RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAK
SYNOPSIS PROFORMA FOR REGISTRATION OF
SUBJECT FOR DISSERTATION
1 / NAME OF THE CANDIDATE AND ADDRESS / MISS RAM KUMARI LIMBU1st YEAR M.Sc. NURSING
No1621.HBR LAYOUT ,
HENNUR ROAD ,
KALYANNAGAR,
BANGLORE-560043
2 / NAME OF THE INSTITUTION / CHRISTIAN COLLEGE OF NURSING
No, 1621, HBR LAYOUT,
HENNUR ROAD,
KALYANNAGAR, BANGLORE- 560043
3 / COURSE OF THE STUDY AND SUBJECT / MASTER OF SCIENCE IN OBSTETRIC AND GYNECOLOGICAL NURSING
4 / DATE OF ADMISSION COURSE / 7/5/2012
5 / TITLE OF THE TOPIC / EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE REGARDING MANAGEMENT OF PPH AMONG STAFF NURSES AT SELECTED HOSPITAL IN BANGALORE
6.0. BRIEF RESUME OF THE INTENDED WORK:
6.1. INTRODUCTION:
Health is fundamental human right. It is central to the concept of quality of life. Health and its maintenance is a major social investment and is a world-wide social goal.
Induction of labour is the process of artificially stimulating the uterus to start labour. It is usually performed by administering oxytocin or prostaglandins to the pregnant women or by manually rupturing the amniotic members. During induction of labour, the woman has restricted mobility and the procedure itself can cause discomfort to her. To avoid potential risks associated with the procedure, the woman and her baby need to be monitored closely. This can strain the limited health-care resources in under-resourced settings. In addition, the intervention affects the natural process of pregnancy and labour and may be associated with increased risks of complications, especially bleeding, caesarean section, uterine hyperstimulation and rupture and other adverse outcomes.
Post-partum hemorrhage (PPH) is a clinical problem of indisputable importance to patients, clinicians and to those interested in achieving equity in reproductive health. Even the mild self-limiting cases have consequences for the patient’s puerperium in the form of fatigue, tiredness, failure to breast-feed and possible need for haematinics or blood transfusion . PPH can transform a normal woman in labour to a critically ill patient within minutes. The management of such a patient is a real test for the thought processes, resources, organizational effort and the education of a labour ward and its staff.
Historically, PPH was one of the leading causes of maternal death in industrialized nations up to the Second World War. It is still a leading cause of maternal death in the rest of the world today. Defined by the World Health Organization (WHO) as post-partum blood loss in excess of 500 ml, it is a clinical diagnosis that encompasses excessive blood loss after delivery of the baby from a variety of sites: uterus, cervix, vagina and perineum . Reproductive health care is the constellation of information and services designed to help individuals attain and maintain the state of reproductive health by preventing and solving reproductive health problems. Reproductive health care includes a variety of prevention, wellness and family planning services as well as diagnosis and treatment of reproductive health,concerns.
Positive reproductive health means that individuals can manage their own sexuality and have unrestricted access to the full range of reproductive health care options. Implicit in this understanding of reproductive health is the right of all women and men to be informed, to have access to safe, effective, affordable, and acceptable methods of family planning of their choice, and to have access to appropriate health care services that enable women to safely go through pregnancy and childbirth.
Haemostasis following placental separation is thereby initially a mechanical process not primarily dependent upon an intact coagulation system. Development of this mechanism was a crucial aspect of viviparity without which mammals would not have evolved. However it is flawed: Primary PPH due to uterine atony occurs when the relaxed myometrium fails to constrict these blood vessels, thereby allowing hemorrhage. Since up to one-fifth of maternal cardiac output, which is in excess of 600 ml/min, enters the uteroplacental circulation at term, it is understandable that primary atonic PPH can be catastrophic—capable of exsanguinating the mother within minutes. We are at the threshold of major developments in its prevention and treatment due to changing ideas about its definition and medical and surgical management. The implementation of these changes is an essential part of a wider commitment towards saving mothers from complications of childbirth. Whilst uterine atony is responsible for the majority of primary PPH, the surgical obstetrical causes such as injury of the cervix, vagina, paravaginal spaces, perineum and episiotomy comprise about 20% of all primary PPH with adequate knowledge and timely intervention the life of the mother can be saved and stabilty can be achieved. The scale of the problem The last two decades have witnessed an increasing awareness of gender-related medical problems in the world. Maternal mortality figures have increasingly become an emotive political issue. The lack of improvement in these figures in the developing world reflects the complex nature of the problems these societies face.
6.2 NEED FOR THE STUDY
Any woman who gives birth can have post-partum haemorrhage which may threaten her life. PPH is one of the leading causes of maternal mortality and an important cause for serious morbidity in the developing and developed world. The incidence of PPH ranges between 5% and 8% in places where some form of prophylaxis is practised, but may be as high as 18% when a physiological approach is the norm. Physiological control of post-partum bleeding occurs by contraction and retraction of the interlacing myometrial fibres surrounding maternal spiral arteries in the placental bed . .World-wide it is the most common reason for blood transfusion after delivery and it is estimated that at least 150,000 women per annum bleed to death during or immediately after labour. This figure is almost certainly an underestimate. Death due to PPH is the reported to represent between 17% and 40% of maternal mortality in some parts of world. Even in developed countries, for example The Netherlands, PPH causes 13% of all recorded maternal deaths. In the USA, it has been reported that obstetric hemorrhage is responsible for 13% of maternal death with PPH the lethal event in over one-third of these cases. In those parts of the world where blood replacement is not possible due to lack of resources, post-partum severe hypotensive shock leads to considerable morbidity including acute renal failure, partial or total necrosis of the anterior pituitary gland and other organ system injury such as pancreatitis and adult respiratory distress syndrome (ARDS). To prevent serious morbidity or death from PPH many systems need to be functioning: trained birth attendants, emergency transport systems (the window of time needed to save life is short), availability of blood transfusion and other essential obstetric functions at the first referral level. It is recognized that routine pharmacological use of uterotonic agents is an important prophylactic measure against PPH. Strategies to reduce post-partum bleeding include the use of uterotonic drugs such as oxytocin, Syntometrine (combination of oxytocin and ergometrine) or ergometrine. Other measures include early clamping of the cord and delivery of the placenta by cord traction. These are collectively termed ‘active’ management of the third stage. With ‘passive’ (expectant, physiologic, conservative) management, oxytocics are used only if there is excessive bleeding, the cord is clamped relatively late and the placenta delivered with the help of gravity and maternal effort. However, many variations of third stage management exist in which a mixture of active and passive management is used. There is a growing need for awareness about the effective management of PPH among staff nurses and hence this research study is undertaken to achieve the same.
6.3 REVIEW OF LITERATURE
Review of literature is a key step in research process. Review of literature refers to an extensive, exhaustive and systematic examination of publications relevant to the research project .Before any research can be started whether it is a single study or an extended project, literature reviews of previous studies and experiences related to proposed investigations should be done. One of the most satisfying aspects of the literature review is the contribution it makes to the new knowledge, insight and general scholarship of the searcher.
Review of literature is divided into 2 parts:-
1.studies related to management of post partum hemorrhage
2.studies related to effectiveness self instruction module
6 .3.1. Studies related to management of post partum hemorrhage
A study was conducted epidemiological study regarding management of PPH in France. This study assessed the quality of care for major PPH and the correct follow-up of the guidelines before and after 2004. A clinical audit had been conducted in all the birthplaces from the region to assess the management of all severe PPH identified . PPH were considered as severe when they presented one or more of the following: blood transfusion, uterine embolisation, hemostatic surgery, difference in hemoglobin rates greater than 4 g / dl, or maternal death. All of these cases have been analysed except those defined by hemoglobin difference. Assessment has been carried out by pairs of practitioners (obstetrician and anesthetist) blinded to the origin of the case. Criteria assessed were the quality of care for major PPH, the correct follow-up of the guidelines and the degree of severity of the PPH which was estimated as moderate or severe on clinical arguments. The number of severe PPH was 34 in 2002 and 63 in 2005. The quality of care was increased with rates of inadequate management falling from 32 to 13% (p < 0,02), respectively. The follow-up of the guidelines was correct in the whole area, most of the criteria having been respected in about 90% of cases in 2005. However, active management of the third stage of delivery was only conducted in 71% of cases. The rates of severe PPH were not significantly different between 2002 (44%) and 2005 (38%). The originality from this study is that the modifications of the practices were conducted at a regional level in order to enhance the management of PPH. The assessment which was performed showed that quality of care was improved all over the area but that there is still place to progress.1
A population based cohort study in France to describe management of severe postpartum hemorrhages (PPH) and its compliance with national guidelines and identify determinants of non-optimal care. The study included 1379 women with severe PPH due to uterine atony after vaginal delivery. The study was conducted in 106 maternity units between December 2004 and November 2006. Severe PPH was defined by a peripartum haemoglobin drop of 4g/dL or more, blood loss of 1000 mL or more, hysterectomy, or transfer to intensive care for PPH. The frequency of each recommended procedure for the management of PPH was described. Associations between quality of care and both individual and institutional characteristics were assessed by univariate analysis and multivariate logistic regression. The result of study showed management of severe PPH was not optimal in 65.9% of cases. The recommended components that were applied least often were administration of second line uterotonics, and transfusion of patients with a low haemoglobin. After adjustment for individual characteristics, the risk of either non- or suboptimal care was significantly higher in non-university public maternity units, compared with university hospital units, in units with fewer than 2000 annual deliveries, and in units without an obstetrician always present. The researchers concluded that management practices for severe PPH can be improved, to an extent that varies by component of care and type of hospital. A qualitative approach should help to identify the individual and organizational factors explaining why guidelines are not fully applied.2
A cross sectional study was conducted to assess the management of post-partum haemorrhage (PPH) in delivery rooms by the anaesthetists of the Auvergne region. Anonymous postal survey was sent to all the anaesthetists working in a public or private hospital with a maternity unit. The response rate was about 70 %. Eight percent of the respondents never practiced in obstetrics; others all declared to have managed PPH at least once. Only 66 % declared to know the right definition of PPH, 98 % declared to have guidelines in the delivery room, 87 % to use graduate blood receipt pockets, 85 % to work under midwives-directed delivery at expulsion, 88 % to have a HemoCue™ system. More than 80 % declared to use first oxytocin and to switch for prostaglandins in case of failure, to put two venous catheters and a urinary catheter, to administer broad-spectrum prophylactic antibiotic and to draw a blood sample for early biology. Packed red cells, platelets and fresh frozen plasma were accessible in less than 30 minutes for 98 %. Transfusion guidelines were applied. Only 27 % could have arterial radiologic embolisation on site. The knowledge about PPH and its consensual care tended to be poorer in practitioners from the university hospital, and younger under 40 also. This survey, with a good response rate, showed a practice generally fitting to the guidelines, although with some failures depending on the practioner's age and type of hospital. 3
The findings of study by Prendiville and colleagues show a conclusive benefit for active management, with an approximate 60% reduction in the occurrence of PPH greater than or equal to 500 mL and 1000 mL, hemoglobin concentration of less than 9 g/dL at 24-48 hours after delivery, and the need for blood transfusion. An 80% reduction in the need for therapeutic uterotonic agents was noted. These results were all highly significant as indicated by the 95% confidence interval figures. The results indicate that for every 12 patients receiving active rather than physiological management, one PPH would be prevented. For every 67 patients so treated, one patient would avoid transfusion with blood products. One concern regarding active management is that retained placenta may occur more frequently. This concern is not supported by the trials. This is especially true if oxytocin is used as the uterotonic.The US RCTs mentioned above compared the use of active management protocols in which the oxytocin was administered either immediately after delivery of the baby or immediately after delivery of the placenta. The authors stated that no statistically significant difference was noted in the PPH rate and that delaying administration until after placental delivery was justified4