closed ended, structured knowledge questionnaire on maternal CPR

3. Interventional teaching programme on maternal CPR.

Data collection:

The investigator herself collects data from staff nurses working in OBG Departments.

 Prior to the data collection, permission will be obtained from the concerned hospital authority for conducting the study.

 Subjects will be selected according to the selection criteria of the study.  Investigator will conduct pre test to determine the knowledge using structured knowledge questionnaire and on the same day, interventional teaching programme on maternal CPR will be conducted.  On the seventh day, post test will be conducted using the same tool to assess the knowledge of staff nurses on maternal CPR. Duration Of Data Collection: 4 weeks

7.2.9 DATA ANALYSIS METHOD

Pre and post test scores of knowledge will be analyzed using the descriptive and inferential statistics.

Descriptive statistics: Includes mean, percentage, and standard deviation.

Inferential statistics: Paired t-test will be used to find out the significant difference between the pre and post test knowledge scores of staff nurses regarding resuscitation of pregnant woman. Chi-square test will be used to find out the association between knowledge scores with selected demographic variables.

7.3 Does the study require any investigation or intervention to be conducted on patients or other humans or animals? Yes, only educational intervention will be needed.

7.4 Has ethical clearance been obtained from your institution? 1. Ethical clearance has been taken from the research committee of Sushrutha College of nursing, Bangalore. 2. Informed consent will be obtained from the subjects.

8. LIST OF REFERENCES: 1. Aarti Dhar; ‘U.N: India likely to miss MDC on maternal health’; ‘The Hindu’; New Delhi; July 2,2012. 2. Dijkman A,Huisman.CM,Smit.M et al; ‘Cardiac Arrest in Pregnancy: Increasing use of Perimortem Caesarean section due to emergency skill training?’; Volume: 117; Pg: 282- 287;BJOG 2010.

19 3. Renee' Jones, Suzanne McMurtry Baird et al; ‘Maternal Cardiac Arrest : An Overview’; Journal of Perinatal and Neonatal Nursing; Volume 26; Number 2; Pg: 117 -123 ;June 2012 4. Chestnutt.A; ‘Physiology of Normal Pregnancy’;20(4)Pg: 609-615, 2004.

5. Steven.Y.Wang, James.F.Lourim, Robert.H.Sanborn; ‘Cardiopulmonary Resuscitation

During Pregnancy and Perimortem Caesarean Delivery’; Pg: 4-12,March 2010.

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9 SIGNATURE OF THE STUDENT 10 REMARKS OF THE This study is useful, reliable and applicable GUIDE in clinical setting

11 NAME AND Ms. K. Mahalakshmi. DESIGNATION OF THE Associate Professor and HOD, GUIDE Sushrutha College of Nursing, Bangalore- 85.

11.1 GUIDE SIGNATURE

11.2 HEAD OF THE Ms. K. Mahalakshmi. DEPARTMENT Head of the Department, Sushrutha College of Nursing, Bangalore- 85.

11.3 SIGNATURE OF HOD

12 REMARKS OF THE CHAIRMAN AND PRINCIPAL

12.1 SIGNATURE OF PRINCIPAL