RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE,

KARNATAKA

SYNOPSIS PROFORMA FOR

REGISTRATION OF SUBJECTS FOR
DISSERTATION

“A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED

TEACHING PROGRAMME REGARDING THE KNOWLEDGE ON
OBSTETRICS EMERGENCIES AMONG DIPLOMA NURSING
INTERNSHIP STUDENTS OF SELECTED NURSING SCHOOLS AT
TUMKUR”

SUBMITTED BY:
ARLINE BESHRA
1STYEAR, M.Sc. NURSING
(OBSTETRICSAND
GYNAECOLOGICAL NURSING)
SRI RAMANA MAHARSHI
COLLEGE OF NURSING,
TUMKUR - 06
2008-2009
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE,
KARNATAKA
SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. NAME OF THE CANDIDATE AND ARLINE BESHRA
ADDRESS 1ST YEAR M.Sc, NURSING
SRI RAMANA MAHARSHI
COLLEGE OF NURSING,
SIRA ROAD, TUMKUR.
2. NAME OF THE INSTITUTION SRI RAMANA MAHARSHI
COLLEGE OF NURSING
3. COURSE OF STUDY AND SUBJECT 1ST YEAR M.Sc, NURSING
OBSTETRICS AND
GYNAECOLOGICAL NURSING
4. DATE OF ADMISSION TO COURSE 30/06/2008
5. TITLE OF THE STUDY “A STUDY TO ASSESS THE
EFFECTIVENESS OF
STRUCTURED TEACHING
PROGRAMME REGARDING
THE KNOWLEDGE ON
OBSTETRICS EMERGENCIES
AMONG DIPLOMA NURSING
INTERNSHIP STUDENTS OF
SELECTED NURSING
SCHOOL AT TUMKUR”
6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION:

Maternal death is a tragedy for individual women, for families and for their

Communities. World wide nearly 600,000 women between the age of 15 and 49 die every

Year, due to complications arising from pregnancy and childbirth. THIS MEANS ALMOST

EVERY MINUTE OF EVERY YEAR, THERE IS A MATERNAL DEATH. 99% of which

occur in the developing countries. Majority (80%) of these deaths are preventable. Expert

from WHO, UNICEF, World Bank, the population council and other National and

International agencies concerned with SAFE MOTHERHOOD concluded that it is possible

to reduce maternal mortality significantly with limited investment and effective policy

Intervention. Therefore, it is considered that maternal death is reflection of “Social

Disadvantage” not merely a “health disadvantage”. ¹

Most complications of pregnancy allow time for transfer to specialized obstetric units,
but a few women present as emergencies where successful outcome depends on prompt
recognition of the problem and rapid stabilizing management. It is not uncommon for staff
with no formal obstetric training to be facing these situations in the Accident & Emergency or
general practice setting.

The obstetric emergencies can divided into two groups.

1. ANTEPERTUM OBSTETRIC EMERGENCIES like Pre Eclampsia and Eelampsia,

Antepartum haemorrhage, Diabetic coma, Motor vehicle accidents etc.

2. INTRAPARTUM OBSTETRIC EMERGENCIES like undiagnosed twin,

undiagnosed breech, cord prolapse, uterine rupture, shoulder dystocia etc.
6.1. NEED FOR THE STUDY

The health of women represents the health status of any country. Women’s health
assumes importance because her status directly affects children’s health.
More women die in India during childbirth than anywhere else in the world. About
5.36 lakh women who died during pregnancy or after childbirth in 2005 globally, India
accounted for 1.17 lakh.

This was followed by Nigeria (59,000), Congo (32,000) and Afghanistan (26,000).
India along with other countries accounted for almost 65% of global maternal deaths in 2005.
This maternal mortality ratio (MMR) in India 450 death per 100,000 live births. In
comparison, Congo had an MMR of 740, Nigeria 1,1000 and Afghanistan 1,800 per 100,000
births. India’s neighbors are better off.

Worldwide, toxemia accounts for approximate 10% of maternal death (Duely 1992) or
5000 maternal death per year. Toxemia will occur 6% of first and 2% of subsequent
pregnancies. APH occurs in 3 percent of all pregnancies. Vasa Previa occurs in less than 0.2
percent of pregnancies. Shoulder Dytocia occur between 0.37 – 1.1 (Bahar, 1996).

Many experts have produced encourage truth regarding causes, prevention and
treatment of obstetrics emergencies. But in spite of their immense work, it shows that the
unexperience nurses need more skill and knowledge to handle obstetric emergencies
promptly. Hence the investigator is determined to assess the knowledge of 4 th year B.Sc.
nursing students regarding obstetric emergencies.
6.2 REVIEW OF LITERATURE

CROFTS JF et al, (2007) conducted a study at Brsiton, UK. To explore the effect of
obstetric emergency training on knowledge. Further more to assess if acquisition of
knowledge is influence by training setting or teamwork training. A total 140 participants
(22 Junior and 23 senior doctors, 47 Junior and 48 senior midwives) were studied.
Participants were randomized to one to four obstetric emergency training interventions 1)
1 day course at local hospital 2) 1 day course at simulation centre. 3) 2 – day teamwork
training at local hospital 4) 2 day course with teamwork at simulation centre. Changes in
knowledge was assessed by a 185 question Multiple – choice questionnaire completed
upto 3 weeks before and 3 weeks after the training intervention. The study showed there
was a significant increase in knowledge following training: mean MCQ score increased
by 20.6 points. Overall, participants increased their MCQ score. ²

BAILEY P et al (2006) conducted a research at USA on the availability of life-

saving obstetric services in developing countries: an in-depth look at the signal functions
for emergency obstetric care. The basic signal functions include parenteral antibiotics,
anticonvulsants and oxytocics, and the procedures of manual removal of the placenta,
removal of retained uterine products, and assisted vaginal delivery. Comprehensive
functions include the six basic functions, cesarean delivery and blood transfusion. Data
collected from 1906 health facilities in 13 countries indicate that the most likely functions
tobe reported are antibiotics and oxytocics. The basic function least likely to be reported
is assisted vaginal delivery. Many of the facilities surveyed did not have the infrastructure
to perform operation or provides blood transfusion. ³

SAIZONOU J et al (2006) conducted study on, to evaluate emergency obstetric

care and the perceptions and expectations of women who experienced “near miss” events
to improve maternal health in Benin. Qualitative survey done in seven hospitals at the
three-referral levels of the health pyramids from July to October 2003. They used two
methods: 557 women near miss events were interviewed in hospital and a standard
questionnaire completed; then semi- structured individual interviews were conducted at
home with 42 of these 557 women. The study showed provided care, accommodation,
 facilities, costs and modalities of recovery, hygiene of the premises, dynamism, expertise,
social support, behaviors and attitude of staff were the criteria used to express patients’
satisfaction. Most women interviewed in hospital happy with physical access,
organization, functioning and environment. However excessive costs and coercive
recovery of the expenses, failure of the referral system, lack of empathy and
discrimination of the nursing staff, lack of resources for emergencies, lack of hygiene and
comfort of the premises were criticized by the women interviewed at home. 4

ONAH HE et al (2005) conducted a study on, in order to assess the current level of
maternal mortality in health institutions with comprehensive emergency obstetric care in
Enugu state, south Easter, Nigeria, a retrospective analysis of maternal deaths for the year
1999-2003 was carried out to establish the maternal mortality ratios in the eligible health
institutions. Each maternal death was studied in detail to establish the socio-demographic
characteristics of the women who died; their referral sources, type of delay (If any), medical
causes of death and their preventability. In depth interviews of the service provides were
carried out to throw more light on the maternal mortality situation in the state. Five out of
seven eligible health institutions were studied. Within five-year period (1999-2003) there
were 141 maternal deaths and 18,257 live births giving a maternal mortality ratio of 772
maternal deaths per 100,000. The folders of 89 out of 141 women who died were retrieved.
Of these 89 maternal deaths, 51.7% of them were unemployed, 52.4% were referred from
private hospital’s; type 3 delay was the commonest type of delay encountered in the care of
the women. It also showed some discrepancies between reality and the health provider
perception of the magnitude of maternal mortality situation in the state. Maternal mortality
remains high due to type 3 delays. Most of the reference comes from private hospitals, hence
the need to retain the private practitioner in emergency obstetric care. 5
 Filippi V, et al (2005) conducted study on, to examines near – miss obstetric events in
African hospital as to the frequency, nature, and ratio of near miss to death and considers
whether these could become useful indications for monitoring the performance of obstetric
services in Africa. Prospective or the retrospective reviews of the medical records were
conducted in nine referral hospitals in three countries (Benin, Cote d’Ivoire, & Morocco).
They calculated the incidence of near miss, obstetric events, near miss cases and maternal
deaths related to hemorrhage, hypertensive disease of pregnancy, dystocia, infections and
anemia and analyzed these according to hospital and timing relative to admission. In this
study they found that the incidence of near – miss cases was varied, and some hospitals
extremely large; from 1% to almost a quarter of all deliveries were near misses. Near – miss
cases were 15 times more common than deaths. The most frequent types of NMEs were
hemorrhage and hypertensive diseases of pregnancy, but anemia was the leading cause in
three first referred level hospital in Benin and cote d’Ivoire. Near miss events due to
infections were rare. 6
BOYLE JJ (2005) conducted a study on, to assess the incidence risk factors and
outcomes of umbilical cord prolapse in current obstetrics practice. The study was a
retrospective chart review at both a community hospital and a tertiary referral center. Study
shows there were 52 cases of cord prolapse in patient population. Of viable singleton
pregnancies with frank prolapse. The rate was 1.6/1000. In this series they found an
approximately 40% higher rate of frank cord prolapse in induced patients at the community
hospital than in general population. Other than 2 fetal deaths related to extreme prematurity,
all mother and infant did well. 7
Mc CORD C et al (2001) conducted a study on efficient and effective emergency
obstetric care in a rural Indian community where most deliveries are at home. The study was
conducted in a part of rural Maharastha. India. 2905 pregnancies were identified and
followed to term to learn the number and types of complications, where these complications
treated, how many women received Emoc and how these services affected outcome, The
outcome or the study was 85%of 2861 deliveries after 24 weeks were at home. A total of
14.4%of deliveries, 78.9% were in a hospital, 48% of hospital deliveries were in a private
hospital, 35% in project hospital and 18% in the government hospital, total obstetric
complication hospitalized was 11.4%. Overall case fatality was 0.5%. However there were
only two maternal deaths from obstetric complication. These outcome and process indicators
are better than those reported in most of India, but both maternal deaths can be prevented by
early referral to hospital. 8

Gilbert WM, Danielsen B (1999) conducted a study on to examine the risk factors
and pregnancy outcome associated with 53 cased of amniotic fluid embolism that occurred in
California during the 2 year period January 1, 1994 to December 31 st, 1995. Data were
obtained from a computerized database that contains linked records from the vital statistics
birth certificate and hospital discharge summaries of both mother and newborn. The study
shows that there were 1,094,248 deliveries during that 2-year period. 53-singleton gestation
had the diagnosis of amniotic fluid embolism, for a population frequency of one per 20,646
deliveries. 14 women with amniotic fluid embolism died, for a maternal mortality rate of
26.4%. There were 35 diagnosed of disseminated intravascular coagulation (DIC), 38
diagnosis of hemorrhage, and 25 diagnoses of obstetric shock. Among 14 women who died,
the frequency of DIC and hemorrhage was not different compared with that of then survivors.
The average maternal length of stay for survivors was 6.5days. 9

ZIADEH SM et al (1996) conducted a research on, to determine the etiological factors of

uterine rupture during labor, and propose preventive measures in north Jordan. This
retrospective study was performed between February 1989 and July 1994, to analyze the
cases of rupture uterus in relation of causes, age, parity, maternal and fetal mortality and
morbidity. The study shows there were 37 cases of uterine rupture at institutions. Obstructed
labor by malpresentation and disproportion was the main cause. The presence of previous
caesarean section scar, dysfunctional labor, injudicious use of uterine stimulant, were the
other causes. There was no maternal death and fetal loss was 17 (46%). 10

STATEMENT OF THE PROBLEM

“A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED
TEACHING PROGRAMME REGARDING THE KNOWLEDGE ON
OBSTETRICS EMERGENCIES AMONG DIPLOMA NURSING
INTERNSHIP STUDENTS OF SELECTED NURSING SCHOOLS AT
TUMKUR”

6.3 OBJETIVES OF THE STUDY

1. To assess the knowledge of diploma nursing internship students regarding obstetric
emergencies before administering the structured teaching program in the selected schools of
nursing.
2. To develop structured teaching program on obstetric emergencies among diploma nursing

internship students of selected nursing schools at Tumkur.

3. To assess the effectiveness of structured teaching program on obstetric emergencies
among diploma nursing internship students of selected nursing schools at Tumkur.
4. To associate the pre and post Score regarding obstetric emergencies among diploma
nursing internship students of selected nursing schools at Tumkur.

6.4 OPERATIONAL DEFINITION

ASSESSMENT – It refers to the organized systematic variables process of collecting
information about pre test and post test knowledge from diploma nursing internship

students regarding obstetric emergencies.

EFFECTIVENESS-
It refers to the extent to which the structured teaching programme on obstetric emergencies
achieves desired effect in improving the knowledge of diploma nursing internship students
as evident from gain in knowledge scores.

STRUCTURED TEACHING PROGRAMME-

It refers to the systematically developed institution method and teaching aids designed for
diploma nursing internship students to provide information on obstetric emergencies.

KNOWLEDGE- It refers to correct responses of the diploma nursing internship

students to knowledge items on obstetric emergencies as achieves by knowledge scores.
DIPLOMA NURSING INTERSHIP STUDENT - In this study it refers to all
diploma nursing students who already appeared final year examination on obstetrics and
gynecological nursing and are gained practical experience in the field.

OBSTETRICS EMERGENCIES A serious situation/occurance that happens

unexpectedly and demands immediate action during pregnancy.

6.5 RESEARCH HYPOTHESIS

There will be significant difference between pre and post test knowledge scores of diploma
nursing internship students regarding obstetrics emergencies.

6.6 ASSUMPTIONS
1. Students may not have adequate knowledge regarding obstetrics emergencies.
2. Structured teaching program will provide knowledge to diploma nursing internship
students regarding obstetrics emergencies.
3. Enhancement of knowledge regarding obstetric emergencies may prone a way for handling
obstetric emergencies promptly.

6.7 DELIMITATIONS
1) The study will be limited to diploma nursing internship students.

2) Sample size will be limited to 60 diploma nursing internship students.

6.8 PILOT STUDY

The pilot study will be conducted with 6 samples. The purpose of pilot study is to find out
the feasibility to conducting study and design on plan out statistical analysis.

6.9 VARIABLES

 INDEPENDENT VARIABLE - Structured Teaching Programmed.

 DEPENDENT VARIABLE - Knowledge on obstetric emergencies among
diploma nursing internship students at selected nursing
schools at Tumkur.

7. MATERIAL AND METHOD OF STUDY(METHODOLOGY)

The study is designed to determine the effectiveness of structured teaching program
on obstetrics emergencies among diploma nursing internship students of selected Nursing
schools in Tumkur.

7.1. SOURCES OF DATA

Data will be collected from diploma nursing internship students in selected Nursing
schools in Tumkur.

7.1.1 RESEARCH DESIGN

One group pre – test and post - test (quasi experimental design)
.

7.1.2 STUDY SETTING

The study will be conducted at selected Nursing schools in Tumkur.

7.1.3 POPULATIONS
The population of the study will be the diploma nursing internship Students who are
studying in selected Nursing schools in Tumkur.

7.2 METHOD OF DATA COLLECTION

 Self-structured questionnaire and structured teaching program on obstetrics
emergencies will be prepared by the investigator.

7.2.1 SAMPLING PROCEDURE

The sample of students will be selected through simple random sampling technique.

7.2.2 SAMPLE SIZE

The sample size of this study will be 60 diploma nursing internship students.

CRITERIA FOR SAMPLE SELECTION

7.2.3 INCLUSION CRITERIA

1. Students who are willing to participate in the study.
2. Students who are doing their internship after appearing diploma nursing final year exam.

7.2.4 EXCLUSION CRITERIA

1. Students who are not willing to participate
2. Students who are not appeared diploma nursing final year exam.

7.2.5 INSTRUMENT (TOOLS)

Self-structured questionnaire, which will be developed by the investigator this, consists of
two parts as follows.
1. Part I: - Demographical data
2. Part II: - Items of knowledge on obstetrics emergencies.

PROCEDURE FOR DATA COLLECTION:

 The data will be collected with the prescribed time period in selected nursing schools
will be taken for study.

The objective of a study will be explained to the head of the institutions before
starting data collection.

7.2.6 DATA ANALYSIS

The investigator will use descriptive inferential statistics.

DESCRIPTIVE STATISTICS – mean, standard deviation of described demographic

variable.
INFERENTIAL STATISTICS – Paired “t” test compare pre and post test knowledge scores.
Chi-square test will be used to find out the association between selected variable with
knowledge scores.

7.2.7 TIME & DURATION OF THE STUDY

The time and duration of study will be as per research committee.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OF

INTERVENTION TO BE CONDUCTED ON PATTEN OF OTHER
HUMAN OR ANIMALS?

Yes, structured teaching programme will be administered for the diploma nursing
internship students.
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR
INSTITUTION IN CASE OF 7.3?
Yes, ethical clearance has been obtained from the institution.

7.5 HAS THE CONSENT TAKEN FROM THE NURSING SCHOOLS TAKEN FROM
THE AUTHORITIES
Yes.

8. LIST OF REFERENCE

1. DC Dutta, Textbook of obstetrics 6th Ed Calcutta (India): new central book agency (P) Ltd;
2004: p-599.
2. Crofts JF, Ellis D, Draycott TJ, Winter C, Hunt LP, Akande VA. “Change in knowledge of
widwives and obstetricians following obstetric emergency training: a randomised controlled
trial of local hospital, stimulation centre and teamwork training”. 2007 Dec; 114(12): 1534-
41.
3. Bailey P, Paxton A, Lobis S, Fry D. “The availability of life-saving obstetric services in
developing countries: an in depth look at the signal functions for emergency obstetric care”.
International Journal of Gynaecology obstetric 2006Jun; 93(3): 285-91.
4. Saizonou J, Godin I, Quendo EM, Zerbo R, Dujardin B. “Emergency obstetrical care in
Benin referral hospitals: “Near-Miss” Patient’s views”. 2006May; 11(5): 672-82.
5. Onah HE, Okaro JM, Umeh U, Chigbu Co. “Maternal Mortality in health institutions with
emergency obstetric care facilities in Enugu State, Nigeria”. Journal obstet Gynaecol 2005
Aug; 25(6): 569-74.
6. Fillippi V, Ronsmans C, Gohou V, Goufodji S, Lardi M, Sahel A etal. “Maternity wards or
obstetric rooms Incidence of “near-miss” events in African hospital”. Acta obstect gynecol
scand 2005 Jan; 84(1):11-6.
7. Boyle JJ, Katz VL. “Umbilical cords prolapse in current obstetric practice”. 2005 May;
50(5): 303-6.
8. Mc cord C, Premkumar R, Arole S, Arole R. “Efficient and effective emergency obstetric
care in a rural India community where most deliveries are at home”. International Journal of
Gynaecol obstet 2001 Dec; 75(3): 297 – 307.
9. Gilbert WM, Danielsen B. “Amniotic fluid embolism: decreased mortality in a population
based study”. 1999 Jun; 93(6): 973 – 7.
10.Ziadeh Sm, Zakaria MR, Sunna EI. “Obstetric Uterine rupture in North Jordan”. Journal
obstet Gynalecol Res 1996 Jun; 22(3): 209-13.
10. Boyle JJ, Katz VL. “Umbilical cords prolapse in current obstetric practice”. 2005 May;
50(5): 303-6.
9. Signature of the candidate

10. Remarks of the guide May be approved

11. Name and designation of:

11.1 Guide Mrs.Shenbagavalli.S

11.2 Signature

11.3 Co-guide

11.4 Signature

11.5 HOD

11.6 Signature

12.1 Remarks of the principles

12.2 Signature