RAJIV GANDHI UNIVERSITY OFHEALTH SCIENCES,
BENGALURU, KARNATAKA.
SYNOPSIS PROFORMA FOR REGISTRATION OF
SUBJECT FOR DISSERTATION
“A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING UTERINE BALLOON THERAPY FOR MANAGEMENT OF POST PARTUM HAEMORRHAGE AMONG 4TH YEAR BSC NURSING STUDENTS AT SELECTED COLLEGES OF NURSING,BENGALURU”.
Ms. SUDIKSHA NIROULA
1ST YEAR M.Sc NURSING
OBSTETRICS & GYNAECOLOGICAL NURSING
SJB COLLEGE OF NURSING,
KENGERI, BENGALURU-560060
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 / NAME OF THE CANDIDATEAND ADDRESS / Ms. SUDIKSHA NIROULA,
S J B COLLEGE OF NURSING,
BGS HEALTH AND EDUCATION CITY,
KENGERI, BENGALURU-60,
2 / NAME OF THE INSTITUTION / S J B COLLEGE OF NURSING,
BGS HEALTH AND EDUCATION CITY,
KENGERI, BENGALURU-60.
3 / COURSE OF STUDY &
SUBJECT / IYEAR M.Sc. NURSING,
OBSTETRICS & GYNAECOLOGICAL NURSING.
4 / DATE OF ADMISSION / 16-7-2013
5 / TITLE OF THE TOPIC / “A Study To Evaluate The Effectiveness Of Structured Teaching Programme On Knowledge Regarding Uterine Balloon Therapy For Management Of Post PartumHaemorrhage Among 4th Year Bsc Nursing Students At Selected Colleges Of Nursing,Bengaluru”.
1
6. BRIEF RESUME OF INTENDED WORK:
6.1 NEED FOR THE STUDY
“Every healthy child needs a healthy mother”.
UNICEF.
Pregnancy is a unique, exciting and often joyous time in a women’s life, as it highlights the woman’s amazing creative and nurturing powers while providing a bridge to future. Giving life is powerful and vital. The physiological transition from being a pregnant woman to become a mother means enormous change for each woman, both physically and psychologically. 1
Labour is a series of events that bring about the dilatation of the cervix, descent of the fetus and finally the delivery of the fetus and placenta. This process of labour sometimes can be accounted by severe life threatening complications after birth, which are significantly categorized as Post PartumHaemorrhage, puerperal sepsis, ruptured uterus etc. Among all, postpartum haemorrhage occupies a lead and is responsible for maternal mortality.2
Worldwide, obstetric hemorrhage remains a significant problem and is responsible for 127,000 deaths annually. Postpartum hemorrhage (PPH) is the most common type of obstetric hemorrhage and accounts for the majority of the 14 million cases annually. Although accountable for only 8% of maternal deaths in developed countries, postpartum hemorrhage is the second leading single cause of maternal mortality, ranking behind preeclampsia/eclampsia.3
World Health Organization estimate that, of the 5,29,000 maternal death occurring every year, 1,36,000 or 25.7 % take place in India where two third of maternal death occur after delivery, Post Partum hemorrhage being the most commonly reported complication and leading cause of death i.e 30%. In Karnataka, maternal death rate is 213 per 100,000 and as estimated 38% was responsible for post partumhaemorrhage .4
Most cases of primary PPH are caused by uterine atony, often a result of prolonged labor, pre eclampsia, or a history of PPH in a previous pregnancy. The risk of death is greatest for women who are anemic or have other underlying health problems that make them less able to deal with blood loss. Although active management of the third stage of labor can prevent up to 60% of PPH cases . PPH continues to have a devastating impact on women in low-resource settings. 4
Obstetric hemorrhage accounts for 34% of maternal deaths in Africa, 31% in Asia, and 21% in Latin America and the Caribbean. Among women who do survive PPH, approximately 12% will have severe anemia. Also, women who survive severe PPH (greater than 1,000 mL of blood loss) are significantly more likely to die during the following year.5
Most cases of severe PPH can be prevented if the bleeding is controlled and managed immediately. This is often accomplished by administering one of a group of drugs called uterotonics. However, these options sometimes fail to control severe PPH and are not available. For this reason, effectively reducing death and injury due to PPH requires a combination of approaches and the adoption of second line interventions that are also appropriate for health facilities in low-resource settings. Uterine balloon tamponade (UBT) is one promising option.6
Since 1983, when Goldrath published evidence that inserting a Foley catheter in the uterus and inflating it with water could achieve tamponade, case series and other studies have suggested that various UBT devices may be effective in treating PPH. The studies used various types of UBT devices, including a condom catheter, a Foley catheter, the Sengstaken-Blakemore Esophageal Tube, the Rusch Balloon, and the Bakri Uterine Balloon. 7
A systematic review of treatment options for PPH using Uterine balloon tamponade found the success rate of over 84% ,which does not significantly vary from surgical treatment outcomes. Based on the findings conclusion was drawn as it should be considered as a first step in the management of intractable PPH, which is not due to genital trauma or retained tissue and which does not respond to uterotonics.8
The World Health Organization (WHO), the International Federation of Gynecology and Obstetrics (FIGO), the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynecologists, and the International Confederation of Midwives (ICM) recognize balloon tamponade as a method that could significantly improve the management of intractable PPH, even in low-resource areas where blood transfusions are not available and surgical interventions are not an option.9
A systematic review on the effectiveness of UBT was conducted in developing countries .The researchers identified 13 studies and described cases in 7 countries; 10 cases were in South and Southeast Asia and 3 in sub-Saharan Africa. A review of these studies suggests that UBT is effective in the treatment of PPH across a wide variety of indications and techniques for use. UBT successfully treated PPH in 234 out of 241 cases reviewed.10
In 2012, WHO updated the Guidelines for the Management of Postpartum Haemorrhage and Retained Placenta to state: “The use of intrauterine balloon tamponade is recommended for the treatment of PPH due to uterine atony. This recommendation is now stronger than the previous guidelines. It can be used for women who do not respond to uterotonics or if uterotonics are not available and even this procedure potentially can avoid surgery. Furthermore, FIGO included UBT as a recommended second-line intervention for the treatment of PPH in their updated guidelines issued in 2012. In conclusion, UBT has the potential to be an effective treatment for PPH even in low-resource settings.11
One of the Millennium Development Goals set by the United Nations in 2000 is to reduce maternal mortality by three-quarters by 2015. If this is to be achieved,
maternal deaths related to postpartum haemorrhage (PPH) must be significantly
reduced. This will include the realistic and sustainable implementation of appropriate interventions as UBT.As nurses it is our duty to contribute towards the reduction of maternal mortality due to PPH, to achieve the millennium development goal by using effective techniques and method which is assessable and feasible. 12
The investigator while working in labour room had a personal experience that woman with Post PartumHaemorrhage after failure of all medical management has undergone to surgical treatment as hysterectomy which has prevented them to enjoy motherhood in future. And also losing a healthy mother despite of any disease condition only because of lack of appropriate treatment modalities. As the investigater came to know that UBT is an imperative treatment modality instead of surgical procedure. Thus a study on Uterine Balloon Therapy was felt needed for the management of PPH. So the investigator is interested to give structured teaching program on Uterine Balloon Therapy to BSc nursing students as they are the future teacher and can apply the knowledge in their work setting, also this will percolate in the patients, staffs and their students.
6.2 REVIEW OF LITERATURE:
Review of related literature is an integral component of any study or research project. It enhances the depth of the knowledge and inspires a clear insight into the crux of the problem. Literature review throws light on the study and their finding reported about the problem under study.
The review of literature are related to the following,
- Literature related to impact of Post Partum Haemorrhage and effectiveness of Uterine Balloon Therapy on management of post partum haemorrhage.
- Literature related to knowledge of nursing students regarding management of Post Partum Haemorrhage.
- Literature related to effectiveness of Structured Teaching Programme.
LITERATURE RELATED TO IMPACT OF POST PARTUM HAEMORRHAGE AND EFFECTIVENESS OF UTERINE BALLOON THERAPY ON MANAGEMENT OF POST PARTUM HAEMORRHAGE.
A retrospective study regarding maternal mortalityand its causes in a tertiary center was conducted by Department of Obstetrics and Gynecology, Regional Institute of Medical Sciences (RIMS), Lamphel, Imphal, Manipur, India. The objective of the study was to assessmaternal mortalityand the complications leading tomaternaldeath. Study of hospital records and death summaries of allmaternaldeaths from January 2000 to August 2009 was carried out. The result showed that there were a total of 80maternaldeaths out of 88,443 live births givingmaternal mortalityrate (MMR) of 90.45 per 100,000 live births. The study concludes that Post PartumHaemorrhagewas the commonest cause of death (52.5%), followed by sepsis (13.75%) and pregnancy-induced hypertension including eclampsia (10%).13
A retrospective study was conducted to determine the leading causes of maternal mortality among 100,531 live births in in a maternity hospital Turkey between 1983 to 1992. Study of hospital records and death summaries of allmaternaldeaths was carried out. The result revealed that overall maternal mortality ratio was 16.9 per 100,000 live births. The leading causes of maternal mortality were haemorrhage in (41.2%) and pulmonary embolism in (35.3%) patients. The majority of deaths were observed in the 25-29 and 30-34 age groups and in patients with parity more than two. Obstetric haemorrhage is still the leading cause of maternal mortality. Pregnant women less than 20 greater than 35 years old and grand multiparous, hypertensive and heart disease are at high mortality risk. 14
A prospective study was conducted in a tertiary care teaching hospital in New Delhi, India. The objective of the study is to evaluate the effectiveness of uterine Tamponade using condom catheter in non-traumatic PPH .Eighteen patients with non- traumatic PPH not responding to medical management were included in the study. Success rate in controlling haemorrhage, time required to stop bleeding, subsequent morbidity and technical difficulties were the quantitative measures utilized. Success rate of condom catheter balloon in controlling PPH was 94% and the average time taken for controlling bleeding was 6.2 minutes. The study concludes that Condom catheter balloon is effective in controlling non-traumatic PPH and is effective, simple to use, easily available and is a cheap modality especially in limited resource settings.15
A retrospective study was conducted by Obstetrics and Gynecology Department, Virgen de las Nieves University Hospital, Granada, Spain, to evaluate the effectiveness of the Bakri balloon in treating postpartum hemorrhage refractory to medical treatment. 24 women with postpartum hemorrhage were treated with a Bakri balloon as a conservative therapeutic option. The result shows that Bakri balloon was successful in controlling hemorrhage in 87.5% of the women. The study concludes that the ease of use and high effectiveness make the Bakri balloon a useful approach for the conservative management of acute postpartum hemorrhage and also avoids the need for more aggressive procedures.16
A case series review on Intrauterine balloon tamponade in the management of postpartum haemorrhage by the department of obstetrics and gynecology department, Exempla Saint Joseph Hospital, Denver, USA, reviewed the report of 23 patients with postpartumhemorrhageunresponsive to medicaltherapymanaged with intra uterine balloontamponade. When properly placed, catheters controlled postpartumhemorrhagein 18 of 20 cases (90%). In two cases, hysterectomy was required despite successful placement of the catheter. Forhemorrhagedue to uterine atony, their success rate was 100% (11/11 cases). In three cases, technical difficulties led to placement failure. For bleeding due to retained placenta, their success rate was 80% (4/5; failure with placenta percreta). Thusballoontamponade is considered as effective adjunct in the treatment of severe postpartumhemorrhage, especially when due to uterine atony when medicaltherapyfails.17
LITERATURE RELATED TO KNOWLEDGE OF NURSING STUDENTS REGARDING MANAGEMENT OF POST PARTUM HAEMORRHAGE.
An exploratory quantitative analytical study was conducted on Managing women with acute physiological deterioration(PPH,APH) by Monash University School of Nursing and Midwifery, Gippsland: Churchill,Australia. The objective of the study was to assess student midwives' ability to assess, and manage maternal deterioration using measures ofknowledge, situation awareness and skill, performance. Thirty-five student, midwives attended a simulation laboratory completing aknowledgequestionnaire and two video, recorded simulated scenarios. Patient actresses wearing a 'birthing suit' simulated deteriorating, women withpost-partumand ante-partum haemorrhage. The result of the study showed that the mean totalknowledgescore was 75% (range 46-91%) with low skill performance, for both scenarios 54% (range 39-70%). The study concluded that Whilstknowledgelevels were generally good, skills were generally poor and decreased as the women deteriorated. 18
A study was conducted to assess the level and determinant(s) of accurate knowledge of obstetric providers regarding Management of Third Stage Labour. 361 labour and delivery professionals from public tertiary obstetric centers were included for this study. Questionnaire based method was used for the survey.Results of the study shows that majority (90.6%) of the respondents reported being aware of Management of Third Stage Labour as an obstetric intervention. Out of the13 potential third stage interventions, 102 respondents (28.3%) correctly and exclusively identified the components of Management. Many procedures reserved for treatment of complicated third stage of labour such as manual placental removal (37.7%), blood transfusion (20.2%), bimanual uterine compression (24.7%) and uterine artery legation (13.9%) ,and uterine temponade (32%) were also included as the as the components of Management of Third Stage Labour. The study concluded that Management of Third Stage Labour was a familiar but poorly understood intervention among the obstetric care providers. This shows that there is urgent requirement of educational interventions that target those who provide routine delivery care in order to improve the health care quality.19
LITERATURE RELATED TO EFFECTIVENESS OF STRUCTURED TEACHING PROGRAM.
An evaluative study was conducted among 30 nurses working in maternity unit of selected hospitals, Belgaum.The objective of the study is to evaluate the effectiveness of STP by assessing changes in knowledge, attitude and management skills of nurses on management on PPH. The findings of the study showed that prior to the administration of structured teaching program, the nurses had minimum knowledge (34.79%) in the area of skill in management of PPH. However, on administration of structured teaching program, the scores show considerably greater gain (44.17%) in the area of skill in management of PPH. This study showed the effectiveness of structured teaching program for nurses.20
A quasi-experimental study was conducted to assess the effectiveness of structured teaching program on knowledge and attitude of adolescent girls in prevention of iron and folic acid deficiency anemia at a selected corporation school at Coimbatore, Tamil Nadu. The sample size was 60. The study revealed that during pre-test 90% of them had inadequate knowledge and 65% of them had unfavorable attitude. After the structured teaching program their knowledge and attitude was improved to 73% and 79% respectively.21
PROBLEM STATEMENT:
“A study to evaluate the effectiveness of structured teaching programme on knowledge regarding uterine balloon therapy for management of post partumhaemorrhage among 4th year BSc nursing students at selected colleges of nursing, Bengaluru”.
6.3 OBJECTIVES
- To assess the knowledge regarding Uterine Balloon therapy for management of Post Partum Haemorrhage among 4th year BSc nursing students at selected colleges of nursing.
- To evaluate the effectiveness of structured teaching programme on knowledge regarding Uterine Balloon therapy for management of Post Partum Haemorrhage among 4th year BSc nursing students at selected colleges of nursing by comparing pre and post test knowledge scores.
- To find the association between pre test knowledge score and selected demographic variables.
6.3.1 HYPOTHESES:
H1:There will be a significant difference in the pre-test and post-test knowledge scores regarding Uterine Balloon Therapy for management of Post Partum Haemorrhage among 4thyear BSc Nursing students.
H2: There will be a significant association between the pre-test knowledge score and selected demographic variables among 4thyear BSc Nursing students.
6.3.2 VARIABLES:
1. Independent variable: Structured teaching programme on Uterine Balloon Therapy for management of PPH.
2. Dependant Variable: Knowledge regarding Uterine Balloon Therapy for management of PPH.
3. Demographic Variable: Gender, source of information and previous exposure to patient with Uterine Balloon Therapy.
6.4OPERATIONAL DEFINITIONS:
a) Effectiveness: It refers to gain in knowledge as determined by significant difference between pre-test and post-test knowledge scores on structured questionnaire.
b) Structured Teaching Programme: It refers to systematically organized teaching program for the purpose of achieving the pre-specified objectives which is prepared by the investigator and validate by the expert regarding Uterine Balloon Therapy for the management of PPH.
c) Knowledge: It refers to correct responses towards the items of the knowledge questionnaire regarding Uterine Balloon Therapy for management of Post PartumHaemorrhage.
d) Uterine Balloon Therapy :Inflation of balloon catheter within the uterine cavity to control uterine hemorrhage.
e)Post Partum Haemorrhage: Refers to blood loss of 500 ml or more after delivery till 7 days.
6.5 ASSUMPTION:
1. 4th year BSc nursing students may have some knowledge regarding Uterine Balloon Therapy for management of PPH..
2. Structured teaching programme is a method to impart the knowledge.
6.6 DELIMITATION:
- The study is delimited to the 4th year BSc Nursing students who are studying in Selected College of Nursing, Bengaluru.
7. MATERIALS AND METHODS
7.1 SOURCES OF DATA : 4th year BSc Nursing Students.
7.1.1 RESEARCH APPROACH : Evaluative Approach.