RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / NAME OF THE CANDIDATE AND ADDRESS / Ms. ANUJA .K.MNO.5, BHOOPASANDRA
MAIN ROAD, RMV II STAGE, BANGALORE-94.
2 / NAME OF THE INSTITUTION / NOOR COLLEGE OF NURSING,
NO.5, BHOOPASANDRA
MAIN ROAD, RMV II STAGE, BANGALORE-94.
3 / COURSE OF THE STUDY AND SUBJECT / M.SC. NURSING, 1ST YEAR,
PEDIATRIC NURSING
4 / DATE OF ADMISSION / 01/06/2010
5 / TITLE OF THE TOPIC / “A STUDY TO ASSESS THE KNOWLEDGE AND PRACTICE REGARDING MANAGEMENT OF BIRTH ASPHYXIA AMONG THE STAFF NURSES WORKING IN NICU AT SELECTED HOSPITAL, BANGALORE”.
6. BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
“Children are on third of our population and all of our future”
All hospital personnel involved with delivery of newborn infant should be able to identify the infant in any assistance and quickly establish normal vital functions in babies who need help. Reversal of asphyxia, normalization of cardiac function and correction of shock are the major considerations in initial management of the compromised newborn in the delivery room. In today’s scenario birth asphyxia is one of the major problem and nurses working in neonatal intensive care units need to have adequate knowledge to manage neonatal emergencies1.
According to world health organization (WHO), birth Asphyxia as failure to initiate and sustain breathing immediately after birth. It is the third major cause of neonatal death after infections. Preterm births in developing countries accounts for an estimated 23% of the annual 4 million neonatal deaths. WHOestimates that 120 million infants born in every year develop birth asphyxia in developing countries and require resuscitation,an estimated 900,000 die each year. The risk of dying due to birth asphyxia varies countries to countries.Highneonatal mortality rate(NMR) have an estimated eight times higher risk than babies in low NMR settings. Based on a literature it is estimated that 24% - 61% ofprenatalmortality is attributed to asphyxia. The cause of specific prenatal mortality rate associated with asphyxia is generally between 10 and 20 per 1000 births.1 Prenatal asphyxia are terms that are used to describe the time period as which the baby suffered the asphyxia injury. Birth asphyxia generally refers to lack of oxygen close to the time of labour and delivery2.
New born babies may not breathe at birth due to many causes originating at different periods of the pregnancy. Birth asphyxia may primarily be due to complications occurring during the ante partum (50%) intrapartum (40%), and post partum (10%) periods. Therefore to reduce the incidence of birth asphyxia, interventions must be directed towards addressing the conditions that occur during each period when birth asphyxia occurs. Mothers of thenew born needs to recognize the importance of interventions that lead to the prevention of birth asphyxia. However, the primary focus of this issue is on the management of birth asphyxia that is new born resuscitation and not on prevention.3
The clinical manifestation of birth asphyxia is progressive hypoxia, hypercapnia, hypo perfusion and metabolic acidosis. According to National Neonatology forum of India has suggested that birth asphyxia should be diagnosed when the baby has gasping and inadequate breathing or no breathing at one minute. It corresponds to one minute Apgar score of 3 or less4.
Every health care personnel working in the delivery room should be able to prepare for resuscitation and able to practice. The components of neonatal resuscitation procedure are maintenance of temperature, establishment of an open airway, initiating of breathing, maintenance of circulation. If the infants has no spontaneous breathing then positive pressure ventilation(PPV) should be started with bag and mask followed by chest compression and endotracheal intubation. Nurses play a vital role in the neonatal resuscitation and preventing from complications5.
The preventive aspects of neonatal asphyxia are very important. Intensive antenatal care to detect risk factors and adequate interventions or referral and vital aspects of prevention. Intranatal assessment of fetal hypoxia and management of fetal distress should be done promptly. Special attention should be paid for avoidance of preterm delivery, care of preterm and low birth weight infant to prevent birth asphyxia. Nursing personnel should work in all levels of care to prevent this life- threatening condition6.
Although birth asphyxia can be predicted for certain conditions such as fetal distress and preterm child birth, most cases of birth asphyxia cannot be predicted. Therefore, every newborn should be considered as risk of asphyxia. Any infant can have neonatal asphyxia without warning signs during labour. Therefore allthe attendants must be competent in newborn resuscitation and must have the necessary equipment ready for the resuscitation of the newborn baby. Approximately resuscitation equipment is essential for optimal management of asphyxia; however, asphyxiated babies can be resuscitated without the use of equipment.7
A study was conducted to assess the incidence of birth asphyxia in the Canadian Institute of health information in Canada between 1991 and 2005. The study results shows that between 1991 and 2005, the incidence of birth asphyxia decreased significantly, from 43.8 to 2.4 cases per 1000 live births. The rate of decrease was highest between 1991 and 19988.
A study was conducted at the Prince Ali Ben Hussein Hospital, Jordan. The aim of the study was to determine the risk factor of birth asphyxia among 97 newborns infants who were admitted in the neonatal care unit of PrinceAliBenHusseinHospital. The study results shows that prematurity, IUGR, antepartum hemorrhage and maternal toxemia were associated with higher incidence of asphyxia9.
6.1 NEED FOR THE STUDY
Birth asphyxia is the fifth largest cause of neonatal death. Birth asphyxia accounts for an estimated 0.92 million neonatal deaths annually and is associated with another 1.1 million intrapartum stillbirths, as well as an unknown burden of long- term neurological disability. Perinatal asphyxia is an insult to the fetus or the newborn due to lack of oxygen (hypoxia) and /or a lack of perfusion (ischemia) to various organs. The common denominator of hypoxic ischemic injury is deprivation of the supply of oxygen to the centre nervous system. An oxygen deficit may be incurred by either hypoxemia or ischemia. Hypoxemia is defined as a diminished oxygen content of the blood and ischemia is characterized by reduced perfusion to a particular tissue; generally the two tend to occur simultaneously or in sequence. Asphyxia is an impairment of gas exchange that results not only in the deficit of oxygen in blood but also an excess of carbon dioxide causing acidosis. The acidosis further leads to hypotension and ischemia culminating in hypoxic-ischemic injury. The brain is especially vulnerable to damage by hypoxia and ischemia because it has one of the highest oxygen requirements and base line blood flow than any other organs in a term fetus10.
Birth asphyxia is a dangerous situation and if it is not managed correctly and promptly can be responsible for brain death, cardiac, lungs and kidneys failure and even death can occur. Neonatal intensive care unit (NICU) is a highly technical specialized unit in a hospital that provide medical/nursing care and technologies support to sick and high risk infants and premature even emergency like birth asphyxia. The common cause of neonatal mortality in each country are asphyxia, prematurity & low birth weight, infections like pneumonia and gastroenteritis and verity of surgical problems. Taking into consideration the factthat the neonatal intensive care unit (NICU) is more expensive that any health care system can provide.11
Nursing constitutes a major role among team members in caring the neonates, with growing demand for quality care, nurses need to be oriented to quality care concept. The nurses who work in NICU require a high level of knowledge about the physiological changes that occurs in newborn as well as keen assessment skills to detect subtle changes in the newborn. The nurses must be able to communicate effectively with family members and members of the entire interdisciplinary NICU team. This will enable quality care which increase likelihood of newborns survival and promote optimal quality care.12
A descriptive survey conducted on birth asphyxia status that programali, financial, knowledge and human responses are prevalent in a setting where birth asphyxia is more common. According to a research survey of health system, gaps and priorities birth asphyxia reflect cross cutting programmatic, financial, knowledge and human resources constraints in a setting where birth asphyxia is more common. More specific national goals to reduce neonatal mortality are necessary to meet Millennium Development Goal 4, and should focus attention, resources and principal causes of mortality such as birth asphyxia.13
Neonatal mortality and morbidity are increasing day by day. In India mortality rate is still high compared to developed countries. Birth asphyxia is the third largest cause of death after infections and preterm births. As birth asphyxia is one of the causes of neonatal death, many of the staff nurses are unaware or without much knowledge & skill in resuscitation of the asphyxiated babies14. Even though birth asphyxia is one of the leading causes of neonatal mortality, many of the nurses are announce, or unskilled inresuscitationof the asphyxiated babies14.
The management of birth asphyxia consists of supportive care to maintain temperature, perfusion, ventilation and a normal metabolic state including glucose, calcium and acid-base balance. Early detection by clinical and biochemical monitoring and prompt management of complications must be done to prevent extension of cerebral injury15.
In view of the above reasons the investigator is interested to take up this problem to assess the knowledge & practice regarding management of birth asphyxia among the staff nurses working in NICU in selected hospital atBangalore.
6.2 REVIEW OF LITERATURE
Review of literature is the key step in research process. The typical purpose for analysis or reviewing existing literature is to generate research questions to identify what is known and not known about a topic. The major goal of the review of the literature is to develop a strong knowledge base to carry out research and other non research scholarly activities.
According to Polite and Hungler a thorough literature review provides a foundations upon which to base a knowledge generally well conducted before any data are collected in any study.16
Review of literature for the present study has been organized under the following heading.
- Studies related to knowledge regarding birth asphyxia among staff nurses working in NICU.
- Studies related to practices regarding birth asphyxia among staff nurses working in NICU.
- Studies related to management of birth asphyxia among staff nurses working in NICU.
- Studies related to knowledge of birth asphyxia
A study was conducted to assess the knowledge and skill on identifying the asphyxiated baby among traditional birth attendants. The study reported that most of the traditional birth attendants are illiterate, poorly trained and giving more emphasis on safe home delivery rather than management at labor or care of the new born17.
A study was conducted by WHO to assess the knowledge related to resuscitation among traditional birth attendants. The study revealed that traditional birth attendants has inadequate knowledge regarding resuscitation of the newborn baby. The study reported that it is a challenging for traditional birth attendants to retain their competency and needs to train them and maintain close supervisors for a period of 3 months18.
A study was conducted to assess the causes of birth asphyxia among 208 most severely affected infants. The study revealed that most frequent causes of birth asphyxia and trauma were prolonged labour, midforceps or breech delivery in full-term infants and unattended precipitate deliveries in immature infants and maternal sedation in premature infants and unattended precipitate deliveries in immature infants. The study concluded that asphyxia following normal labour and delivery usually occurred in infants with fetal malnutrition. Improved obstetrical management with more frequent use of Cesarean section delivery might have been of value in preventing much of this fetal injury. Asphyxia due to complications of delivery were twice as frequent on the ward as on the private service. This may have been due in part to a lower Cesarean section rate on the ward service. A monthly review of birth asphyxia and trauma is recommended to help maintain a high standard of obstetrical practice19.
2. Studies related to practice of birth asphyxia
A study was conducted by WHO reveals that very few of the traditional resuscitation practices are beneficial.Someas harmful, slapping the newborn, soaking in cold water, stimulating the anus using onion juice, cooking the placenta, and milking the cord are a few examples of ineffective and harmful practices still in use. The harmful and/or infective resuscitation practices still observed in the community and one route performed by TABs as health facilities. Routine aspiration of upper airway is not beneficial if newborn start crying or breathing immediately after birth. Routine postural drainage, gastric suction, squeezing the chest, giving soda bicarbonate are some of the examples still follow by the TABs.20
As per the article of the Global Public Health until the twenty first century, newborn health was virtually absent from policies, programmes and research in developing countries. Almost one half of all births occurred at home often without skilled assistance, post natal services, new traditional practices. Such delayed breast feeding, contributed to high new born mortality rates, in their context with 99% of nearly form million newborn deaths occurring in developing countries. Mothers and newborns frequently went without life saving care, and newborn deaths remained relatively invisible and neglect21.
As per the daily newspaper – The Hindu –InformAndhra Pradesh - Birth asphyxia is reportedly high in the state, 93 percent neonatal emergency care are from rural areas where skilled birth attendants were not present and 78 deaths per 1000 neonatal, due to birth asphyxia and preterm birth.22
A report stated that a birth asphyxia in developing countries, the majority of childbirths occur more than 10 minutes from a health facility and without a skilled birth attendant, if no action is taken to resuscitate an asphyxiated baby who was delivered at home, that baby will most likely to die. When babies are delivered at home they are left naked and wet and put aside until after the placenta has been delivered, irrespective of whether the baby is breathing or not.23
3. Study related to management of birth asphyxia
A practical guide on basic newborn resuscitation by WHO state – Basic resuscitation will revive more than three quarters of newborns with birth asphyxia. It consist of three basic tasks: maintaining or covering body temperature control,cleaning airway and inflating the lungs with air, however first two tasks in the resuscitation process (i. e. Maintaining or covering body temperature control and cleaning the airway) done now a days and in most cases not requiring any resuscitation equipment. Babies can be kept warm by drying and wrapping and airways cleared by correctly positioning the baby’s head. At tertiary or secondary health facilities, other means (such as suctioning or insertion of endo-tracheal tube) can be used to maintain a clear airway, if necessary.24
An article published in periodical states an asphyxiated baby not resuscitated within 10 minutes will usually die or suffer severe brain damage. The effective method is stimulation by quickly drying and wrapping the baby may be all that is required to resuscitate an asphyxiated newborn. Teaching all birth attendants to immediately dry and wrap all babies including those who fail to initiate or sustain breathing and are not obviously, maceratedwill reduce neonatal deaths attributable to mild asphyxia, Another action that can stimulate breathing is gentle flicking (not smacking) of the babies feet. If these two tactile stimulation fail,the next task is to teach home birth attendants is to open or maintain the airway by positioning the head with the neck slightly extended and initiate mouth – to – mouth resuscitation(this was shown to reduce the Asphyxia Specific Mortality Rate (ASMR) by approximately 12% in India25.
A study was published in Journal, Health Research Policy System, States birth asphyxias causes 23% of neonatal deaths globally and treatment has been available only in facilities. A global review of the state of the art related to the prevention and management of birth asphyxia at the community level documented article gaps in knowledge, including evidence needed regarding how best to intervene, as well as the long term implications of improved birth asphyxia management.26
Research implication in Indonesia helped close this knowledge gap, and documented the feasibility and impact of training community midwives to recognize and manage babies who do not breath at birth using simple resuscitation device that bag and mask. In 2003 in Cirebon, Indonesia, some 45% of newborn deaths were caused by birth asphyxia, almost all occurring at home and in the absence of anyone skilled in resuscitation. To address their problem, “Save the Children” The programme for Appropriate Technology in Health (PATH) and the Ministry of Health designed a training course for “Bidans” (Community midwives) that included improved antenatal and delivery cases as well on a special focus on mastering the use of resuscitation devices. In a Pilot study 40 bidans were trained in the intervention package. The study demonstrated a 47% reduction in birth asphyxia related deaths, and also that the bidans’ knowledge and resuscitation skills were adequately maintained nine months after training. Based on the results of the pilot study the Bidan Training Package has been adapted and implemented in a number of district in Indonesia. It is being further developed and tested for incorporation into the Nation Bidan Programme27.