Rajiv Gandhi University of Health Sciences, Karnataka s28
Rajiv Gandhi University of Health Sciences, Karnataka
SYNOPSIS
FOR REGISTERATION OF SUBJECT FOR DISSERTATION
1 / Name of the Candidate / THENESHA K2 / Name of the institution / Diana College of Nursing
No.68, Chokkanahalli, Jakkur Post,
Bangalore – 560064
3 / Course of Study and Subject / Masters of Science in Nursing
Obstetrics and Gynecological Nursing
4 / Date of Admission to Course / 08.06.2010
5 / Title of the Topic / Assess the effectiveness of video assisted teaching on knowledge regarding prevention of Pregnancy Induced Hypertension (PIH) among high risk antenatal mothers attending antenatal clinic in a selected hospital, Bangalore, Karnataka.
INTRODUCTION
Pregnancy is a normal process but it is unique and boon to every woman. It is one of the wonderful and noble services imposed by nature. The body undergoes enormous functional changes during pregnancy and the functioning is altered in order to nourish the mother, baby and to have normal delivery. Normal Pregnancy is dramatic and often underestimated. The timing and intensity of the changes vary between systems but all are designed to enable the women to nurture to the fetus and to prepare her body for labor and lactation. Most of the women may not have many problems during pregnancy, but the unlucky ones, face problems related to pregnancy and child birth. In developing countries, pregnancy and child birth are some of the leading causes of death for women in the reproductive age group. Yet, the fate of these women and children is too often overlooked or ignored.1
The WHO slogan for 2005 “Make Every mother and child count”, reflects the reality that today, Government and the International Community needs to make the health of the women and children the top priority.2
Various Complications can develop during the course of the pregnancy and can affect the health and well being of the mother and fetus, as well as the outcome of the pregnancy. With early recognition and today’s advanced technology, the incidence of maternal mortality resulting from complication is declining.3
Common Health Disorders complicating pregnancy are PIH, GDM, Cardiac disease, renal disease and jaundice in pregnancy. A report “Global statistics – PIH” estimated that global prevalence of PIH among pregnant women is 13%.4
PIH is more common in a woman's first pregnancy and in women whose mothers or sisters had PIH. The risk of PIH is higher in women carrying multiple babies, in teenage mothers and in women older than age 40. Other women at risk include those who had high blood pressure or kidney disease before they became pregnant. The exact cause of PIH isn't known.5
High blood pressure in pregnancy (hypertension) is a very serious complication. It puts both the mother and the fetus at risk for a number of problems. Hypertension can exist in several different forms. One of these is the preeclampsia-eclampsia continuum (also called pregnancy-induced hypertension or PIH). In this type of hypertension, high blood pressure is first noted sometime after week 20 of pregnancy and is accompanied by protein in the urine and swelling. Chronic hypertension is another form of hypertension. It usually exists before pregnancy or may develop before week 20 of pregnancy.6
Nurses have a vital role in the successful operation and ultimate outcome of antenatal high risk mothers’ care. The ultimate goal of nurse is to prevent hypertensive disorders of pregnancy or to assist in early diagnosis and appropriate treatment of these disorders to maximize outcome. Preeclampsia is a much study disease of pregnancy but the triggering factor remains unknown. This makes prevention difficult; however, because research indicates that several factors, such as early appropriate prenatal care, adequate fluid intake and optimal nutrition plays important roles, the nurse should include these in the prenatal instructions. When a mother develops preeclampsia during pregnancy, the goal becomes the prevention of eclampsia and uteroplacental insufficiency while attempting to facilitate fetal maturity.7
NEED FOR THE STUDY
PIH is a multi system syndrome characterized by vasoconstriction, metabolic changes, and endothelial dysfunction, activation of coagulation cascade and increase inflammatory response. PIH contributes to (MMR) Maternal Mortality Rate, Prenatal mortality rate and still birth with variations to geographical location and race.8
Hypertensive disorders of pregnancy are frequent cause of maternal and fetal morbidity and mortality, the most common being preeclampsia and eclampsia. Pregnant mothers should be screened routinely. Early recognition and prompt care form a multidisciplinary service, including obstetrics, cardiology, and hypertensive disorders of pregnancy reflect endometrial endothelial dysfunction and abnormalities and systematic endothelial dysfunction, which might predict future cardiovascular disease in these young women, prompting early preventive measures.9
In a study it was stated that in most of the countries, PIH is the single largest cause of maternal mortality. WHO (2000) stated that maternal mortality is said to be an indicator of social inequity and discrimination against women. The Goal of national health policy was to reduce maternal mortality rate to 100 / 1, 00,000 like births by 2010.10
In Global, Pre-eclampsia or PIH is a condition that affects up to 80% of pregnancies every year and is among the leading cause of maternal and fetal illness worldwide .The incidence of pre-eclampsia and eclampsia was higher in the developing countries with the highest rate reported for pre-eclampsia as 7.1% in Zimbabwe and for eclampsia as 0.81% deliveries in Columbia. The Maternal and fetal mortality rate was 0.4% for pre-eclampsia reported in Magpies and as 6.1% for eclampsia reported from Columbia. Hypertension disorders of the pregnancy are the common and direct cause of maternal deaths in South Africa. 19.1% of maternal deaths in a three year period (2002-2004) were associated with hypertensive disorders of pregnancy.11
A study was conducted in US, stated that pregnancy associated hypertension is a leading cause of maternal death. The study reported Maternal death rate in 2005 was 9.8/1, 00,000.12
In national level, the developing countries like India, the maternal and prenatal mortality rates are still high. It is of great concern to suggest mothers to improve the health status of the Mother and the child. It is well accepted that only a healthy mother can give birth to a healthy baby. In 2003, Maternal mortality has declined to 301/1, 00,000 live births.13
A study was conducted on comprehensive antenatal care and prevention of pregnancy induced hypertension. Hypertensive disorders in pregnancy are a universally common disease. How pregnancy induces and aggravates hypertension is still not understood fully. The incidence of pregnancy induced hypertension (PIH) in India ranges from 5-15%. In Primi mothers16% and Multi mothers7%. It causes IUGR leading to low birth weights. It increases the maternal mortality by 10-15% and the prenatal mortality and morbidity by 15 to 25%.14
PIH can be detected early during regular prenatal visits, which is one of the reasons they are so very important. PIH can be result in preterm baby, a stillborn baby and a baby who has growth retardation (IUGR). 15
The pregnant woman's interview at her first visit the health care provider is conducted by the nurse, who obtains the data necessary to begin the high-risk screening. The physician or midwife caring for a pregnant woman should review the prenatal assessment sheet, order lab data, and obtain ultrasounds to determine if any risk factors are present. If it is determined that a woman has a high-risk pregnancy, she should be referred to a perinatologist for advanced care. This is the specialist who establishes and implements the medical regimen needed for the particular maternal/fetal complication and the inter-disciplinary team associated with the prenatal center works in its management. The prenatal team usually comprises a nutritionist, social worker, nurse educators, geneticists, ultrasonographers, and additional nursing staff who are responsible for the monitoring and supervising of ongoing team care of the patient.16
A nursing care program was conducted to reduce the role of pregnancy-induced hypertension in patients with clinical complications. The study was conducted to investigate the predictability of complications of pregnancy induced hypertension nursing program. Methods to confirm the diagnosis of 400 patients with PIH were randomly divided into the nursing care intervention group and control group of 200 patients in the control group received routine treatment and care, nursing care intervention study group in addition to conventional treatment and care, the law of development of the disease given under nursing care interventions. The study group maternal complications (eclampsia, placental abruption, postpartum hemorrhage, acute renal failure, fetal death, neonatal asphyxia, etc.) compared with the control group, the incidence of the differences were statistically significant (P <0.01), study group was significantly lower than the control group. It was concluded as PIH nursing intervention for patients with predictability measures can significantly reduce the incidence of maternal complications.17
A study was conducted to determine the health education in enhancing the self care agency of pregnant women among 30 antenatal mothers in Turkey. The study concluded that after health education the self care agency scores of the pregnant women increased significantly.18
It was felt that maternal mortality rate from high risk factors during pregnancy could not diminish until their knowledge and attitude where understood and brought more into line with the norms of modern obstetric care. The investigator during her clinical experience noted many high risk antenatal mothers who have inadequate knowledge. The investigator planned to assess their knowledge regarding prevention of Pregnancy Induced Hypertension and she also felt the immense need to provide video assisted teaching programme for the high risk mothers.
REVIEW OF LITERATURE:
Review of literature is defined as a broad, comprehensive, in-depth, systematic and critical review of scholarly publications, unpublished scholarly print materials and audio visual materials.19
Literature review for the present study has been collected and presented under the following headings.
1. Literature related to incidence and prevalence of PIH.
2. Literature related to the management of PIH.
3. Literature related to the complications of PIH.
4. Literature related to prevention of PIH.
5. Literature related to effectiveness of teaching program on PIH.
Literature related to incidence and prevalence of PIH:
Worldwide, it is estimated that 5, 29,000 women die yearly from complication of pregnancy and childbirth, about one women every minute. The incidence of the pre-eclampsia in hospital practice varies widely from 5-15%. The incidence in primigravidae is about 10% and in multigravidae 5%. Imperfect documentation and lack of uniformity in the diagnostic criteria are the responsible factors in variation of its frequency. In the developing countries, the incidence is expected to be higher. Comparative low figures in the hospital statistics is due to inclusion of only severe degree of the syndrome, the minor ones being ignored.20
It was reported that the rate of PIH has risen steadily by about 30% to 40% since 1990. Now it is 38.8/1000 live births.21
In India 10% to 30% of pregnancies belong to the high risk category. About 5,85,000 women die each year from pregnancy related census, 99% of them are from the developing countries, out of each 80% of the deaths are due to direct obstetrics causes (such as hemorrhage, infection, hypertension, abortion) and 20% are due to indirect causes ( such as anemia, malaria, hepatitis, AIDS). Secure maternal mortality is 6 to 10 times more frequent than maternal mortality. WHO estimates that 95% of these deaths are handicaps is avoidable.22
According to Indian Council of medical researchable task for a study (2002) in India where maternal mortality rate is 582/1, 00,000 live birth and hypertensive disorders were responsible for 24% of all maternal deaths.23
A retrospective study to determine the maternal outcome in pregnant women with hypertensive disorder. A retrospective analysis was undertaken on 255 consecutive cases of PIH. Of the 255 cases 11% had eclamptic convulsion, 11% of women demonstrated to have HELLP syndrome.24
Literature related to the management of PIH:
Ideally all patients of pre-eclampsia are to be admitted in the hospital for effective supervision and treatment. There is no place of domiciliary treatment in an established case of pre-eclampsia. However, in some centers cases of preeclampsia are managed in the day care unit (p 639). In the developing countries where the prevalence of pre-eclampsia is more and hospital facilities are meagre, there is no alternative but to put the uncomplicated mild pre-eclampsias in domiciliary treatment regime. Rest, high protein diet and mild sedative at bed time are prescribed and the patient is investigated and checked after one week or even earlier. If treatment fails, the patient is to be admitted. It is essential that she should be warned against the ominous symptoms such as headache, visual disturbances, vomiting, epigastric pain or scanty urine.25
A study was conducted about the short and long term strategies for the management of hypertensive disorders of pregnancy. In this study, the main focus was given on recent developments in the prediction and pathogenesis of these disorders, prevention of preeclampsia and current strategies for the treatment of hypertension in pregnancy. It also explores the evidence relating adverse pregnancy outcome to an increased future risk of cardiovascular disease and potential strategies to minimize this risk.26
A study was conducted about “A comparison of walking versus stretching exercise to reduce the incidence of preeclampsia: a randomized clinical trial”. Women were randomized to either the walking group (n=41) or the stretching group (n=38). The walkers exercised an average of 36 (SD, 6) minutes at 18 weeks gestation, 34 (SD, 7) minutes at 28 week of the intervention. Equally on average, the stretching group exercised 4 (SD, 2) times a week at 18 weeks gestation, 5 (SD, 1) times a week at 28 weeks gestation. The incidence of preeclampsia was 14.6% (95% CI, 0.07 to 13.8) among the stretchers. The mean transferring level, an antioxidant marker, was significantly higher in the stretching group mean (412 mg/dL, 95%CI, 389 to 435) than the walkers at the time of labor (mean=368 g/dL, 95%CI, 346 to 391) (P=0.05). Regular stretching exercise may promote endogenous antioxidants among women at risk for preeclampsia.27
Literature related to the complications of PIH:
Pregnancy induced hypertension may develop into eclampsia, the occurrence of seizures. Fetal complications may occur because of prematurity at time of delivery.28