SYNOPSIS FOR REGISTRATION OF
SUBJECT FOR DISSERTATION
SUBMITTED BY:
Mrs. PUSHPA SUSAN JOHN
I M.Sc. NURSING
OBSTERTIC AND GYNECOLOGICAL NURSING
(2012-2014 BATCH)
SHARABHESWARA COLLEGE OF NURSING
6TH WARD, GUGGARAHATTI, BANGALORE ROAD,
BELLARY – 583 102
SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. / NAME OF THECANDIDATE AND ADDRESS / Mrs. PUSHPA SUSAN JOHN
M.Sc. NURSING 1ST YEAR
SHARABHESWARA COLLEGE OF NURSING, 6TH WARD,GUGGARAHATTI, BANGALORE ROAD, BELLARY-583102
2. / NAME OF THE
INSTITUTION / SHARABHESWARA COLLEGE OF NURSING
3. / COURSE OF THE STUDY AND THE SUBJECT / M.Sc. NURSING, 1ST YEAR
OBSTERTIC AND GYNECOLOGICAL NURSING
4. / DATE OF ADMISSION TO COURSE / 15 JUNE 2012
5. / TITLE OF THE TOPIC / “STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE AND PRACTICE ON PARTOGRAM AMONG STAFF NURSES WORKING IN LABOUR WARD IN SELECTED HOSPITAL AT BELLARY.”
INTRODUCTION
Each year 210 million women become pregnant of which 20 million experience pregnancy related illnesses. Also, approximately, over half a million women lose their lives every year because of complications of pregnancy and childbirth. In developing countries, poor outcomes during labour account for 99% of maternal deaths and for every 100,000 live births an average of 450 women die1.
Despite the continued focus on the reduction of maternal mortality by stakeholders and the development partners, it still remains a major public health problem2. Maternal Mortality Rate (MMR) is mostly institutional. They vary from one geographical zone to another and are worse in the rural, when compared to the urban areas2.
Available data show that MMR, in the early 1990s, was 1400-1500/100,000 live births. This however dropped to 1000/100,000 live births in the late 1990 and dropped further to 704/100,000 live births in 1999 and 800/100,000 in 2002. There was an increase in 2005 to 1100/ 100,000 live births3, but the current estimates (2011) by the WHO is 840/100,000 live births4. 60 – 65% of pregnant women are at risk of dying during childbirth mainly from preventable and avoidable conditions and complications5.
Majority of these deaths could have been prevented by early detection of abnormal progress of labour with the use of the partograph which is a cost-effective and affordable health intervention6-8. In addition; the early detection of obstructed labour with the use of the partograph prevents maternal morbidity and improves neonatal outcomes6.
The partograph is a graphic recording of progress of labour and salient conditions of the mother and fetus plotted against time in hours6-8. When used effectively, the partograph will prevent prolonged or obstructed labour, which accounts for about 8-10 % of maternal deaths7, 8. It was originally produced by Philpott and Castle in 1972, and later modified and adopted by the WHO in 1988 and recommended for worldwide use in all healthcare settings6.
6.0 BRIEF RESUME OF THE INTENDED WORK
6.1 NEED FOR THE STUDY
Pregnancy is a seemingly a long journey that is best travelled with support. Labour is almost an overwhelming experience because it involves sensations and emotions at such an intense level. Women need supportive persons with them to cope with their experience of labour. Labour and birth, need all psychological and physical coping methods available for a woman, no matter, how many children birth neither preparations she had nor how many times she had already gone through the experience9.
Labour has been termed the most dangerous journey a human ever undertakes. The reason being that although it is a natural process but complications can arise at any time during its course. Maternal mortality remains between 500 and 1000 deaths for 100,000 live births in developing countries10.
A major cause of these deaths is prolonged obstructed labour primarily because of cephalopelvic disproportion. In those who survive, morbidity is significant due to complications like sepsis, post partum haemorrhage, ruptured uterus and urinary fistula. Obstructed labour is also a major precedent of perinatal deaths, birth asphyxia and neonatal sepsis10.
World Health Organization have produced and promoted partogram with view to improving labour management and reducing maternal and fetal morbidity and mortality. Introduction of the partogram with agreed labour management protocol reduced both prolonged labour from 6.4% to 3.4% labors and proportion of labour requiring augmentation from 20.7% to 9.1% emergency caesarian section fells from 9.9% to 8.3%, intrapartum still births from 0.5% to 0.3%11.
Introducing partogram help staff nurses to reduce the number of vaginal examinations, oxytocin use and obstructed labour, decrease fetal death and early neonatal death. It helps to assess progress of labour. Hence World Health Organization calls for health personnel or midwives to use and manage protocol both in labour ward and management of labour complications in health center12.
Partogram is the part of the midwifery tool of practice used every day, but in India rarely used, it is the management tool for the prevention of prolonged labour. The use of a Partogram for the management of labour has been shown to be beneficial in that it clearly differentiates normal from abnormal progress in labour and intervention12.
The majority of the deaths and complications could be prevented by cost effective and affordable health interventions like the partograph and indeed the measures that would prevent maternal deaths would also prevent morbidity and improve neonatal outcome. The partograph is an effective tool for monitoring labour, and when used effectively, will prevent prolonged labour, which accounts for about 8% of maternal deaths. The partogram, thus serves as an early warning system and assist in early decision on transfer, intervention decision in hospitals and ongoing evaluation of the effect of interventions13.
A woman dies from complications from child birth approximately every minute. Most maternal deaths and injuries are caused by biological process and can be prevented, not from disease, and have been largely eradicated in the developed world such as post partum haemorrhaging which causes 34% of maternal death in the developing world and only 13% of maternal death in developed countries14.
A cross sectional study was conducted with an aim to assess the improvement in knowledge and skills amongst trainees of the workshop on labour and partograph concluded that training workshops should be done on a larger scale to train the staff in order to achieve the targets set under millennium development goals15.
The observation of clinical midwifery practice in Nigeria within the maternity unit of the FMC and NDUTH by one of the researchers (MMO) revealed a haphazard utilization of the partograph in labor monitoring and most studies on the partograph are done in abroadNigeria16-20
Partogram a graphic record of progress of labour that helps caregivers to detect whether labour is progressing normally or not, indicates when augmentation of labour is appropriate and assists in recognizing cephalopelvic disproportion long before labour becomes obstructed. The partogram assist nursing staff in early decision on transfer and termination of labour. It also increases the quality and regularity of all observation on the foetus and the mother during labour and aids in early recognition of problems with other21.
According to the world health report, bad maternal conditions account for the fourth leading cause of death for women after HIV, malaria and tuberculosis. 99% of these deaths occur in developing countries; while only one of 4000 women a chance of dying in pregnancy or child birth in a developed nation. Further, maternal problems cause almost 20% of the total burden of disease for women in developing countries. Almost 50% of the births in developing countries take place without a medically skilled attendant to aid the mother and the ratio is even higher in South Asia14.
In many developing countries, complications of pregnancy and child birth are the leading causes of death among women of reproductive age.
The World Health Organization recommends partogram with a 4- hour action line from alert line, denoting the timing of intervention for prolonged labour; others recommend earlier intervention to allow for referral.
Appropriate use of partogram requires adequate number of skilled health workers with a positive attitude towards its use especially midwives at various levels of health care facilities and actual availability of the partogram tools at all times22.
According to the recommendation of the Indian Nursing Council, the trained birth attendants should maintain a partogram when the woman reaches active labour. The partogram should contain foetal condition, labour process, maternal conditions and interventions14.
Partogram is more commonly used in tertiary than in primary and secondary health care centers in developing countries. Several factors affecting the utilization of the partograph include poor knowledge23-25, non-availability of the partograph charts in the labour wards16, 17, lack of adequate number of health care personnel17, an additional time consuming task for the inadequate staff 23, and lack of understanding of the relevance of the partograph in preventing obstructed labour18. Other factors include lack of standard institutional guidelines on the use of the partograph in labour17, lack of support from management in terms of providing essential supplies24, leading to lack of motivation of the health workers23.
The aim of present study is therefore; to assess staff nurses knowledge and practice about the use of the partograph during labour, find out the relationship between the demographic variables and knowledge and practice of the use of the partograph in the selected hospital at Bellary.
6.2 REVIEW OF LITERATURE
A cross-sectional study assessed knowledge and utilization of the partograph among midwives in two tertiary health facilities in the Niger Delta Region of Nigeria. A descriptive survey design was utilized, using a structured questionnaire administered to 165 midwives purposively selected from the Federal Medical Center (FMC) 79 and Niger Delta University Teaching Hospital (NDUTH) 86. Results revealed that 84% of midwives knew what the partograph was and 92.7% indicated that the use of the partograph reduces maternal and child mortality. About 50.6% midwives in FMC and 98.8% in NDUTH indicated that it was routinely utilized in their centers. Assessment of utilized partograph charts revealed that only 18(37.5%) out of 48 in FMC and 17(32.6%) out of 52 in NDUTH were properly filled. Factors in the utilization of the partograph were:-non-availability of the partograph (30.3%), shortage of staff (19.4%), little or no knowledge in the use of the partograph (22.2%), and 8.6 percent indicated it was time consuming. A significant relationship existed between knowledge of the partograph and its utilization (χ 2 = 32.298. df = 1; P <0.05) and between midwives years of experience and its utilization (χ 2=4.818, df = 4; P <0.05). However, this study also showed that despite midwives good knowledge of the partograph, there was poor utilization in labour monitoring in both centers. Training of midwives on the use of the partograph with periodic workshops and seminars and a mandatory hospital policy are recommended and vital to the safety of women in labor in the Niger Delta region of Nigeria26.
A comparative study was for 50 midwifes including 6187 women to assess Partogram V/s no Partogram use with aim to contribute or decrease maternal and paternal mortality during labour, a quasi-randomized method was used and concluded that routine use of Partogram during labour results in reduction of mortality and morbidity rate. Further trial is required to establish effectiveness of Partogram used27.
One group pretest and post test design study was conducted for 45 registered nurses working at Primary Health Centre to evaluate the effectiveness of self instructional module in increasing nurses knowledge in Partogram. The result of the study signified increase of 20.2% in participants, mean knowledge and cure of the post test (M = 69%) SD = 8% as compared with pre test (M = 49%), SD = 12% based on paired test analysis and concluded that a Partogram self instructional module for registered nurses was effective in increasing knowledge of Partogram and improve maternal outcome in developing countries with skilled attendants28.
A descriptive study was conducted study to assess knowledge of nurses on modified WHO Partogram in selected urban and rural hospitals. Among 86 nursing personnel partogram were generally plotted very well and 86% of eligible couple. It is statistically significant (V2 = 5.99, P =0.05) and concluded that knowledge of Partogram is strongly associated with qualifications and experience and gives quality of cure and definitely improve management of labour29.
A randomized control study was conducted for 250 nurses to enhance early recognition of dystocian and avoid unnecessary caesarian section with an objective is to evaluate the effectiveness of partogram use with uncomplicated pregnancies at term. Result revealed that nurse’s knowledge of basic partogram is insufficient and they need additional training and study concluded that use of a partogram without a mandatory management of labour protocol had no effect on rate of labour or intrapartum interventions30.
A study was conducted with an aim to assess the impact of training on use of the partograph for labour monitoring among various categories of primary health care workers among 56 health workers over a period of 7 months in Niger through hospital based survey and the result revealed that 242 partographs of women in labour were plotted and out of this 76.9% of them correctly plotted and 6.6% were inappropriate and concluded that effective training to use the partograph among primary health care workers can contribute towards improved maternal outcomes in developing countries31.
A study was conducted with an objective to evaluate the knowledge and use of the partogram for 396 maternity care providers over a two month period in University Teaching Hospital, Nigeria through the questionnaire based survey and the results revealed that only 39 (9.8%) of all the personnel routinely employed the partogram for labour management and almost half of these individuals had a poor level of knowledge and concluded that training should be given to the care providers especially junior personnel for the effective use of the partogram32.
A cross sectional study was conducted to assess the knowledge and utilization of the partograph for 719 health care workers from primary, secondary and tertiary levels of care over a period of one year in South Western Nigeria and the results revealed that only 32.3% used the partograph to monitor women in labour and partograph use was reported significantly more frequently by health care workers in tertiary level compared with health care workers from primary or secondary levels and concluded that the knowledge about partograph is poor among the health workers and partograph is commonly not used to monitor the women in labour33.