RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECTS
FOR DESSERTATION.
1 / Name of the candidate and address / MRS. BETSIE ANNA MATHEWI year M.Sc.(N)
Faran College of Nursing
Bangalore -49
2 / Name of the institution / Faran College of Nursing
3 / Course of the study and subject / M.Sc.Nursing
Obstetrical And Gynaecological Nursing
4 / Date of admission to course / 15. June.2010
5 / Title of the topic /
“To assess the effectiveness of a self instructional module on Intrapartum fetal monitoring for staff nurses in selected hospitals, Bangalore.”
6. BRIEF REVIEW OF THE INTENDED WORK
INTRODUCTION:
Any sufficiently advanced technology is indistinguishable from magic.”
Arthur .C. Clarke
The mother during labour is a vital period where caring is important. Labour is a period of physiological stress for the fetus. 1 The assessment of fetal well being during this time is a component of a total care package of intrapartum care provided to women. Intrapartum fetal surveillance aim to improve, fetal outcomes by identifying fetus with hypoxia or academia and has the potential to promote fetal health and neonatal status at birth. 2 Fetal heart rate patterns provide important insights into response to labour and alternations can signal developing problems. The goal of monitoring fetal heart rate is to assist care provides to identify fetuses experiencing distress (hypoxia or asphyxia) and to intervene in a timely manner to reduce or relieve that distress.3
The ability to assess the fetus by auscultation of fetal heart tones was initially described more than 300 years. With the advent of the fetoscope and stethoscope after the turn of twentieth century, the listener could hear clearly enough to count the fetal heart rate.1 Until 1960s intermittent auscultation was the only method of monitoring the fetal heart rate it may be performed by the midwife using a Doppler sonic aid or a pinnard stethoscope.4 Electronic monitors was widely adopted in the mid 1970’s as a means of detecting variations in fetal heart rate and to intervene at the earliest to save the babies life or to prevent brain damage.5 Several retrospective studies published during 1970s observed a decrease in fetal death rate associated with use of electronic fetal heart rate monitoring.6
Presently we use two basic approaches to intrapartum fetal monitoring, low technology and high technology. The nurse may use either or both these approaches to assess fetus during labour depending risks status and institutional policy. The low technology approach uses intermittent auscultation of fetal heart rate manually, which employs small fetoscope, stethoscope or a small handled Doppler device. Electronic fetal monitoring is the high technology approach to fetal surveillance. Electronic fetal monitoring is cardiotocography, cardio refers to heart rate and toco derived from Greek refers to uterine activity and it is the most commonly method used, in physicians offices, clinics and hospitals, which detects fetal the correlation between the fetal heart rate patterns and uterine contractions.7
Monitoring of the woman and fetus during labour is a continuous process until the delivery of newborn. This will help to identify fetal distress at the earliest which helps to prevent further neonatal complications Fetal heart rate pattern recognition in light of fetal condition must be constantly reassessed. Fetal monitoring whether by auscultation or electronic means has expanded the role of the nurse in caring for the women during labour and delivery.8
6.1 NEED FOR THE STUDY
Fetal heart rate monitoring is now practiced universally during intrapartum period. Some studies have confirmed the safety of fetal heart rate monitoring. The primary goal Intrapartum fetal heart rate monitoring is to identify hypoxic and acidiotic fetuses in whom timely intervention will prevent death. The abnormal fetal heart rates correlate with fetal distress was initially proposed by Killian, 1948. Since then, the goal of fetal heart rate monitoring has been early identification of fetuses at risk for hypoxic insult.6 One of the major cause of neonatal death is asphyxia .It is estimated that in developing countries asphyxia causes around 7 per 1000 births whereas in developed countries this proportion is less than one death per 1000 births. Fetal death rate has decreased more than half over 30 years and is about 5.5 per 1000 total births. Hypoxia is thought to be a factor in 90% of intrapartum death and much of the reduction in death has been credited to continuous fetal heart rate monitoring. Several randomized studies conferred a decrease in perinatal mortality with continuous fetal monitoring.9
The assessment of fetal well being is a primary consideration for perinatal nurses. The nurse needs to have sufficient knowledge to assess the changes in maternal or fetal condition and how these changes may affect the fetal heart rate pattern. It’s important to have a sound knowledge regarding the causes of various fetal heart rate patterns so that appropriate assessment may be anticipated and completed. All nurses who provide care to women in labour should be skilled in application of electronic monitoring equipment and assessment of baseline and periodic changes. She should know the appropriate terminology, interpretation, documentation and communication with other health team members. The perinatal nurse must obtain initial competency in fetal assessment that meets standards of care and institutional policy and accuracy in fetal assessment.10
A study was done to evaluate the effectiveness of a fetal monitoring education programme on midwives' fetal monitoring knowledge and intrapartum Cardiotocograph interpretation skills. A two group, before-after, randomized-controlled trial was used in which 55 midwives were randomly assigned to either in the experimental group (n=27) or the control group (n=28).The experimental group participated in a 1.5 hr fetal monitoring education programme, whereas the control group attended an alternative education programme consisting of a non-fetal-monitoring-related video presentation. In the fetal monitoring knowledge post-test, the median percentage correct responses for the control and experimental groups were 56% (IQR 18.75) and 88% (IQR 12.5), respectively. This difference, 31.2%, was statistically significant (U=78.5, 95.1% CI -31.25 to -18.75, p<0.001). In the intrapartum cardiotocograph interpretation skills post-test, the median percentage correct responses for the control and experimental groups were 55.6% (IQR 16.7) and 66.7% (IQR 22.2), respectively. This difference, of 11.1%, was statistically significant (U=186, 95.2% CI -16.67 to -5.56, p<0.001). The study concluded that in-service fetal monitoring education programme can increase midwives' fetal monitoring knowledge and cardiotocograph.11
A randomized control trial was done to evaluate the effectiveness of a fetal monitoring education program in increasing nurses' knowledge and clinical skill. Twelve hospitals were included in the study. One hundred nine volunteer registered nurses randomly assigned, within each hospital, to an experimental (n = 47) or control (n = 62) group. Ninety-six nurses (40 in the experimental group and 56 in the control group) completed the 6-month follow-up (88% retention).The experimental group participated in a 1-day fetal monitoring workshop and a review session 6 months later. The outcome is measured on a 45-item knowledge test and a 25-item skills checklist. The passing score was at least 75% correct on each test. The percentage of nurses in the experimental group passing both the knowledge and the clinical skills tests after the workshop was significantly higher (p < 0.01) than that of the nurses in the control group: 68.1% versus 6.5%, respectively. A large difference between the groups remained at the 6-month follow-up (experimental, 45%; control, 6.5%). The performance of the nurses in the experimental group improved to an 85% pass rate after they attended the 6-month review session. These findings shows that this comprehensive, research-based program is effective in increasing fetal monitoring knowledge and clinical skill.12
A study was done to survey midwives' attitudes and practices related to intrapartum fetal monitoring in regional and district maternity unit and related community area within one health authority. A descriptive co-relational design was used for the study. All midwives were invited to participate. Two hundred and forty two questionnaires were administered and 117 were returned (48% response rate).The questionnaire information was collected on professional/demographic details, education and practices related to intrapartum fetal monitoring, together with a 20-item attitude scale which encompassed attitudes towards fetal monitoring and related issues. As expected, the findings show that that midwives' preferred methods of fetal monitoring varied with the client's risk category. However, midwife preference did not necessarily match actual choice of method. There are many factors influencing choice, not least of which is confidence in ability. Significant differences were found between midwives. The findings highlight some of the issues relating to individual confidence. 97% of the midwives felt they would benefit from in-service training in cardiotocography interpretation. The findings support the development of continuing in service education programmes for midwives.13
All the above facts show that intrapartum fetal monitoring remains as the one of the most important modality to prevent fetal death rate due to hypoxia or asphyxia (fetal distress). The investigator through her detailed review and clinical experience found that health professional’s especially nurses are having very little knowledge regarding various aspects of fetal heart rate monitoring. However, fetal monitoring is an important aspect of intrapartum care. The studies also revealed that an education programmes can improve nurses’ knowledge and skills on various aspects of fetal monitoring. So the researcher found it relevant to assess the effectiveness of a self instructional module on Intrapartum fetal monitoring for the obstetrics staff nurses to improve their knowledge.
6.2 REVIEW OF LITERATURE
The primary purpose of reviewing relevant literature is to gain abroad background or understanding of the information that is related to a problem. In conducting research, the literature review facilitates selecting a problem and purpose, developing a framework and formulating a research plan. Literature review is a key step in research process. Review of relevant literature is an analysis and synthesis of research sources to generate a picture of what is known about a particular situation and the knowledge gaps that exist in the situation.14
A descriptive correlation study was conducted on labour and delivery nurses attitudes towards intermittent fetal monitoring more than 20 years. There were 145 nurses who participated for the study, 72.4% agreed that intermittent fetal monitoring should be the standard of care. Nurses’ attitudes were significantly influenced by education level (P = .004), and 48% were unsure about current research findings related to intermittent auscultation. Nurses have a positive attitude toward intermittent monitoring, although safe nurse/patient ratios and clear policies need to be addressed. The study concluded that lack of knowledge regarding the current evidence and other barriers may contribute to intermittent auscultation not being used routinely, despite the fact that its use for women of low obstetrical risk is supported by current research and professional organizations.15
A study was conducted on intrapartum fetal surveillance education practice in Victorian public hospitals. A structured survey comprising 25 questions was developed and mailed to both a senior obstetric and a midwifery manager in all public maternity hospitals in Victoria. One hundred and twenty surveys were sent to 60 hospitals, of which 103 replies from 58 hospitals were received, representing a 97% hospital response rate. The findings show that Only 19 (33%) of respondent hospitals had an existing education program. Hospitals with > 2000 births per annum were more likely to have a program than those with < 1000 births per annum (86% vs. 23%, P = 0.004). Of the 19 existing education programs, only nine contained any fetal physiology. All respondents thought that Intrapartum fetal surveillance education should be compulsory for relevant staff. Only six (10%) of the hospitals had any assessment of competency but 90% of respondents thought that such an assessment should be compulsory. These findings reveal that there is a need to provide quality intrapartum fetal surveillance education.16
A qualitative study was conducted to explore midwives' values, attitudes and beliefs when using intrapartum fetal monitoring techniques in clinical practice. A total of 58 registered midwives across two National Health Services Trusts in one region in the north of England were interviewed using a qualitative approach. Midwives attempted to manage the psychological burden of the threat from clinical negligence by using electronic fetal monitoring. This meant that some midwives used electronic monitoring regardless of clinical need. Midwives lack confidence in the ability of electronic fetal monitoring to accurately detect fetal compromise. The study concluded that Multidisciplinary strategies may be required to overcome barriers to the effective implementation of clinical guidelines.17
A study was done to determine the predictive value of each fetal heart rate variable and of patterns of fetal heart rate variables for fetal asphyxia during labor. This matched case-control study included an asphyxia group of 71 term infants with umbilical artery base deficit greater than 16 mmol/L and a control group of 71 term infants with umbilical artery base deficit less than 8 mmol/L. Each fetal heart rate record available for the 4 hours before delivery was scored in 10-minute cycles for each fetal heart rate variable. The fetal heart rate variables associated with fetal asphyxia included absent and minimal baseline variability and late and prolonged decelerations. It was found that fetal heart rate patterns with absent baseline variability were the most specific but identified only 17% of the asphyxia group. The sensitivity of this test increased to 93% with the addition of less specific patterns. The estimated positive predictive value ranged from 18.1% to 2.6%, and the negative predictive value ranged from 98.3% to 99.5%. The findings of the study reveals that study with careful interpretation, predictive fetal heart rate patterns can be a useful screening test for fetal asphyxia.18
A study was done to determine the current status of electronic fetal monitoring in Canadian teaching and nonteaching hospitals, to review the medical and nursing standards of practice for electronic fetal monitoring and to determine the availability of electronic fetal monitoring educational programs. Data was collected through a national survey. Questionnaire was sent to 737 directors of nursing of different hospitals providing obstetric care. The response rate was 80.5% (593/737). Forty four hospitals did not have deliveries in 1988 and were excluded. The remaining hospitals varied in size from 8 to 1800 (mean 162.1) beds and had 1 to 7500 (mean 617.1) births in 1988; 18.8% were teaching hospitals. Of the 549 hospitals 419 (76.3%) reported having at least 1 monitor (range 1 to 30; mean 2.6); the mean number of monitors per hospital was higher in the teaching hospitals than in the nonteaching hospitals (6.2 v. 1.7). Manitoba had the lowest mean number of monitors per hospital (1.1) and Ontario the highest (3.7). In 71.8% of the hospitals with monitors almost all of the obstetric patients were monitored at some point during labour. However, 21.6% of the hospitals with monitors had no policy on electronic fetal monitoring practice. The availability of electronic fetal monitoring educational programs for physicians and nurses varied according to hospital size, type and region. It was noted that most hospitals providing obstetric services have electronic fetal monitors and use them frequently. The study recommended that national committee should be established to develop multidisciplinary guidelines for intrapartum fetal assessment.19