ABSTRACT
Pregnancy and delivery are supposed to be a safe process when well-managed, but a number of times it is complicated withmajor health risks one of which is postpartum haemorrhage (PPH). This study assessed nursing intervention on midwives’ knowledge and skills in the management of Postpartum Haemorrhage.
Pretest-posttest quasi-experimental research design was adopted. Total enumeration method was used in recruiting 68midwives in the two randomly selected secondary health facilities in Ondo State. 37 midwives in State Specialist Hospital Akure formed the experimental group while 31 midwives in State Specialist Hospital Ondo formed the control group. A developed questionnaire and rating scale were used to collect data. Face and content validity was determined and reliability was ascertained using spearman correlation statistical procedure which was calculated to be 0.91 and 0.83 respectively. Data obtained w analyzed using the statistical package for social sciences (SPSS), version 21. Descriptive analysis was used to provide answers to the six research questions while inferential statistics of student’s t-test was utilized to provide answers to the four hypotheses generated at 0.05 level of significance.
Mean knowledge score in the use of misoprostol increased from 8.89±2.57 to 14.73±2.30 post intervention, mean knowledge score in the use of NASG increased from 12.24±5.05 to 20.32±1.61, the application skills on NASG increased from 6.32±4.97to 17.14±0.95 post intervention in experimental group.Hypothesis result shows that there is no significant difference in the pre intervention knowledge of misoprostol and NASG use in the management of PPH in both groups (p=0.06), there is significant difference in the post intervention knowledge of misoprostol and NASG use in the management of PPH in the both groups (p=0.01), there is a significant difference in the pre and post intervention knowledge of misoprostol use in the management of PPH in the experimental group (p=0.01) and there is a significant difference in the pre and post intervention practice of NASG use in the management of PPH in the experimental group (p=0.01).
In conclusion, nursing intervention improved the skills of midwives in the use of misoprostol and NASG. It is recommended that midwives should be exposed to regular training and hands on practice on the use of misoprostol and NASG in the management of PPH.
Keywords: Knowledge, Nursing Intervention, postpartum haemorrhage, Non-pneumatic
Anti-shock garment, Misoprostol.
Word Count: 373
TABLE OF CONTENTS
Content Page
Title page i
Certification ii
Dedication iii
Acknowledgements iv
Abstract v
Table of Contents vi
List of Tables xi
List of Figures x
Appendices xi
Abbreviations xii
CHAPTER ONE: INTRODUCTION
1.1 Background to the Study 1
1.2 Statement of the Problem 3
1.3 Significance of the Study 4
1.4 Scope of the Study 4
1.5 Objective of the Study 4
1.6 Research Questions 5
1.7 Hypotheses 5
1.8 Operational Definition of Terms 6
CHAPTER TWO: REVIEW OF LITERATURE
2.0 Introduction 7
2.1 Concept of Postpartum Haemorrhage 7
2.2 Relationship between Postpartum Haemorrhage and Maternal Mortality 7
2.3 Classification of Postpartum Haemorrhage 8
2.3.1 Blood loss Quantification 8
2.3.1.1 Blood loss during and after Delivery 8
2.3.1.2 Hematocrit Changes 9
Content Page
2.3.1.3 Blood Loss Rate 9
2.3.1.4 Blood volume insufficiency 9
2.4 Etiology of Postpartum Haemorrhage 10
2.4.1 Atonic uterus 10
2.5 Pathophysiology of Postpartum Haemorrhage 12
2.6 Evidence based Measures for immediate Management of Postpartum
Haemorrhage 12
2.7 Non-Pneumatic Anti-shock Garment, strategy against Postpartum
Haemorrhage 13
2.8 History of Non-Pneumatic Anti-shock Garment 13
2.9 Mechanism of action of NASG 14
2.10 Application of NASG 14
2.10.1 Procedure of Application 14
2.10.2 Procedure for NASG Removal 15
2.10.3 Contra-indications to NASG 15
2.11 Benefits of the NASG 15
2.12 Empirical Studies 16
2.13 Evidence based report of NASG for Postpartum Haemorrhage in
University College Hospital, Ibadan, Nigeria 17
2.14 Misoprostol 18
2.15 Concept of Active Management of third Stage of Labour 19
2.16 Trends of Uterotonic drugs used in the Prevention of PPH 19
2.17 Reasons why Misoprostol is Preferred 20
2.18 Misoprostol and its Mode of Action 20
2.19 Benefits of Misoprostol over other conventional Uterotonic drugs in management of postpartum haemorrhage 21
2.20 Empirical Studies on Misoprostol 21
2.21 Expanding Midwives Skills 22
2.22 Theoretical Model 23
2.22.1 Bloom’s Model 23
Content Page
2.22.2 The Cognitive Domain 24
2.22.3 The Psychomotor Domain 25
2.23 Application of Model to the Study 25
2.24 Application of the Psychomotor Domain in the Application of NASG 26
2.25 Conceptual Model; source; adapted from bloom taxonomy (1956) 27
CHAPTER THREE: METHODOLOGY
3.0 Introduction 28
3.1 Research Design 28
3.2 Population 28
3.3 Sample size and sampling Technique 29
3.4 Instrument 30
3.5 Validity and Reliability of Instrument 30
3.6 Method of Data Collection 30
3.7 Method of Data Analysis 31
3.8 Ethical Consideration 32
CHAPTER FOUR: DATA ANALYSIS, RESULTS AND
DISCUSSION OF FINDINGS
4.0 Introduction 33
4.1 Data Analysis and Result Presentation 33
4.2 Discussion of Findings 43
CHAPTER FIVE: SUMMARY, CONCLUSION AND
RECOMMENDATIONS
5.1 Summary 52
5.2 Conclusion 53
5.3 Recommendations 54
5.4 Limitation of the study 54
5.5 Suggestion for Further Studies 54
REFERENCES 56
APPENDICES 62
LIST OF TABLES
Table Page
2.1 Showing Standardized Classification of PPH as described by Benedetti 10
4.1 Showing Frequency and Percentage on participant’s Socio Demographic data 33
4.2 Showing Pre and Post Intervention Knowledge level of Midwives on
Misoprostol use in the Management of PPH in Control and Experimental
groups 35
4.3 ShowingPre and post Intervention Knowledge level of Midwives in the use of
NASG in the Management of PPH in the Control and Experimental Groups 36
4.4 Showing Application of NASG by the Midwives in the Management of PPH Pre
and Post Intervention in the Control and Experimental group. 37
4.5 ShowingRemoval of NASG by the Midwives in the Management of PPH Pre
and post intervention in the Control and Experimental group. 38
4.6 Showing Inferential Statistics comparing mean scores of Post Intervention
Knowledge of Misoprostol and NASG in the Control and Experimental group 40
4.7 Showing Inferential Statistics comparing mean scores of Post Intervention
Knowledge of Misoprostol and NASG in the Control and Experimental group 41
4.8 Showing Inferential Statistics comparing Knowledge mean scores of Misoprostol
use in Experimental group Pre and Postintervention 42
4.9 Showing Inferential Statistics comparing Pre and Post Skills in the Application of
NASG 43
LIST OF FIGURES
Figure Page
1 Conceptual Model 27
- Research Design 28
APPENDICES
Appendix Page
Informed Consent Form 62
Questionnaire 63
Pathfinder Teaching Package 68
Pictures from the field work 73
ABBREVIATIONS
PPH Postpartum Haemorrhage
NASG Non Pneumatic Antishock Garment
BUHREC Health Research Ethics Committee
OSHREC Ondo State Health Research Ethics Committee
SPB Systolic Blood Pressure
UNFPA The United Nationsfund for population activities
POPPHI Prevention of postpartum haemorrhage initiative
AMTSL Active Management of Third Stage of Labour
CCT Control Cord Traction
ANC Antenatal Clinic
CHWs Community Health Workers
FMOH Federal Ministry of Health
NASA/AMES National Aeronautics and Space Administration/Ames Research Centre
PASG Pneumatic Anti Shock Garment
MDG Millennium Development Goals
FIGO International Federation of Gynaecology and Obstetrics
ICM International Confederation of Midwives
UNPD United Nation Population Division
MMR Maternal Mortality Ratio
UNPF United Nations Population Funds
HIV Human immunodeficiency virus
AIDS Acquired Immune Deficiency Syndrome
UNICEF United Nations Children’s Emergency Fund
CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
Pregnancy and delivery are supposed to be a safe process when well-managed, but a number of times it involves major health risks, even to women with no pre-existing health problem. Thousands of women die all over the world from issues directly associated with pregnancy, delivery and its complications (Maya, Buntugu, Lovelace, Emmanuel, & Srofenyoh, 2015). According to World Health Organization, (2012) Sub-Sahara Africa is responsible for approximately 60% of maternal deaths with total lifetime risk as high as 1 in 39 pregnancies when compared with 1 in 2900 in Europe. Although Postpartum haemorrhage affects about 4% of all pregnancies (Combs, Murphy, & Laros, 1991), making it the leading cause of maternal death all over the world.
Recent evidence from World Health Organization, (2008) estimated that postpartum haemorrhage of all etiologies accounts for 25% of the maternal deaths worldwide. However, statistics from the same organization showed disparity in the documentation of findings as record could reach as high as 40% in South East Asia, Latin America and some countries in Africa. Postpartum haemorrhage is responsible for about 50% of maternal mortality in Guatemala and Afghanistan (Miller & Martin, 2008). Every year, a total number of 529,000 women died due to complications of pregnancy and childbirth (Ojengbede, Morhason, Galadanti, Meyer, Nsima, & Gamin, 2010). Similarly, statistics has shown that 358,000 women lose their lives due to negative outcome of pregnancy and delivery (WHO,2010).
According to Adesokan (2010), PPH is excessive bleeding from the genital tract after the birth of a baby up to 6 weeks which is in excess of 500mls or any amount sufficient enough to cause cardiovascular collapse which is dangerous to the life of the woman. According to Reynders Sentennm, Tjalma and Jacquemyn, (2006) majority of these maternal deaths occur within the first four hours after birth. They occur as a result of either lack or poor management of the stage three of labour by skilled midwives and birth attendants, most pregnant women are liable postpartum haemorrhage. Therefore midwives need to possess the knowledge and skill in third stage management of labour, recognize asses, treat excessive blood loss and prevent postpartum haemorrhage.
Postpartum haemorrhage is a killer, and also one of the obstetric complications with established and effective intervention through the use of a low technology device referred to as Non-Pneumatic Anti-Shock Garment or life wrap. NASG is a device in form of a lower bottom suit of an articulated neoprene with Velcro parts which gives lower body circumferential counter pressure that supplies blood to the vital organs of the body, thus reversing hypovolemic shock and decreasing postpartum haemorrhage. Evidence suggests that this promising technology helps overcome further damage and plays a part in sophisticated modern care units by stabilizing women whilst waiting for definitive haemorrhage therapies such as blood transfusion and surgeries.
Uterine atony is the inability of the uterine muscle to effectively contract after delivery which can be managed with the use of appropriate of uterotonic drugs like misoprostol (International Confederation of Midwives and International Federation of Gynecology and Obstetrics, 2007). Misoprostol is a prostaglandin based drug that has aroused the interest of significant others as an effective uterotonic agent due to its ease of administration, safety profile, cost and ease of storage. Though, studies on use of misoprostol as auterotonic agent in management of postpartum haemorrhage have been conducted in many centres (El-Refaey & Templeton, 2006).
Besides, the Nursing and Midwifery Council of Nigeria in the recent past organized workshops and training on the use of NASG for midwives and nurses in Nigeria both in the clinical setting and academia to educate them on the availability and the use of the garment in the control of PPH. However, there is paucity of literature on the appropriate application of their skills on the use of NASG in the Secondary Health Care Facilities in Ondo State. Hence, this study seeks to assess the skills of midwives on the utilization of Anti Shock Garment and administration of misoprostol in the management of postpartum hemorrhage in selected Secondary Health Facilities in Ondo State, Nigeria.
1.2 Statement of the Problem
Postpartum haemorrhage (PPH) is rated among the five leading factors responsible for maternal mortality constituting about 25% of maternal deaths worldwide. Out of these maternal deaths, 99% occurred in developing which is an average of 290 deaths per 100,000 deliveries in contrast to 14 deaths per 100,000 live births in developed countries with uterine atony been responsible for 80-90% of haemorrhage (WHO, 2007).
Nigeria, as a country, constitutes the 4th largest country with highest maternal mortality rate worldwide (The World Bank & United Nations Population Division, 2014). The Millennium Development Goals (MDGs) performance track in Nigeria, 2015 also reported that maternal death rate was 350 per 100,000 deliveries as at 2013 which was still 40 % short of the 250 maternal deaths per 100,000 deliveries as projected for Nigeria in 2015 (Nigeria MDG 2013 Report, 2015)
Postpartum haemorrhage is one of the few obstetric complications with established and effective interventions to reduce maternal death. The midwife require skills in the use and application of non-pneumatic Anti-shock garment, the garment reverses the hypovolemic shock and requires knowledge in the use of misoprostol which is effective in managing post-partum haemorrhage. Despite the introduction of this evidence based and low cost first aid device into Nigeria in 2008, there has not been a significant reduction in maternal morbidity and mortality as both India and Nigeria is rated third worldwide with former at 19% (56,000), and later at 14% (40,000), (United Nations, Population Fund, WHO, UNCF and World Bank 2012), with postpartum haemorrhage still the leading cause of maternal mortality. Thus, Nigeria as a nation has the highest maternal mortality ratios (MMR) with national figure officially at 814 maternal deaths/100,000 live births (United Nations Population Division, 2014).
Evidence also suggests that Non pneumatic Anti shock garment and misoprostol are not been effectively utilized by midwives in the course of managing clients with postpartum haemorrhage in many health care center’s as investigated by Onasoga, Awhanaa, &Amiegheme, (2012), as maternal mortality indices are still very poor. Hence, this study seeks to assess the midwives skills in the application of Anti-shock garment as well as their knowledge and utilization of misoprostol as a measure of controlling postpartum haemorrhage in selected health facilities in Ondo State.
1.3 Significance of the Study
The findings of this study reveals the level of knowledge, utilization and if midwives have the skills in the application of Anti-shock garment and the use of misoprostol management of PPH, thereby reducing maternal morbidity and mortality. Furthermore, the available information would be made available in developing the curriculum for students in training midwives, policy makers and other health workers in planning strategies and intervention to improve midwifery practice as well as promoting the utilization of this low technology, evidence-based and low cost strategy to reduce maternal morbidity and mortality from postpartum haemorrhage. It would also provide data for further studies
- Scope of the Study
The researcher studied on nursing intervention on midwives’ skill in the management on postpartum haemorrhage. The study was limited to midwives working in the Labour and Postnatal ward of State Specialist Hospital Akure and Ondo, Ondo State, Nigeria.
- Objective of the Study
The main objective of the study is to determine the effects of nursing intervention on midwives skills in the management of postpartum haemorrhage in Ondo State, Nigeria.
The specific objectives are to:
- determine the pre intervention knowledge level of midwives on misoprostol in the management of PPH
- determine the pre intervention knowledge level of midwives on NASG in the management of PPH
- determine the effect of nursing intervention on midwives knowledge in the use of misoprostol in the management of PPH
- determine the effect of nursing intervention on knowledge of midwives in the use of NASG in the management of PPH
- determine the effect of nursing intervention in the application of NASG in the management of postpartum hemorrhage
- determine the effect of nursing intervention in the removal of NASG in the management of postpartum hemorrhage
- Research Questions
- What is the pre intervention knowledge level of midwives on misoprostol in the management of PPH?
- What is the pre intervention knowledge level of midwives on NASG in the management of PPH?
- What is the effect of nursing intervention on knowledge of midwives in the use of misoprostol in the management of PPH?
- What is the effect of nursing intervention on knowledge of midwives in the use of NASG in the management of PPH?
- What is the effect of nursing intervention in the application of NASG in the management of postpartum hemorrhage?
- What is the effect of nursing intervention in the removal of NASG in the management of postpartum hemorrhage?
- Hypotheses
H01: There is no significant difference in the pre intervention knowledge of misoprostol
and NASG in the management of PPH in the experimental group and the control
group.
H02: There is no difference in the post intervention knowledge of misoprostol and
NASG in the management of PPH in the experimental and control groups.
H03: There is no difference in the pre and post intervention knowledge of midwives in
the use of Misoprostol in the management of PPH.
H04: There is no difference in the pre and post intervention skills of midwives in the use
of NASG in the management of PPH in the experiment group.
- Operational Definition of Terms
- Knowledge: Ondo State midwives understanding of midwives on the use of misoprostol and anti-shock garment as measures of managing postpartum haemorrhage.
- Knowledge level of Misoprostol: A score of 0-6 on the misoprostol knowledge scale is regarded as low knowledge; 7-12 as moderate knowledge while 13-18 as high knowledge respectively. Total mark obtainable is 18.
- Knowledge level of NASG: A score of 0-7 on the Anti-shock knowledge scale is regarded as poor knowledge, 8-12 moderate knowledge and 13-22 as high knowledge. The total mark obtainable is 22
- Knowledge level of practice: A score of 0-13 on the Anti-shock practice of skill scale is regarded as poor knowledge, 14-25 moderate knowledge and 26-38 as high knowledge. The total mark obtainable is 38.
- Postpartum Haemorrhage: Is the loss of blood after delivery that is sufficient enough to cause cardiovascular collapse which is detriment to the life of a woman.
- Anti-Shock Garment: Is a form of lower bottom suit used in the management of postpartum haemorrhage.
- Midwives skills: Ability to use and administer misoprostol and anti-shock garment in the control of postpartum hemorrhage.
- Nursing Intervention: is the approach utilize by the researcher to give information on knowledge on use of Misoprostol and Anti-shock garment and demonstration on the use Anti-shock garment.
- Management of postpartum haemorrhage: the use of Misoprostol and NASG in the control postpartum haemorrhage.
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