DISSERTATION PROTOCOL

1. / Name Of The Candidate / Mrs. Beaula M Babu
Ist yr M.Sc. Nursing
S B College of Nursing
5th phase, KHB Colony
Yelahanka New Town
Bangalore
2. / Name Of The Institution / S B College Of Nursing
5th phase, KHB Colony
Yelahanka New Town
Bangalore
Course of study and subject / M.Sc. Nursing
( OBG Nursing )
4. / Date of admission to course / 28-06-2012
5. / TITLE OF THE TOPIC
“A study to assess the effectiveness of self-instructional module on knowledge regarding prevention of Caesarean Section by maternal request on non-medical basis among antenatal mothers at selected urban areas at Bangalore.”
6.0: BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
A Caesarean Section, is a surgical procedure in which one or more incisions are made through a mother's abdomen called laparotomy and uterus called hysterotomy to deliver one or more babies, or, rarely, to remove a dead fetus. A late-term abortion using caesarean section procedures is termed a hysterotomy abortion and is very rarely performed. The first modern caesarean section was performed by German gynecologist Ferdinand Adolf Kehrer in 1881.1
A caesarean section is usually performed when a vaginal delivery would put the baby's or mother's life or health at risk, although in recent times it has also been performed upon request for childbirths that could otherwise have been natural. In recent years the rate has risen to a record level of 46% in China and to levels of 25% and above in many Asian, European and Latin American countries. In 2007, in the United States, the caesarean section rate was 31.8%. Across Europe, there are significant differences between countries: in Italy the caesarean section rate is 40%, while in the Nordic countries it is only 14%. Medical professional policy makers find that elective cesarean can be harmful to the fetus and neonate without benefit to the mother, and have established strict guidelines for non-medically indicated cesarean before 39 weeks. 1
The mortality rate for both caesarean sections and vaginal birth, in the Western world, continues to drop steadily. In 2000, the mortality rate for caesarean sections in the United States was 20 per 1,000,000. The UK National Health Service gives the risk of death for the mother as three times that of a vaginal birth. However, it is misleading to directly compare the mortality rates of vaginal and caesarean deliveries. Women with severe medical conditions, or higher-risk pregnancies, often require a which can distort the mortality figures.2
It is difficult to study the effects of caesarean sections because it can be difficult to separate out issues caused by the procedure itself versus issues caused by the conditions that require it. For example, one study found women who had just one previous caesarean section were more likely to have problems with their second birth. Women who delivered their first child by caesarean delivery had increased risks for malpresentation, placenta previa, antepartum hemorrhage, placenta accreta, prolonged labor, uterine rupture, preterm birth, low birth weight, and stillbirth in their second deliveries. However, the authors concluded some risks may be due to confounding factors related to the indication for the first caesarean , rather than due to the procedure itself.2
Nurses should play a vital role in advising mothers regarding the effects of caesarean section in their future life. If they are not getting adequate care and follow up it leads to so many complications and increases the morbidity and mortality rates. In the early pregnancy itself, the nurse should focus on the interventions regarding this decisions.
6.1: NEED FOR THE STUDY
Women are not a homogeneous group in terms of their requirements for information, nor their desire to be involved in the decision on mode of delivery. Health professionals need to be responsive to this variability and to agree on standards for communicating with women during pregnancy about the possibility of operative delivery and for debriefing women after caesarean section , and women's satisfaction with this involvement.3
Caesarean section rates are rising in many middle- and high-income countries, with the justification that higher rates of caesarean section are associated with better outcomes. Emergency caesarean section was associated with previous caesarean section , parity, age and a score reflecting medical risk, but not fear of childbirth or anxiety measures. There were no differences in fear between women experiencing spontaneous-vertex, forceps/ventouse, emergency or elective caesarean section deliveries. The W-DEQ was factor analyzed and was found to measure four distinct domains: fear, lack of positive anticipation and the degree to which women anticipate isolation and riskiness in childbirth. 4
Incidence rate of Karnataka shows that the increases in institutional deliveries and growing access to gynecological and obstetric care, caesarean section deliveries too have shown an increasing trend. A study by the Indian Council of Medical Research in 33 tertiary care institutions noted that the average caesarean section rate increased from 21.8 per cent in 1993-’94 to 25.4 per cent in 1998-’99. According to the National Family Health Survey, 1992-’93, two states, Karnataka and Goa, have shown the highest percentage of caesarean section deliveries . A rising trend in caesarean section rates, from 11.9 per cent in 1987 to 21.4 per cent in 1996 has been reported from Karnataka. Another study in Jaipur showed that caesarean section rates in a leading private hospital rose from 5 percent in 1972 to 10 percent in late 1970s and to 19.7 per cent between 1980-’85 .Studies show that in India, the rate of caesarean-section delivery is relatively much higher in private hospitals rather than in public health facilities. For instance, Padmadas et al (2000) observed in the case of India the deliveries are mostly occurring in private rather than public institutions.5
In India, out of 420 elective s (10.6%, from a total of 3971 births) recorded in the planning book in our labour ward, the major indications were previous caesarean section (186, 44%), maternal request alone (no other indication) (59, 14%), and breech delivery (55, 13%). All women who had previously had a caesarean section or who had a breech presentation were given the opportunity to try vaginal delivery, so the ultimate decision in these cases was arguably also maternal request. Thus, 300 (72%) of all our elective caesarean sections were because of either purely or mainly maternal request (7.6% of all births).It is clear from these data that maternal choice is now a major factor influencing the mode of delivery, at least in affluent areas in the United Kingdom, and should be taken into account in resource planning for the maternity services.6
Worldwide incidence rate of caesarean section audit of the patient records over a period of one year was done. No personal identifiers were noted or reported on. All relevant clinical data were pooled and used to analyze the clinical information. There were 364 deliveries in the study period and 209 of these were caesarean, giving a rate of 60.4%. Most of the caesarean section were carried out because of a previous caesarean; maternal request and HIV status also contributed to the high rate. The high caesarean rate in private practice is probably a window to the increased rates of caesarean section being performed worldwide. This high rate is in keeping with trends in countries such as South America, and is considerably higher than the ideal rate of 10 to 15% in low-risk obstetric populations suggested by the WHO.7
As a result of this findings suggest the importance of giving awareness to the mothers regarding the effects of caesarean section to decrease further complications in their future lives. Nursing personnel should help the women to follow the good decisions. Nurse should give the motivation to decrease the rate of caesarean section on maternal request.
6.2: REVIEW OF LITERATURE
Review of literature is a key step in research process. It refers to an extensive, exhaustive and systematic examination of publication relevant to the research project. Nursing research may be considered as a continuing process, knowledge gained from earlier studies is an integral part of research in general. Before any research can be started whether it is a single study or an extended part of project, a literature previous studies and experience related to the proposed investigation should be done.
A researcher analyses existing knowledge before de-living into a new area of the study and while conducting a study and when making judgement about application of a new knowledge in nursing practice. 8
Review has been divided under the following headings :
1. Studies related to prevention of caesarean section by maternal request on non-medical basis.
2. Studies related to the effectiveness of self instructional module on knowledge regarding prevention of caesarean section by maternal request on non-medical basis.
1. Studies related to prevention of caesarean section by maternal request on non-medical basis.
A study had done on ‘An investigation of women's involvement in the he decision to deliver by caesarean section . It was an observational study in a maternity unit in a large teaching hospital. They selected One hundred and sixty-six women undergoing caesarean section . The result was The majority of the women were satisfied with the information they received during pregnancy on caesarean section and with their involvement in making the decision, but the proportions were significantly higher for elective than emergency sections.For7% of the women, maternal preference for caesarean section was a direct factor in making the decision9.
A study had done on ‘ Women's Request For a caesarean section: A Critique of the Literature’ .It provides a critique of published research relating to women's request for cesarean delivery. The role of the woman's caregiver in the generation, collection, and entry of data, and the occurrence of post hoc rationalization, recall bias, and women's tendency to be less critical of their care immediately after birth are possible areas of concern. Due consideration is rarely given to the influence of obstetric risk for women who may be requesting a cesarean section or to the information women used in making their decision. Women's perceptions of their involvement in decision-making regarding cesarean section are used to draw conclusions regarding women's request. 10
A study was conducted ‘To assess women's familiarity with breech presentation and external cephalic version (ECV), and women’s preferences and attitudes regarding ’. It was a cross-sectional survey conducted in King George V (KGV) Memorial Hospital for Mothers and Babies. Data were obtained from 174 pregnant women using a self-administered questionnaire. Of the 174 respondents, 85% could correctly identify breech presentation, and 66% had heard of ECV. For 87% this information was from books, and family/friends, and not their midwife/doctor. Equal numbers of women responded that they would or would not choose ECV (39%), and the remaining 22% were uncertain. 11
A study had done on ‘Health Consequences of the Increasing caesarean section rates’. A review of 79 studies comparing outcomes of elective caesarean section with vaginal deliveries, including both observational studies and randomized trials, suggests that s may have substantially greater risks than vaginal deliveries. Testing of interventions to reduce unnecessary caesarean sections is also needed, with strategies to enhance the role of women in the process of their obstetric care. 12
A study had done on ‘The perceptions and attitudes towards caesarean section among women’ attending maternity car. Some 413 consecutive women, attending antenatal care in the hospital, were interviewed with a structured questionnaire Result says that the women had good knowledge of caesarean section; however, only 6.1% were willing to accept caesarean section as a method of delivery, while 81% would accept caesarean section if needed to save their lives and that of their babies. Up to 12.1% of women would not accept caesarean section under any circumstances. Logistic regression showed that women's low level of education.13
A study had done on ‘Attitudes of Singapore women toward cesarean and vaginal deliveries’ to assess the attitude, knowledge, and expectations of Asian pregnant women toward cesarean and vaginal deliveries. Written questionnaires were given to pregnant women attending the National University Hospital antenatal clinics, and 160 responses were tabulated and analyzed. Result says that the participation rate was 65% and 50% of the respondents were Chinese, 20% Indian, 21% Malay, 2% White, and 9.2% Other. The median age was 31 years, and approximately 43% were primiparas. Only 3.7% of them would prefer an elective cesarean delivery, and although 50% had friends or relatives who requested one, only 3% felt that this influenced their preference. The most common reasons for choosing a cesarean delivery were avoiding labor pains and lowering the risk of fetal distress. 14
A study had done on ‘The influence of maternal request on the elective caesarean section rate’. The study was a prospective patient interview and case note review, set at a District General Hospital. Eligible patients included all women undergoing elective caesarean section , with the main outcome measure being the number of elective caesarean section performed without obstetric contraindication to vaginal delivery. Out of 3025 deliveries, 570 (18.8%) were delivered by caesarean Section, 276 (9.1%) electively and 293 (9.7%) as an emergency procedure. Of the elective procedures (18.2% of the total number of operations), 38% were performed because of maternal request. We conclude that maternal request is a significant factor in the rise in caesarean section rate. 15