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.
CHAPTER ONE
INTRODUCTION
1.1
Background tothe 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
1.4 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.
1.5 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:
1.
determine the pre intervention knowledge
level of midwives on misoprostol in the management of PPH
2.
determine
the pre intervention knowledge level of midwives on NASG in the management of
PPH
3.
determine
the effect of nursing intervention on midwives knowledge in the use of
misoprostol in the management of PPH
4.
determine
the effect of nursing intervention on knowledge of midwives in the use of NASG
in the management of PPH
5.
determine
the effect of nursing intervention in the application of NASG in the management
of postpartum hemorrhage
6.
determine
the effect of nursing intervention in the removal of NASG in the management of
postpartum hemorrhage
1.6
Research
Questions
1. What is the pre intervention
knowledge level of midwives on misoprostol in the management of PPH?
2. What is the pre intervention
knowledge level of midwives on NASG in the management of PPH?
3. What is the effect of nursing
intervention on knowledge of midwives in the use of misoprostol in the
management of PPH?
4. What is the effect of nursing
intervention on knowledge of midwives in the use of NASG in the management of
PPH?
5. What is the effect of nursing intervention in the application of NASG in
the management of postpartum hemorrhage?
6. What is the effect of nursing intervention in the removal of NASG in the
management of postpartum hemorrhage?
1.7
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.
1.8 Operational Definition of Terms
1
Knowledge:Ondo Statemidwives understanding of
midwives on the use of misoprostol and anti-shock garment as measures of
managing postpartum haemorrhage.
2
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.
3
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
4
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.
5
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.
6
Anti-Shock Garment: Is a form of lower bottom suit used
in the management of postpartum haemorrhage.
7
Midwives skills: Ability to use and administer
misoprostol and anti-shock garment in the control of postpartum hemorrhage.
8
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.
9
Management of postpartum haemorrhage: the use of Misoprostol and NASG in
the control postpartum haemorrhage.
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