SUBMTTED BY,
Mrs.JITHA JOHN,
1st year M.Sc (Nursing), Obstetrics &Gynecological Nursing
2009-2011 Batch, Oriental college of Nursing, Banglore-79
Download the originalRAJIV GANDHI UNIVERSITY OF HEALTH
SCIENCE, KARNATAKA, BANGALORE
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS / Mrs. JITHA JOHN,1st year M.S.c (Nursing),Oriental College of Nursing,#43/52,2nd Main,Industrial Town ,West of Chard Road, Rajaji Nagar, Bangalore-10.
2. / NAME OF THE INSTITUTION / Oriental College of Nursing, Bangalore-10
3. / COURSE OF STUDY AND SUBJECT / 1st year M.Sc Nursing,
(Obstetrics and Gynecological Nursing)
4. / DATA OF ADMISSION OF THE COURSE / 22/10/2009
5. / TITLE OF THE TOPIC / “A study to evaluate the effectiveness of structured teaching programme on alternative birth positions among staff nurses in selected hospitals,bangalore”
6. / Brief resume of the work
6.1 Introduction
6.2 Need for the study
6.3 Statement of the problem
6.4 Review of related literature 6.5 Objectives of the study
6.6 Operational definitions
6.7 Hypothesis
6.8 Sampling criteria
6.9 Assumptions / Enclosed
Enclosed
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7. / MATERIALS AND METHODS:
7.1 Sources of Data: Data will be collected from the adults in selected communities of Banglore.
7.2 Method Of Data Collection: Questionnaire method.
7.3 Does the study require any investigations or interventions to be Conducted on
The Patients or other human beings or animals?
No
7.4 Has Ethical clearance been obtained from the institution?
Yes, Ethical committee’s report is here with enclosed.
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE,
KARNATAKA, BANGALORE
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION:
1. / NAME OF THE CANDIDATE AND ADDRESS / JITHA JOHN,1st YEAR M.Sc,(NURSING),ORIENTAL COLLEGE OF NURSING,. #43/52,2ND MAIN,
INDUSTRIAL TOWN ,
WEST OF CHARD ROAD,
RAJAJI NAGAR, BANGALORE-10.
2. / NAME OF THE INSTITUTION / ORIENTAL COLLEGE OF NURSING. RAJAJI NAGAR, BANGALORE-10.
3. / COURSE OF STUDY AND SUBJECT / 1ST YEAR M.SC NURSING, OBSTETRICS&GYNAECOLOGICAL NURSING.
4. / DATA OF ADMISSION OF THE COURSE / 22/10/2009
5. / TITLE OF THE TOPIC / “A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON ALTERNATIVE BIRTH POSITIONS AMONG STAFF NURSES IN SELECTED HOSPITALS, BANGALORE”
6. BRIEF RESUME OF INTENDED WORK
6.0INTRODUCTION
“We try to give a birthing woman freedom to find the right position for her own needs and comfort. Unfortunately, in our society we think of birthing as something done while lying down.”
MICHEL ODENT
Childbirth, in any woman’s life, is an exceptional act,partly instinctive and partly learned skill. Giving birth is different for every woman. Childbirth should be a timefor joy and celebration. For most women it takes a lot of strength and concentration, and it is not unusual to feel exhausted after the baby is born. But the joy of holding the new baby makes most women forget the pain or discomfort they may have had.1
The term childbirth positions ormaternal birthing positions refer to the various physical postures the pregnant mother may assume during the process of childbirth. It may also be referred to as ‘Delivery positions ‘or ‘Labor positions’. The choices of labor and birth positions have a huge impact on a mother’s comfort level during birth and how quickly and effectively her labor does or doesn’t progress.2
Other than the traditional Lithotomy position used by Obstetricians, there are several alternate birthing positions that have been successfully used by midwives and traditional birthattendants, the world over. 2
Positions for first stage labor includes side-lying , semi-sitting, sitting with one foot up and activities like walking, climbing stairs. Positions for second stage labor include squatting, hands and knees position, semi -lying, kneeling and upright position.3
Changing positions and moving around during labor and birth, offers several benefits. It has equally important effects on the body and on the progress of labor. Some are obvious to the mother in labor: increased comfort / reduced pain, distraction and an enhanced sense of control: merely having something active to do can relieve the sense of being overwhelmed and out of control.3
Squatting positions are helpful in opening the pelvis to allow a baby to find the optimal position for birth. It can be performed through use of a birth companion or a tool such as squatting bar.Side-Lying positions are beneficial for resting during labor, promoting body- wide relaxation and minimizing extra muscular effort.4
Upright or Standing Positions use gravity to the mother’s advantage. They help the baby drop into the pelvis and prevent pressure from being concentrated in a particular spot. Changing positions can reduce the length of labor. Mendez-Bauer and Newton (1986) states: ‘the duration of labor was about 50% shorter in patients who attended supine and standing, standing and sitting positions.3
Historical manuscripts often show women giving birth in a standing or squatting position with their legs spread. There is now substantial evidence to suggest that these positions increase the outlet of the pelvis.5
Over the last couple of decades,“alternative birthing positions” have become more popular once more. However, thereseems to be considerable resistance to using them among midwives – perhaps because they believe that it might cause to the criticism among colleagues. These positions can be very beneficial and should be part of every midwives repertoire.5
6.1 NEED FOR THE STUDY
There is a misconception that the only one way for a woman can perform labor is lying flat on her back, knees drawn up or legs dangling from stirrups.
For a hospital birth, the most –used birth positions are the lithotomy(flat- on- back) or C- position (resting on tailbone with body curled in the shape of a “C”. The reasons for using these positions have nothing to do with comfort or effectiveness of labor. They are used solely because they are convenient for doctor / nurses for performing obstetric interventions, including maintaining sterility, monitoring fetal heart rate, administering anesthetics and performing and repairing episiotomies.4
A prospective mother needs more knowledge and information about pregnancy, labor and birth. Midwives are the major influence on whether a woman is free to mobilize or not. Actively encouraging women to mobilize during childbirth is a fundamental component of good midwifery practice and a safe , cost- effective way of reducing complications caused by restricted mobility and semi-recumbent postures ( Gupta et al, 2004 ) as well as enriching the woman’s birth experience.6
Poor birth positions can decrease fetal heart rate or cause other types of fetal distress, which may lead to continuous or internal fetal monitoring, increased risk of shoulder dystocia / problems with presentation or a prolonged pushing phase.
Many women spend their labor lying on their backs propped up by pillows or wedges. Most women laboring upright say they would do the same again, and those who remained supine would prefer to be upright for any subsequent labor and birth (MIDIRS, 2007). However, one in five women still report that they were not enabled to choose the most comfortable position in labor (Reds haw et al,2007).6
“Except for being hanged by the feet, the supine position is the worst conceivable position for labor and delivery”, States International Federation of Obstetricians and Gynecologists. There are a number of problems generated by this position:
a) It focuses most of the woman’s body weight squarely on her tailbone, forcing it forward and thereby narrowing the pelvic outlet, which both increases the length of labor and makes delivery more difficult.7
b) It compresses major blood vessels, interfering with circulation and decreasing blood pressure, which in turn lowers oxygen supply to the fetus. For example; several studies have reported that in the majority of women delivering in the lithotomy position, there was a 91% decrease in fetal transcutaneous oxygen saturation. (Humphrey et al .1973, 1974; John stone et al 1982).7
c) Contractions tend to be weaker, less frequent, and more irregular in this position, and pushing is harder to do because increased force is needed to work against gravity, making forceps extraction more likely and increasing the potential for physical injury to the baby.7
d) Placing the legs wide apart in stirrups can result in venous thrombosis or nerve compression from the pressure of the leg supports, while increasing both the need for episiotomy and the likelihood of tears because of excessive stretching of the perineal tissue and tension on the pelvic floor.7
Alternative positions also have psychological advantages. When encouraged to find the most comfortable position, the woman has a better sense of participation in her labor.8A policy of encouraging mobilization, particularly in early labor, can potentially facilitate the progress of labor and increase comfort. Giving women the liberty to select positions for labor and birth involves few risks and has potential benefits.9
In the UK midwives play a significant role in the support and care of women during
childbirth and have autonomous practitioner status in the care of women experiencing
normal birth (Nursing and Midwifery Council 2004).10
A study was conducted to explore the views of midwives on women's positions during the second stage of labor. Six focus groups were conducted in 2006-2007 with a purposive sample of 31 midwives. The data were interpreted using Thachuk's models of informed consent and informed choice. The study concluded that to give women an informed choice about birthing positions, midwives need to give them information during pregnancy and discuss their position preferences. Women should be prepared for the unpredictability of their feelings in labor and for obstetric factors that may interfere with their choice of position. Equipment for non-supine births should be more midwife-friendly. In addition, midwives and students need to be able to gain experience in assisting births in non-supine positions.11
A clinical audit was carried out in UK to assess the degree of change that occurred in the practice of encouraging positions for birth. This was conducted for 18 months. The study reveals that a remarkable change happened in the usage of alternative positions from 18% to 40%. The birth positions used include kneeling 29%, all- fours 28%, left lateral 23%, standing 9%, pool 7% and squatting 4%.12
A study was conducted to assess the effectiveness of staying upright during childbirth in UK. The study reveals that being upright during labor appeared to reduce the duration of the first stage of labor by about an hour. It also states that there was 17 % reduced risk of having epidural analgesia.13
A case study was carried out on women’s position during labor and its influence on maternal and neonatal outcome. A total of 307 women who delivered in an upright position and 307 controls, delivering in a supine position were selected for the study. The study reveals laboring and delivering in an upright position is associated with beneficial effects such as lower rate of episiotomy and a reduced use of medical analgesia and oxytocin.14
Whichever position the mother chooses, she is most likely to trust a midwife who allows her freedom of choice and active participation in her labor. The decisions midwives make whilst supporting and caring for women at this time are highly significant and influence a variety of childbirth outcomes (Raynor and Bluff 2005). Positive and dramatic effects can be achieved by encouraging the mother to change and adapt her position in response to the way her body feels10
Education of nurses is necessary to make alternatives to the supine position a logical option for all women. So the investigator had a felt need to do study among nurses on alternative birth positions.
6.1.1 STATEMENT OF THE PROBLEM
‘’ A Study to evaluate the effectiveness of Structured Teaching Programme on alternative birth positions among staffnurses in selected hospitals, Bangalore.
6.2 REVIEW OF LITERATURE
“Review of literature is a critical summary of research on a topic of interest often prepared to put a research problem in a context or as the basis for an implementation project”.
The review of literature is an integral component of any study or research project. It enhances the depth of the knowledge and inspires clear insight in to the crux of the problem. Literature review throws light on the studies and findings reported about the problems under the study.
The review of literature for the present study is organized under the following heading:
1. The literature related to nurses knowledge regarding alternative birth positions.
2. The literature related to importance of alternative positions in labor.
3. The literature related to maternal position and mobility in labor.
4. The literature related to maternal position and perineal outcome.
1. The review related to nurses knowledge regarding alternative birth positions.
A quantitative study was conducted to gain insight into the influences on women's use of birthing positions, and into the labor experiences of women in relation to the birthing positions they used. In this study in-depth interviews were conducted to gain a deeper understanding of the relationship between birthing positions and the labor experience. Study found that the advice given by midwives was the most important factor influencing the choice of birthing positions. Midwives have an important role to play in widening the range of women's choices. Midwives should empower women to find the positions that are most suitable for them, by giving practical advice during pregnancy and labor.15
A national survey of 800 certified nurse-midwives (CNMs) in active clinical practice was conducted in 1994. The purpose of the survey was to study the extent to which eight operationally defined positions were used by CNM-attended women during the second stage of labor and factors that affected their use. This, the first of a two-part article, describes the positions used as well as the CNMs’ preferences for the eight second-stage positions. The most frequently used second-stage position was sitting; the lithotomy position was rarely used by the CNMs. The survey findings reflect the preferences of birthing women. The use of nonlithotomy positions is one nontechnologic way to enhance the normal process of birth.16
2. Literature related to importance of alternative positions in labor.
A study conducted in Karachi to assess the benefits of squatting position during second stage of labor and its comparison with the supine position. A total of 200 patients of similar ante partum, intra partum and socioeconomic conditions were selected. Random selection was done after informed consent and alternately divided in to two groups A and B. Both groups were ambulatory during first stage of labor. In second stage, group A adopted the squatting position, while group B remained supine in lithotomy position .The third stage of labor, in both the groups was conducted in supine position. The result was that second and third degree perineal tears occurred in 9% of patients in the non- squatting group but none in the squatting position ( <0.05) . Forceps application was also significantly less in group A (11%) and (24%) in group B. There were 2 cases of shoulder dystocia in group B but not in the group A. The study reveals that squatting position may result in less instrumental deliveries, extension of episiotomies and perineal tears.17
A study conducted to assess the effectiveness of vertical position during the first stage of course of labor and neonatal outcome. This study included 369 normal term labors. In 145 cases, the women were sitting, standing or walking at will during the first stage, whereas 224 remained lying in bed during the whole labor. The study reveals that when the mothers remains in the ‘vertical’ position during first stage of labor, a) duration of first stage is shortened in 25%. -this shortening may reach 34% in the nulliparous b) Incidence of forceps delivery diminishes.18
A clinical trial was conducted to assess the acceptability and outcome of second-stage labor in upright positions involving 151 primigravidae and 18 midwives. Result was that of the women allocated to the upright position, 74% completed the second stage upright, with kneeling being the most favored position. Adoption of upright positions resulted in a higher rate of intact perineum. The study concluded that alternative positions in the second stage of labor appear safe, acceptable to most parturient and their midwives.19
3. The literature related to maternal position and mobility in labor.
A study was conducted among antenatal woman to learn more about maternal position in labor. 80 consecutive patients with uncomplicated normal spontaneous vaginal delivery over the course of labor to ascertain the positions volitionally chosen by each. Data were collected on position preferences and phase of labor. It was found that gravidas chose a number of different principal positions in the early phase of labor, but that they became more narrowly selective in the deceleration phase and second stage at the same time, they tended to change position more often in late labor.20
A study was conducted among antenatal women to evaluate the maternal positions and mobility during first stage of labor. Women were encouraged to mobilize and remain upright as much as possible during the first stage of labor The study found that the women who assume upright positions during the first stage of labor-such as walking , sitting , standing or kneeling as opposed to lying –down experience a shorter first stage of labor . The review also found that women who labored in upright position were less likely to seek pain relief through epidural analgesia.21
An exploratory study conducted to assess the mobility and maternal position during childbirth. The study used quantitative and qualitative methods. The practice rates for mobility during labor and delivery position, women’s experiences, preferences and views about the care provided and provider views of current practice and barriers and opportunities to evidence- based obstetric practice were measured. The study state that more women were mobile at home (15%) than in the labor ward ( 2.9%) but movement was quite restricted at home before women were admitted at home before women were admitted to labor ward ( 51.6%) . Supine position for delivery was used routinely at all 4 hospitals this was consistent with women’s preferred choice of position, although very few women are aware of other positions. Qualitative findings suggest that obstetricians and midwives favored confining to bed during the first stage of labor and supine position for delivery. Study concluded that the barrier to change appear to be complicated and require providers to want to change , and women to be informed of alternative positions during the first stage of labor and delivery.22