SCHOOL OF NURSING SCIENCE AND RESEARCH

“A study to assess the knowledge and

practice of active management of 3rd
stage of labour with the help of osce
among final year B.Sc. Nursing
students in snsr Sharda University,
Greater Noida UP”

RESEARCH SYNOPSIS

Name of Students: Name of Guide:

Bhawna Joshi Ms. Shilpy Mittal

Msc. Nursing’ 1styr HOD $ Assistant Professor

SNSR Obstetrical and Gynaecological

Nursing
 SCHOOL OF NURSING SCIENCE AND RESEARCH

SHARDA UNIVERSITY, GREATER NOIDA

1. Name of the Candidate Bhawna joshi

2. Name of the institution School of Nursing Science and Research, Sharda

University

3. Address of the institution Sharda University, Plot No. 32,34, Knowledge Park lll ,
Greater Noida, UP- 201306

4. Course of the study and the M.Sc. Nursing 1st year

subject
Obstetrical and Gynaecological Nursing

5. Name of the department Obstetrical and Gynaecological Nursing

6. Title of the study “A study to assess the knowledge and practice of

active management of 3rd stage of labour with the
help of osce among final year B.Sc. Nursing
students in snsr Sharda University, Greater Noida
UP.”

7. Signature of the candidate

8. Remarks of the guide

9 Name and designation of guide Ms. Shilpy Mittal

HOD $ Assistant Professor
SNSR

10 Signature of guide
.
11 Name and designation of Co-
. guide

12. Signature of co-guide

13. Head of the department

14. Signature

15. Remarks of the research

coordinator

16. Signature

17. Principal Prof.Pauline Sharmila

( Principal SNSR)

18. Signature of principal

 INSTITUTIONAL ETHICS COMMITTEE (IEC)
School of Nursing Science & Research
Sharda University____________________

1. Title of the Research Project A study to assess the knowledge

and practice of active
management of 3rd stage of
labour among Students
2. Name, designation and Address of the Principal Investigator Bhawna Joshi
Msc Nursing 1st yr SNSR
3. Name, designation and Address of the Supervisor Ms. Shilpy Mittal
HOD $ Assistant Professor

4. Name and Designation of the Co-Supervisor(s) NIL

5. Name of the Department(s) where research is proposed to be School of nursing science and
carried out research
6. Name of the Department(s) that would collaborate in the
project
7. Name of outside institution(s) that would collaborate in the Selected colleges of nursing in
project Greater Noida UP
8. In case the study is multi-centric, give details of all other NIL
centers, investigators etc.
9. Name and address of agency proposed to fund the project and NIL
whether any such grant is already available
10. Duration of the proposed study with phasing and limitations,
if any
11. Brief description of work to be undertaken:

Aim A study to assess the knowledge

and practice of active
management of 3rd stage of
labour among Students
Objectives To observe the effects of active
management of 3rd stage of
labour with oxytocin.

True experimental research

Methodology design
Study Design
 Location/Setting Bsc nursing students of SNSR
Study Duration

Study population
Sample Size

Inclusion Criteria Will be calculated after pilot

study

Exclusion Criteria Students who are willing to

participate

Method Students who have attended a

prior workshop or training

Statistical analysis Descriptive and inferential

statistics

12. Anticipated risks involved in the implementation of the NIL

project and remedies suggested (Give full Details)
RISKS
 Procedural
 Adverse drug reaction due to investigational drug
treatment
 Invasive investigation
 Any other risk
Explain measures to counter/compensate the above risks
13. Are the necessary facilities available in the department where NIL
the research is proposed to be carried out? If so, give details
thereof.
Will patient/subject be sent to other places?
Give reasons thereof.
(Letter of permission/willingness to cooperate from other
department(s)/institution(s)
14. Details of facilities which are not available in the department NIL
and are proposed to be sought from other department.
(Letter of permission/willingness to cooperate from other
department(s)
15. Details of facilities which are not available in the NIL
SMS&R/Sharda Hospital and are proposed to be sought from
other institution(s).
(Letter of permission/willingness to cooperate from other
institution(s)
16. Details of any fees/honorarium payable to NIL
investigators/collaborators/patient/others, if any
17. A) Well-Informed Consent is necessary from the participating
 subject. A copy of the proposed Informed Consent Form in
English and Hindi be enclosed.
Informed Consent Form
 Does it have the name of the institution at the top
 Does it also have the name, address and telephone No.
of the Guide/Investigator etc.

B) Patient Information Sheet informing patient about

 Freedom of individual to withdraw from research.
 Publication, if any including photographs and
pedigree chart
 Duration of participation in study
 Benefit to the subject, that may be expected as an
outcome of research.
 Alternative procedure or treatment if available
 His/Her right to prevent use of his/her biological
sample(s) at any time during the conduct of research
 Foreseeable discomfort or risk to the subject
 Extent to which confidentiality of record could be
maintained
 Responsibility of Investigator
 Provision of compensation for risk

C) Case Record Form

18. Whether clearance has been obtained from any other agency NIL
related to the proposed project, if so details thereof.
19. Whether clearance is necessary from any other agency? If so, NIL
details therof
20. Is there any provision to compensate the NIL
investigators/participants in case of a mishap? If so, details
thereof.
21. In case, the project is sponsored by a private agency, NIL
particularly a multinational agency having a business interest
in India, whether prior approval of the competent authority
has been obtained?
22. Full justification of the Project keeping in view the policies NIL
and programmes of the Government including details of
current knowledge on the subject and therein.
23. Has the project been sent to any other Institution /Body for NIL
Ethical Clearance? If yes, give details.
24. Whether there is any conflict of interest involved. If so, NIL
specify
25. Any other information which may be useful for consideration NIL
of the project by the IEC
 SUBJECT INFORMATION SHEET

Protocol title: “A study to assess the knowledge and practice of active management of 3 rd stage
of labour with the help of osce among final year B.Sc. Nursing students in snsr Sharda
University, Greater Noida UP”.

Principal investigator: Bhawna Joshi

Designation I year M.Sc. Nursing Student
School Of Nursing Science And Research
Contact number—9756665405.
Please read this form carefully. If you don’t understand the language or any information in this
document, please discuss with investigator. If you decide to volunteer on behalf of your client to
take part in this study, you must sign the end of this form.

Introduction to the research study:

You are being asked to take part in this study because I am to assess the knowledge and practice
of active management of 3rd stage of labour with the help of osce among final year B.Sc. Nursing
students in snsr , Sharda University, Greater Noida UP
Purpose of the study:
The purpose of the study is to find the knowledge and practice on active management of
third stage of labour among nursing students.

Who can take part?

Students of nursing colleges who are willing to participate in the study and who falls in the
inclusion criteria.

What will happen during the study?

The researcher will visit the bsc.nursing 4th year class in SNSR ,Sharda university to gather the
data regarding the knowledge and practice of nursing students regarding neonatal basic life
support and will divide the sample in experimental and control group and pre test will be taken
for both the groups and practice teaching will be done for the experimental students only. After
the practice teaching is provided a post test wil be taken for both the groups and the results will
be analyzed.

Your role/ responsibility in the study:

 Provide accurate information whenever asked.
 Must inform the investigator about any difficulties to participate in the study.
 Follow the investigator instruction.
 If you want to discontinue from the study, investigator to be informed

What are the risks?

No risk associated with this study.

What are the potential benefits of participating in the study?

This study helps to the participants to gain knowledge regarding the active management of 3 rd
stage of labour and it will help them in gaining better knowledge and skills which will enable
them to perform better in near future .

Cost of participation in the study:

The procedures required by the study are provided at no cost to you.

Compensation for injury:

No risk for injuries.

Confidentiality of information:
Information from the study including your name, demographic proforma, results of the study will
be reviewed only by the authorized personnel who are involved in the study, ethics committee or
regulatory bodies. Information and results from this study may be represented at meetings or
published in journals without including your name and personal identification.

New information about the study:

Any new information available during the course of the study will be informed to you if it has
relevance to your decision regarding continuing in the study.

Voluntary participation:
Entering research study is voluntary. If you volunteer for a research study, you have the right to
withdraw at any time and you need not give any reason for the same.Your decision not to
participate in the study will not affect your future. The investigator may stop the research or your
participation in it at any time for some or other reason without your permission.

Whom to contact in case of questions:

If you have any questions about this form or any study related issue, you may contact the
following person.

Name: Ms. Shilpy Mittal

HOD $ Assistant Professor
School Of Nursing Science And Research

विषय सूचना पत्र

प्रोटोकॉल शीर्षक : स्कू ल ऑफ नर्सिंग साइंस एंड रिसर्च

, ग्रेटर नोएडा, यू.पी. के छात्रों के बीच प्रसव की तीसरी अवस्था का सैक्रिय प्रबन्ध का आकलन करने के लिए एक अध्ययन। "

प्रधान अन्वेषक: भावना जोशी

पदनाम I वर्ष M.Sc. प ििरचारीका िवद - याथीृ

स्कू ल ऑफ नर्सिंग साइंस एंड रिसर्च

संपर्क नंबर- 9756665405

कृ पया इस फॉर्म को ध्यान से पढ़ें। यदि आप इस दस्तावेज़ में भाषा या किसी भी जानकारी को नहीं समझते हैं, तो कृ पया

जांचकर्ता के साथ चर्चा करें। यदि आप इस अध्ययन में भाग लेने के लिए अपने रोगी की ओर से स्वेच्छा से निर्णय लेते हैं, तो

आपको इस फॉर्म के अंत पर हस्ताक्षर करना होगा।

शोध अध्ययन का परिचय:

आपको इस अध्ययन में भाग लेने के लिए कहा जा रहा है क्योंकि मैं स्कू ल ऑफ नर्सिंग साइंस एंड रिसर्च, ग्रेटर नोएडा, यू.पी. के

छात्रों के बीच प्रसव की तीसरी अवस्था का सैक्रिय प्रबन्ध का आकलन करने के लिए हूं।

अध्ययन का उद्देश्य:

 अध्ययन का उद्देश्य स्कू ल ऑफ नर्सिंग साइंस एंड रिसर्च, ग्रेटर नोएडा, यू.पी. के छात्रों के बीच प्रसव की तीसरी अवस्था का सैक्रिय प्रबन्ध

बताना है। ”
कौन भाग ले सकता है?

बीएससी नर्सिंग चतुर्थ वर्ष के छात्र छात्राएं

अध्ययन के दौरान क्या होगा?

शोधकर्ता स्कू ल ऑफ नर्सिंग साइंस एंड रिसर्च, ग्रेटर नोएडा, यू.पी का दौरा करेंगे और प्रसव की तीसरी अवस्था का सैक्रिय प्रबन्ध के बारे में

नर्सिंग छात्रों के ज्ञान और अभ्यास के बारे में आंकड़े एकत्र करेंगे और नमूना को प्रयोगात्मक और नियंत्रण समूह में विभाजित करेंगे

और दोनों समूहों और अभ्यास शिक्षण के लिए प्री टेस्ट लिया जाएगा। के वल प्रयोगात्मक छात्रों के लिए। अभ्यास शिक्षण प्रदान किए जाने

के बाद दोनों समूहों के लिए पोस्ट टेस्ट वाइल लिया जाएगा और परिणामों का विश्लेषण किया जाएगा।

अध्ययन में आपकी भूमिका / जिम्मेदारी:

• जब भी पूछा जाए सटीक जानकारी दें।

• अध्ययन में भाग लेने के लिए किसी भी कठिनाइयों के बारे में अन्वेषक को सूचित करना चाहिए।

• अन्वेषक अनुदेश का पालन करें।

• यदि आप अध्ययन से विरत रहना चाहते हैं, तो अन्वेषक को सूचित किया उसके खतरे क्या हैं?

इस अध्ययन से जुड़ा कोई जोखिम नहीं हैं ।

अध्ययन में भाग लेने के संभावित लाभ क्या हैं?

यह अध्ययन प्रतिभागियों को प्रसव की तीसरी अवस्था का सैक्रिय प्रबन्ध के बारे में ज्ञान प्राप्त करने में मदद करता है और यह उन्हें बेहतर

ज्ञान और कौशल प्राप्त करने में मदद करेगा जो उन्हें निकट भविष्य में बेहतर प्रदर्शन करने में सक्षम करेगा।

अध्ययन में भागीदारी की लागत:

अध्ययन द्वारा आवश्यक प्रक्रियाएं आपको बिना किसी लागत के प्रदान की जाती हैं।

चोट के लिए मुआवजा:

चोटों के लिए कोई जोखिम नहीं।

जानकारी की गोपनीयता:

आपके नाम, जनसांख्यिकीय प्रोफार्मा सहित अध्ययन से जानकारी, अध्ययन के परिणामों की समीक्षा के वल उन अधिकृ त कर्मियों द्वारा

की जाएगी जो अध्ययन, आचार समिति या नियामक निकायों में शामिल हैं। इस अध्ययन से प्राप्त जानकारी और परिणामों को आपके

नाम और व्यक्तिगत पहचान को शामिल किए बिना बैठकों में प्रकाशित या प्रकाशित किया जा सकता है।

अध्ययन के बारे में नई जानकारी:

अध्ययन के दौरान उपलब्ध कोई भी नई जानकारी आपको सूचित की जाएगी यदि अध्ययन में इसे जारी रखने के संबंध में आपके

निर्णय की प्रासंगिकता है।

स्वैच्छिक भागीदारी:

शोध अध्ययन में प्रवेश स्वैच्छिक है। यदि आप एक शोध अध्ययन के लिए स्वयंसेवक हैं, तो आपको किसी भी समय वापस लेने का

अधिकार है और आपको इसके लिए कोई कारण बताने की आवश्यकता नहीं है। अध्ययन में भाग नहीं लेने का आपका निर्णय आपके

भविष्य को प्रभावित नहीं करेगा। अन्वेषक आपकी अनुमति के बिना किसी भी समय किसी अन्य कारण से अनुसंधान या इसमें आपकी

भागीदारी को रोक सकता है।

सवालों के मामले में किससे संपर्क करें:

यदि आपके पास इस फॉर्म या अध्ययन संबंधी किसी भी समस्या के बारे में कोई प्रश्न हैं, तो आप निम्नलिखित व्यक्ति से संपर्क

कर सकते हैं।
S.NO CONTENT PAGE NO

1. INTRODUCTION 1-3

2. BACKGROUND OF THE STUDY 4-5

3. TITLE OF THE STUDY 6

4. OBJECTIVES OF THE STUDY 6

5. HYPOTHESIS 6

6. OPERATIONAL DEFINITION 7-8

 7. CONCEPTUAL FRAMEWORK 8-11

8. RESEARCH METHODOLOGY 12-13

 RESEARCH APPROACH
 RESEARCH DESIGN
 SETTING OF THE STUDY
 SAMPLING OF THE STUDY
 TOOLS OF THE STUDY
 DATA COLLECTION AND ANALYSIS OF THE
STUDY

9. ETHICAL CLEARANCE 14

10. WORKPLAN 15

11. BUDGET 16

12 REFERENCE 17

CHAPTER I
The best and most beautiful things in the world cannot be seen on even touched. They must be
felt within the heart
- Helen killer

INTRODUCTION
Active Management of Third Stage of Labour (AMTSL) as a prophylactic intervention
is composed of a package of three components. WHO recommendations have supported active
management of the third stage of labour (AMTSL) as a critical intervention for PPH
prevention. The study aimed to assess the knowledge and practice of AMTSL among nursing
students .
Labor is defined as the process by which the fetus is expelled from the uterus. Progress of labor
is measured with multiple variables. Labour is divided into four stages. The first stage starts from
the onset of true labour pains and ends with full dilatation of the cervix. The second stage starts
from the full dilatation of cervix and ends with expulsion of the fetus from the birth canal. The
third stage begins after the expulsion of fetus and ends with expulsion of the placenta and
membranes. The fourth stage is the stage of early recovery; it begins after the expulsion of
placenta and membranes lasts for one hour.

The third stage of labour has traditionally been defined as the time between the birth of the baby
and the delivery of the placenta and membranes. It is the third stage that is the most perilous for
the woman because of the risk of postpartum haemorrhage (PPH). The third stage of labour
typically lasts between 10 and 30 minutes; if the placenta fails to separate within 30 minutes after
childbirth, the third stage is considered to be prolonged. If the third stage of labour lasts longer
that 18 minutes, it is associated with a significant risk of PPH; and there is a six-fold increase in
PPH when the third stage of labour lasts longer than 30 minutes.

Active Management of Third Stage of Labour (AMTSL) as a prophylactic intervention is

composed of a package of three components: 1) administration of a uterotonic, preferably
oxytocin, immediately after birth of the baby; 2) controlled cord traction (CCT) to deliver the
placenta; and 3) massage of the uterine fundus after the placenta is delivered. WHO
recommendations have supported active management of the third stage of labour (AMTSL) as a
critical intervention for PPH prevention. AMTSL has become a central component of the PPH
reduction strategies of governments around the world.

The world health organisation (WHO) defines postpartum haemorrhage as vaginal bleeding in
excess of 500ml after childbirth. Globally postpartum haemorrhage occurs in 10.5% of live
births. It is the leading cause of maternal mortality worldwide. Experts recommend that all
women should benefit from active management of the third stage of labour, the only intervention
known to prevent postpartum haemorrhage.6Atonic postpartum haemorrhage is the most
common cause of postpartum haemorrhage and the leading cause of maternal death. One
intervention that has been promoted as an effective intervention in preventing atonic postpartum
haemorrhage is the active management of the third stage of labour.
Maternal mortality is unacceptably high. About 830 women die from pregnancy- or childbirth-
related complications around the world every day. It was estimated that in 2015, roughly
3,03,000 women died during and following pregnancy and childbirth. Almost all of these deaths
occurred in low-resource settings, and most could have been prevented.

A descriptive study was done to assess the normal labor practices in an Egyptian teaching
hospital, where postpartum haemorrhage is the leading cause of maternal mortality. 176 normal
births were directly observed. Women were interviewed postpartum and study findings were
shared with providers. Third-stage active management was correctly done for 15% of women
observed. Most common deviations for the remaining 85% were, giving uterotonic drugs after
placental delivery (65%) and without cord traction (49%). The preventive role actively managing
the third stage can provide against postpartum haemorrhage was lost in the majority of the
deliveries observed. Obstacles to adopting protocols shown to reduce haemorrhage should be
explored, given the contribution of postpartum haemorrhage to maternal death in Egypt.

A prospective single blind study was conducted to find the quality of service incorporated in the
active management of third stage of labour in Maternity Hospital, Thapathali, Kathmandu,
Nepal. 325 labouring women were randomly selected. Loading of the oxytocin was correctly
done immediately when the women were seen to bear down at second stage in 99.5% of the
cases. In 5.8% of cases, the oxytocin doses were different from the standard 10 units. The
possibility of second baby was not ruled out in 81.9% of the cases before the administration of
10 units of IM oxytocin. Moreover, the study revealed that controlled cord traction was applied
in 56% of the cases without confirming uterine contractions. The study concluded that
improvement in the standard of active management of third stage of labour is still needed in the
training providing institutions.

According to Sikkim.data.gov.in, the maternal mortality rate of Sikkim in the year

2015-2016 is 6 in total also contributing to the maternal mortality rate of the country. Evidence
shows that management of third stage can directly influence important maternal outcomes such
as blood loss, need for manual removal of the placenta, and postpartum haemorrhage. On the
basis of current evidence, if a decrease in postpartum bleeding or avoidance of manual removal
is desired, an active approach to third stage is the one that should be adopted until and unless
contradictory findings are published. Nurses caring for women during labour and birth should
be knowledgeable about the normal and abnormal processes of labour and birth; have a mastery
of appropriate technical skills; communicate and collaborate well with the health care team;
and possess the necessary judgment, self-confidence, and skills to cope with stressful,
emergency conditions.

The third stage of labour usually lasts between five and 15 minutes, but any duration up to one
hour may be within normal limits (McDonald, 2004). This period is considered to be the most
hazardous stage for the birthing woman due to the risk of profuse hemorrhage (Jangsten, 2009).
The major complication associated with this stage is postpartum hemorrhage (PPH), PPH is
generally defined as blood loss greater than or equal to 500 ml within 24 hours after birth, while
in severe condition blood loss is greater than or equal to 1000 ml within 24 hours (Tan, 2008).
Postpartum hemorrhage (PPH) is a major cause of maternal mortality and morbidity, particularly
in developing countries, where most pregnancy-related deaths are associated with hemorrhage
(ICM, IFGO, 2003).
The two management packages for the third stage of labour are commonly used, known as active
management and expectant management. In active management, several prophylactic
interventions are applied in combination. WHO recommends administration of Oxytocin soon
after delivery of the baby, controlled cord traction, and uterine massage after placental delivery.
In expectant management, the interventions included in active management are withheld unless
needed (Rabe, 2004).
Active management of third stage of labour (AMTSL) is a simple and practical intervention to
reduce the incidence of PPH has been identified, globally endorsed, and widely promoted for
more than a decade as part of programs to reduce maternal mortality (WHO, 2007).
Overall, the risk of PPH was more than 60% lower with active management than with expectant
management. Active management of the third stage of labour consists of interventions designed
to facilitate the delivery of the placenta by increasing uterine contractions and to prevent PPH by
averting uterine atony. Every attendant at birth needs to have the knowledge, skills, and critical
judgment to carry out active management of the third stage of labour, as well as access to
required supplies and equipment (ICM, IFGO, 2004). AMTSL is a feasible and inexpensive
intervention that can help to prevent primary PPH and save millions of women's lives (POPPHI,
2006).
The third stage of labor can be seen as a period of great potential hazard, or it can be viewed as a
normal physiologic process with some risks. The third stage of labor is associated with
postpartum hemorrhage (PPH), which is an important cause of maternal morbidity and mortality
worldwide (Tina, 2005).
The risk of death from childbirth represents one of the greatest inequities in global health.
Globally, at least 585,000 women die each year by complications of pregnancy and child birth
(WHO, 2005). The majority of maternal deaths (61%) occur in the postpartum period, and more
than half of these take place within a day of delivery. Approximately 30% (in some countries,
over 50%) of direct maternal deaths worldwide are due to hemorrhage. Despite our knowledge of
the risk factors, we can’t predict which birth will be complicated by PPH. Postpartum
Haemorrhage (PPH) is the leading cause of maternal deaths (WHO, 2005). Active management
reduces the relative risk of postpartum haemorrhage by around 60%, compared with
physiological care (Prendville, 2003).
In Ethiopia maternal deaths account for 21.6 percent of all deaths among women aged 15-49.
This shows that women of reproductive age face a very high risk of maternal death in the
population, regardless of the level (CSA, 2006).Most maternal deaths due to PPH occur in low
income countries in settings (both hospital and community) where there are no birth attendants or
where birth attendants lack the necessary skills or equipment to prevent and manage PPH and
shock (ICM, IFGO, 2003). Therefore, PPH remains one of the top five causes of maternal
mortality and as such active management of the third stage of labor should be given full
consideration in an effort to reduce maternal mortality. Therefore, this study was conducted to
evaluate the knowledge, attitude and practice of midwives on active management of third stage
of labour working at health centers in Addis Ababa, Ethiopia. The study is important for
different stakeholders addressing the issues related to maternal morbidity and mortality. Findings
from the study provide information for the policy makers to develop strategies and guidelines or
standards for scaling up the use of active management of third stage of labour as an important
tool to prevent maternal morbidity and mortality and improve maternal health

NEED OF THE STUDY

The review of literature of the present study is as follows:

  Studies related to Active management of third stage of labour
 Studies related to effectiveness of Active management of third stage of labour simulation
among nursing students
 Studies related to simulation teaching in improving the skills of the students

 Studies related to Active management of third stage of labour

1) A descriptive co-relational research approach was conducted by Sangay Bhutia et al (

Issue 4 - 2018 ). The study is to assess the effectiveness of aimed to assess the knowledge and
practice of AMTSL among nursing students among nursing students. The students were
explained about the nature and purpose of the study and a written consent was obtained from the
participants prior to their recruitment in the study. Investigators adopted quantitative approach
with descriptive co-relational research design where 40 students were selected by convenient
sampling technique. Validated structured knowledge questionnaire and observational checklist
were used to collect the data. Pretesting and reliability of the tool was done which was found to
be reliable Active Management of Third Stage of Labour (AMTSL) as a prophylactic
intervention is composed of a package of three components. WHO recommendations have
supported active management of the third stage of labour (AMTSL) as a critical intervention for
PPH prevention. The study aimed to assess the knowledge and practice of AMTSL among
nursing students in selected hospitals. The findings revealed that majority of the students i.e. out
of 40 students, 33 (82.5%) had average knowledge, 5 (15%) students had poor knowledge and 1
(2.5%) had good knowledge. Majority 21 (52.5%) had poor practice and 19 (47.5%) had good
practice on AMTSL. There was a positive correlation between knowledge and practice of
AMTSL among nursing students which means with the increase of knowledge, the practice of
AMTSL improves. Also, there was an association of practice with the number of return
demonstration shown to the supervisor. Knowledge of Active Management of Third Stage of
labor is a vital possession for the nurses and birth attendants to be skillful in the practice of
AMTSL to prevent post-partum hemorrhage and other obstetric complication, which may risk
the life of the women. Knowledge based skill is optimal solution for reducing the maternal
mortality rate.
2) A quasi experimental study was conducted Veronika Jones et al (Issue 2 July - December
2016) in King Saud University Medical City Riyadh, Saudi Arabia. The overall aim of this study
is to achieve effective implementation of active management of third stage of labour and
assisting for optimal management of obstetrical hemorrhage. The research design was quasi
experimental one group pretest posttest survey method using purposive sampling technique. A
total of 50 students GNM nursing 3rd year of King Khalid University were selected. To test the
statistical significance paired sample t-test was used and to test the relation between the
demographic variables and the test scores, one way ANOVA was used. The aim of this study is
to assess the knowledge and practice on active management of third stage of labour and identify
the gaps for the effective implementation of this quality improvement initiative.50 student nurses
participated in the study, while 16 studen nurses dropped out of the study after the pretest. The
mean pretest score was 9.42 (n=50), and the post test score after teaching and intervention is
13.65. Standard Deviation of pre and post test scores is 1.706 and 2.640 respectively.There is a
significant difference in the means of pre and posttest scores on knowledge of nurses (9.42 vs.
13.65) with the mean difference of 4.23in the scores. The‘t’ value in the paired sample‘t’ test is
13.645 (P < 0.001). Relationship between demographic variables and test scores by one way
ANOVA showed statistically insignificant results. The results were compared with the latest
scientific evidences to identify gaps in the nurses’ knowledge and in the effective
implementation of the active management of the third stage of labour across the King Saud
University Medical City Riyadh, Saudi Arabia With the existing percentage (1- 1.5%) of
postpartum hemorrhage in our maternity services, the knowledge on active management of third
stage of labour (AMTSL) is imperative among student nurses to reduce the rate of postpartum
haemorrhage by 60 – 70%.

 Studies related to effectiveness of Studies related to effectiveness of Active

management of third stage of labour simulation among nursing students

1) A quasi experimental study was done by Melba Sheila D’souza et al in college of

nursing Sultan Qaboos University, Oman q(November 18, 2017). This study is to evaluate the
effectiveness of simulation in critical care nursing among students in a public university. A
single quasi experimental design was used to evaluate the effectiveness of simulation compared
to videos and high fidelity simulation. A convenient sample of 100 students in the critical care
nursing course was selected in the year 2015-2016. Standardized simulation instruments were
used to measure the knowledge and performance and ANOVA and t test was used to analyze the
findings. Mean overall satisfaction was higher among students exposed to high fidelity students
than those students with video. Hence the study confirms that the overall satisfaction and self
confidence was higher among the students exposed to high fidelity simulation students compared
to the students exposed with video learning.

2) A study was conducted by Yasemi Celik, et al at Afyonkarahisar city of Turkey health

training school.(January 2015). This study aims to detect the overall evaluation of nursing
students towards simulation throughout the practice education and to reveal their learning styles
in relation to certain individual features. The study included 3 rd yr nursing students in nursing
department in Afyonkarahisar city of Turkey. The practice steps were demonstrated by an
instructor by doing with a group of 10-12 students each week after theoretical lesson by means of
utilizing simulation in the related topics. The questiionaire was administered to the students.

 Studies related to simulation teaching in improving the Attitude, and

Practice skills of the students

1. A cross sectional study was conducted by AL Kadi AS et al (January 2015 ). In this

study was to assess the Knowledge, Attitude, and Practice of Midwifes on active
management of third stage of labour at selected private medical college. The third stage
of labour which, starts immediately after the infant is born, includes the separation and
detachment of the placenta from the uterine wall, and ends with complete expulsion of
the placenta and membrane. This period is considered to be the most hazardous stage for
the birthing woman due to the risk of profuse hemorrhage. Severe bleeding is the single
most important cause of maternal deaths worldwide. Over 90% of women who die of
postpartum hemorrhage, the most important cause is uterine atony, however, research
shows that a simple, inexpensive, effective, adaptable and evidence based practical
technique known as active management of third stage of labour effectively reduces the
occurrence of hemorrhage caused by uterine atony by 60%. A cross sectional study
supplemented with observation was conducted among nursing student selected private
 medical college in Addis Ababa. Convenience sampling method was carried out. The
questionnaires contain open as well as closed ended questions which covers socio
demographic information, knowledge, attitude and practice of midwives on active
management of third stage of labour. After checking for completeness and consistency,
data was coded and entered into Epi-info programs and transported to SPSS version 17
for analysis Data was presented by tables. 136 Gnm 3rd year student studies in the private
medical collage on Addis Ababa were included in the study. The findings revealed that,
although students generally had good knowledge about active management of third stage
of labour 82.4% stated the definition, about, 69(50.7%) of student stated that active
management of third stage of labour preventing PPH and about, 35 (25.7%) of them
responded that it is increases the ability of uterus to contract, and facilitate separation of
placenta. Attitudes towards active management of third stage of labour was positive, 133
(97.8%) stated that active management of third stage of labour should be used and
advantageous to all pregnant mothers to prevent postpartum hemorrhage. Practical
aspects regards active management of third stage of labour, 106 (77.9%) had given
oxytocin with in the first minute, 121(89%) used controlled cord traction, 117 (86%)
performed uterine massage with in the first minute after delivery and only 92 (67.6%)
had estimated blood loss. When considering that standard observation guide and standard
questions set on active management of third stage of labour, only 70 (51.5%) of student
achieved satisfactory standard scores in knowledge question and 64 (47%) had achieved
good in skills. Student should be trained to update the knowledge and skill in order to
provide safe and qualified care.

2. A descriptive cross-sectional study was conducted by Olufemi T. Oladapo et al in

private medical collage in southwest Nigeria (March 2009) . This study was conducted to
current evidence and practice on active management of third stage of labour (AMTSL)
demands assessment of providers’ knowledge on the subject. To assess the level and
determinant(s) of accurate knowledge of obstetric providers regarding AMTSL.
Questionnaire-based survey of 4 medical institute in southwest Nigeria. (90.6%) of the
respondents reported being aware of AMTSL as an obstetric intervention and 49.7% were
aware of FIGO/ICM recommendation on AMTSL. Out of 13 potential third stage
 interventions, 102 respondents (28.3%) correctly and exclusively identified the
components of AMTSL as deWned by FIGO/ICM. 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
ligation (13.9%) were also selected as AMTSL components. Multivariate logistic
regression analysis indicated that being in administrative position (adjusted OR: 2.68; CI
1.19–6.02) and frequent compared to rare or no consultation of books, journal and
internet sources for information (adjusted OR: 2.58; CI 1.21–5.52) increased the odds of
having accurate knowledge of AMTSL. AMTSL was a familiar but poorly understood
intervention among students in this region. Improvement in knowledge and practice of
healthcare quality adherence to recommended guidelines on AMTSL urgently requires
educational interventions that target those who provide routine delivery care and
organisation of the health care delivery system in such a way that enables providers to act
on acquired knowledge.

Research Problem Statement:

 “A study to assess the knowledge and practice of active management of 3 rd stage
of labour with the help of osce among final year B.Sc. Nursing students in snsr
Sharda University, Greater Noida UP”.
.
Objectives of the Study:
The objectives of the study were:
 To assess the knowledge and practice on active management of third stage of
labour among nursing students.
 To find the correlation between the knowledge and practice of active management
of third stage of labour among nursing students.
 To find the association between knowledge and practice with selected variables.
 To develop and distribute an informational booklet on AMTSL.

Hypothesis:

Hypothesis will be tested at 0.05 level of significant.

 Ho1: There will be no significant difference between mean pretest and post test
simulation score of the two groups
Ho2: there will be no significant association between the simulation score of nursing
students and selected variables

Purpose of the Study:

The purpose of the study is to assess the effectiveness of Simulation teaching of active
management of 3rd stage of labour among Nursing Students of College of Nursing (SNSR). The
findings of the study can help the nursing educators as well as health care professional to obtain
the base line data about best method of teaching the students nurses about active management of
3rd stage of labour.

Assumptions:

o The students may have adequate knowledge regarding the 3rd stage of labour.
o The simulation of active management of 3rd stage of labour may have a significant
increase in the knowledge of nursing students .

Variables:

Demographic variable:

o Age
o gender
o Programme
o Source of information

Independent variable:

o Active management of 3rd stage of labour.

Dependent variable:

o Knowledge and practice regarding active management of 3rd stage of labour.

Operational Definition:

 Assess: In this present research study assess means to examine for the purpose of
evaluation and quality of improvement.
 Knowledge:
 Practice:
 Active management:
 Labor : Labor is defined as the process by which the fetus is expelled from the uterus.
 3rd stage of labor:
 OSCE:

 Nursing students : In this Present research study nursing students are the students of Bsc
Nursing students of selected colleges of Nursing in Greater Noida UP

Conceptual Framework

A conceptual framework is made up of concepts in which it provides the guidelines to

attain the objectives of the study. It is the presentation of the activities, steps and action of the
study. A conceptual framework is used in research study to outline the possible course of action
to present a preferred method of an idea. To explain the various concepts of the study regarding
the active management of 3rd stage of labor Roy’s adaptation model is used.

Sister Callista Roy is a highly respected nurse theorist, writer, lecturer and teacher who currently
holds the position of professor and nurse theorist at the Boston College William F Connell
School of Nursing.

The concepts of Roy’s adaptation model are input, control process, effectors and output

1. INPUT
Adaptive system has input coming from external environment as well as from the person. In
Roy’s system, input is identified as stimuli. Adaptation level is determined by the combined
effect of:

 Focal stimuli is the one to which an individual must make an adaptive response
 Contextual stimuli which are the other stimuli present that contribute to the behavior
caused by the focal stimuli
 Residual stimuli are those factors that may be affecting behavior but whose effects are
unclear

In this study the focal stimuli is the student’s knowledge and skill during the course of their
study

The contextual stimuli are their study mates, teachers and the learning activities which they
acquire in the college

The residual stimuli is the age of the students, gender, year of study and source of information
and programme.

2. CONTROL PROCESS

Control process are innate or acquired ways of interacting with the changing environment. Roy
view the regulator and cognator as methods of coping.

In this study the student control process are influenced by the perception of the stimuli. The
student perceives these simulations and may lead to an increase in knowledge and skills for
Active management of 3rd stage of labor.

3.EFFECTOR

Although cognator and regulator processes are essential to the adaptive response of the person,
these processes are not directly observed. Roy identified 4 modes for assessment of behavior that
results from coping mechanism which are physiological needs, self concept, role function and
interdependence
 In this study the effector for the experimental group is the Active management of 3rd stage of labor ,
routine classes and clinical duty. As for the control group it is their normal routine classes and
clinical procedures which they will be attending during the time.

OUTPUT

It is the response of the person. It can be observed, intuitively perceived by the nurse, measured
and subjectively reported by the person. Output maybe adaptive or ineffective responses.

Depending on the effectiveness of the simulation of Neonatal BLS it will be either effective or
ineffective. Effective simulation will lead to cooperation and good knowledge and simulation
skills of Neonatal BLS while ineffective simulation will result in poor knowledge and skills.
Therefore though this study the nursing education can be benefitted as to which methods of
teaching must be adapted.

EXPERIMENTAL GROUP

Among the experimental group, the Active management of 3rd stage of labor is done. Therefore it
may lead to the increase in knowledge and skills of the experimental group regarding the Active
management of 3rd stage of labor

CONTROL GROUP

In the control group, only the normal and routine class and clinical procedures will be done. So
EXPERIMENT
among the control group the knowledge and practice regarding Active management ofAL 3rd GROUP
stage of
labor The
experim
INPUT CONTROL PROCESS EFFECTOR OUTPUT
ental
EXPERIMENTA group
FOCAL
IiiinSTIMULI
rgrtkinnn In this the control
L GROUP may
process is the which
 Students the student will be
have
knowledge  Active increase
receiving during the
and practice manageme in
study due to which
nt of 3rd knowled
they will have an
stage of ge and
increase in knowledge
labor. practice
and practice for
 Routine regardin
neonatal basic life
classes g Active
support
 Clinical manage
duty ment of
3rd stage
of labor.
CONTEXTUAL
STIMULI

 Study mates,
teachers
 Learning
activities

CONTROL
CONTROL GROUP
GROUP
The
 Routine knowledge
RESIDUAL STIMULI and practice
classes
of the
 Age of the  Clinical
control
students group
 Gender of regarding
students active
 Year of the management
of 3rd stage
study
of labor may
Methodology:
Source of remain
information constant
RESEARC
Programme

METHODOLOGY

Research Approach: Quantitative research approach

Research Design: True experimental research design

Setting of the Study: The present study will be conducted in SNSR colleges of nursing, Greater
Noida UP

Population: The study population will be the nursing students of Bsc nursing 4th year students of
SNSR colleges of nursing in Greater Noida ,UP

Sample: The study Sample will be the Bsc nursing 4 th year students of SNSR colleges of
nursing , Greater Noida UP .

Sample Size: Sample size will be calculated based on the previous research studies. An estimate
of 50-60 samples will be takes for the study.

Sampling Technique: In this present study simple random sampling techniques will be adapted
to conduct the research study.

Sampling Criteria:

Inclusion criteria Exclusion criteria

 Students of SNSR nursing colleges of  Students who are not in the field of
Greater Noida up nursing
 All Bsc Nursing 4th year of Sharda  Students who are not present during the
university, Greater Noida UP data collection
 Participant who are willing to
participate in study  Students who have attended prior
 Students with attendance of 60% and workshop or training regarding active
above management of 3rd stage of labor.

 Participants who are not willing to

participate in the study.

Method of Data collection:

The study data will be collected by using of
Tool 1: Self constructed knowledge questionnaire.
Tool 2: Observational check list to assess the practice of nursing students

Plan for pilot study:

Students of Bsc nursing students of SNSR colleges of nursing in Greater Noida UP will
be selected for the pilot study.

Plan for Data collection:

- The data collection for the study is will be carried out in the month of January and
February 2020.
- Data collection will start after taking permission from the ethical committee and principal
of SNSR colleges of nursing in Greater Noida ,UP
 The data will be collected by the use of self constructed questionnaire and observational
check list regarding the active management of 3rd stage of labor.

- Plan for data analysis:

- Based on the objectives and hypothesis of the study both descriptive and inferential statistics
are planned to be used.
- Descriptive statistics will be used to analyses the sample characteristics.
- The inferential statistics that will be used Paired‘t’ test, Independent‘t’ test. And Chi –square
test, to find the association

Ethical Clearance:

Permission to be obtain from..

o Principal, SNSR ( Sharda University)nursing colleges in Greater Noida , UP.

o University Ethical Committee, Sharda University.
o Participants consent will also be taken for the study

Procedure of Data Collection

 • Students of Bsc Nursing 4th year who will be present at the time of study in SNSR
nursing colleges of Greater Noida UP will be taken for the study on the basis of the
inclusion criteria mentioned above

• The procedure of the study will be explained to the students.

• Written consent will be obtained from the authority, participants of the nursing colleges

• The students to be included in the study will be taken based on the inclusion and
exclusion criteria and it will be further divided into experimental and control group by
simple random sampling.

• Pretest will be taken for both the groups and active management of 3rd stage of labour
will be given to experimental group only and post test will be taken for both the groups
and results will be evaluated.
Work plan:

June Aug Sep Oct Nov Dec Jan Feb Mar Apr May June July

Problem 
presentation

Finalization of
research
Proposal
Tool
preparation
Proposal
presentation
Review of
literature
Validity,
pretest,
Reliability
 Pilot study
Data collection
and analysis
Analysis
presentation
Spiral bound
submission
Model viva
Submission of
research
Article
Final spiral
bound
submission to
dean
University
exam
Final thesis
submission

Budget:

Sl no Item Amount
• Print material 20000
2 Travel charge 3000
3 Translation 1000
4 Miscellaneous 8000
5 Final thesis 9000
Total (Around) 41000
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labour and delivery 2017: 267-286.
2. Mowafi DM. Normal Labour, Obstetrics Simplified. 2017: 1-5.
3. Arulkumaran S. The Active management of third stage of labor. A comprehensive textbook
of postpartum haemorrhage: An essential clinical reference for effective management.
Sapiens 2012: 101-112.
4. World Health Organization. Active management of third stage of labour. Available from:
https://www. who.int/reproductivehealth/publications/maternal_ perinatal_health/new-
recommendations-amtsl/en/.
5. International Confederation of Midwives, International Federation of Gynaecologists and
Obstetrician. Joint statement: management of the third stage of labour to prevent postpartum
haemorrhage. Journal of Midwifery and Womens Health 2004; 49(1): 76-7.
6. Kongnyuy EJ, Broek NV. A clinical audit of the management of postpartum haemorrhage in
Malawi. The Internet Journal of Gynaecology and Obstetrics 2007; 9(2): 873.
7. Mathai M, Gulmezoglu M, Casna RP. WHO recommendations for the prevention of
postpartum haemorrhage. 2006. 18-20.
8. Alkema L, Chou D, Hogan D et al. Global, regional and national levels and trends in
maternal mortality a systematic analysis by the UN maternal mortality estimation inter
agency group. Lancet 2016; 387(10017): 462-474.
9. Upadhyay M, Sharma G, Chataut D. Active management of third stage of labor, assessment
of standard of care in one of the training institute. Nepal Journal of Obstetrics and
Gynaecology 2006; 1(2): 28-30.
10. Vivio D, Fullerton JT, Forman R et al. Integration of the practice of active management of
the third stage of labor within training and service implementation programming in Zambia.
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