RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED

TEACHING PROGRAMME ON PARTOGRAM AMONG THIRD

YEAR Bsc. NURSING STUDENTS OF SELECTED COLLEGE OF

NURSING IN BANGALORE.

Ms. BHIM MAYA SHRESTHA

JUPITER COLLEGE OF
NURSING,
RAJIV GANDHI UNIVERSITY OF
HEALTH SCIENCES,
BANGALORE, KARNATAKA.
 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION ON SUBJECT FOR DISSERTATION

1. NAME OF THE Ms. BHIM MAYA SHRESTHA (SHAKYA)

CANDIDATE AND 1ST YEAR M.Sc. NURSING
ADDRESS
JUPITER COLLEGE OF NURSING,
NELAMANGALA,BANGALORE

2. NAME OF THE INSTITUTE JUPITER COLLEGE OF NURSING,

NELAMANGALA, BANGALORE

3. COURSE OF STUDY AND DEGREE OF MASTER OF NURSING

SUBJECT OBSTETRIC AND GYNAECOLOGICAL
NURSING

4. DATE OF ADMISSION TO 01/06/2012

THE COURSE

A STUDY TO ASSESS THE

5. TITLE OF THE TOPIC EFFECTIVENESS OF
STRUCTURED TEACHING
PROGRAMME ON PARTOGRAM
AMONG THIRD YEAR Bsc.
NURSING STUDENTS OF
SELECTED COLLEGE OF
NURSING IN BANGALORE
6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION:
Maternal mortality is still a concern in India. Approximately 40% of
all maternal deaths in India are due to haemorhage (most post partum) and
another 5% due to obstructed labour.

Over the past one decade WHO has shown beyond any doubt that
active management of the third stage of labour (AMTSL) reduces bleeding
from pregnancy by almost 50%, and plotting a partograph enables the
service providers in the early identification of prolonged labour, thereby
avoiding delayed labour and the resultant complications from exhausted or
ruptured uterus.

Under the child survival and safe motherhood programme a lot of

emphasis was given on training to use these tools, however, follow up was
missing. Members felt that the current increase in institutional deliveries
because of the Janani Suraksha Yojana (JSY) scheme. It demonstrates the
need for close monitoring of quality of delivery care in institutions to bring
significant improvement in maternal and perinatal mortality.

The WHO version of Partograph is a most simplified version. It helps

in correlating the fetal condition, strength of uterine contraction, and
progress of labour very clearly. Only issue is to learn to note the cervical
dilation properly. The transition from antenatal care to management of
labour is critical for both the other and the fetus.

It poses a challenge to midwifery care. In the labour ward, the

partograph is a major instrument used during this transition. Also, recent
advances in safe motherhood and the challenge to reduce maternal and infant
morbidity and mortality by at least 50% by the year 2000, have put health
staff, including midwives, under constant pressure. All the countries were
called upon by the world health organization (WHO) to put strategies in
place that will ensure that the health care system has the capacity to provide
maternity care services with appropriately trained and supported midwives.

These services should be based on established norms and procedures,

for example, standardized tools for practice such as the partogram (Daly et al
1993). The first obstetrician to provide a tool for the assessment of
individual labour was Friedman. It is interesting to note that the Department
of Public Health, government of Tamil Nadu has given guidelines to all the
PHCs for the implementation of active management of third stage of labour
and partograph. Even though many of the PHCs are following the
guidelines, there are no followers for these steps in the secondary and
tertiary care centers when more than 60% of cases managed in such centers
are normal deliveries.
6.1 NEED FOR THE STUDY

It was found out that many of the section of the obstetric records
including those on the partograph had been filled in either incomplete or an
incorrect manner. Since the obstetrical record was designed to facilitate
application approach, it is therefore a need to update midwives in its use.

Against this back ground, there was also a need for a study on the use
of the partogram by midwives. Since it is one of the tools use to reduce the
high incidences of maternal and neonatal mortality in developing countries.
The researcher decided to do this study on the use of the partogram by
midwives because of the reasons given above.

According to the Indian news (19th January 2009), Indian has to do

much more to improve maternal and child healthcare for its citizens. The
release of UNICEF’s flagship publication “The state of the world’s Children
Report 2009 in New Delhi on Jaunary 15” was a time to assess where India
stood, in comparison to the rest of the world, with its effort to support and
improve maternal and newborn health.

“78,000 women die from pregnancy and childbirth and about a

million neonatal deaths occur in India every year. The health and survival of
mothers and their newborns are intrinxically linked, and many of the same
interventions that save maternal lives also benefit their infant’s”, said
UNICEF India Representative, Karin Hulshof.

This implies that on an average every seven minutes, one woman dies
from complications related to pregnancy and childbirth, report says. The
report also highlights that India; more than two-thirds of all maternal deaths
occur in a few states _ Uttar Pradesh, Uttarakhand, Bihar, Jharkhan, Orissa,
Madhya Pradesh, Chhattisgrah, Rajisthan and Assam.

According to the report, India has managed to cut under-five mortality

rate from 117 per 1000 live births in 1990 to 72 in 2007. But there has been
little change in the 2001-2003 maternal mortality rate of 301 for every one
lakh live births, and the UNICEF says there is little chance of reaching the
goal of cutting the ratio to 109 by 2015.

According to UNICEF’s initiative, UNICEF is committed to

programming in India that helps lessen the risk that pregnant women and
newborn babies face. The facts for life communication Initiative’s television
serial, Kyunki…Jeena Issi ka Naam Hai” (Because… that’s what life is), is
one of such efforts, speaking to audiences in a persuasive and attractive
manner so as to educate and empower parents, caregivers and others to
embrace pro-social behavior critical to the welfare of mothers, newborns and
children.The entertainment- education programme that is packaged into the
popular soap opera format is becoming increasingly popular with both urban
and rural audiences since its launch in April 2008.

Holding fast to facts for Life’s principle of not merely providing

information, Kyunki….comunicates these messages in a manner that makes
it possible for viewers to incorporate them into their day-to-day living.
Almost a decade into this millennium, statistics regarding maternal and child
health may have improved, but a lot still needs to be done to secure the
condition of the world’s mothers and children. Bringing together messages
that urgently need to be communicated across India, Kyunki…is a platform
to promote an environment that can enable maternal and newborn health.
6.2 REVIEW OF LITERATURE

Geri Lo Bindo Wood, 2000The review of literature is an organized

critique of the important scholarly literature that supports a study, and a key
step in the research process.

(Polit and Hungler, 2000)Review of literature is a vital aspect of

scientific research. It involves systematic identification, location scrutiny
and summary of written material that contain information on research
programme.

The purposes of reviewing literature was to develop a deeper

understanding of the problem area, development of tools and structure
teaching programme regarding the assessment of knowledge.

Bo O (2009) conducted a study on improving intraparum care with

better use of the partogram. The main result of intrapartum care is reduced
the incidence of post-partum haemmorrage and obstructed labour.1

Cochrane database systematic review(2008) conducted a study on

to assess the impact of training on use of partogram for labour monitoring
among various categories of primary health care workers. The main result of
the study was lower cadres of primary health care workers can be effectively
trained to use the partogramme with satisfactory results, and thus contribute
towards improved maternal outcomes in developing countries with scarcity
of skilled attendants.2

Kwast EB, Poovan P, Vera E, Kohis E (2008) conducted a study on

assess the frequency and mode of delivery of women admitted in the latent
and active phase of labour showed the women admitted in the latent phase
had more operative (both abdominal and viginal) deliveries as labour
progressed to the right of the alert line in active phase compared to women
admitted in the active phase compared to women admitted in the active
phase of labour. Partographs were generally plotted very well. With 86% of
those eligible for partography available for analysis. Application of the
management protocol needs to improve as the average monthly Cesarean
section rate is 25.5% and augmentation of labour is rarely applied. It is
recommended that a management protocol for women admitted in the latent
phase is formulated and applied.3

Orji E (2008) conducted a study to evaluate the progress of labour

in nulliparous and multi paras using the modified WHO partograph. The
main result of this study is labour duration was similar in the 2 groups and
cervical dilatation remained normal for most women. In both groups, the
incidence of spontaneous vaginal delivery was highest among women with
normal labour progress and the incidences of both labour augmentations
operative intervention increased when labour progress was delayed. Labour
progress and duration were found similar for nulliparas and multiparas when
monitored with the modified WHO partograph.4

Mathews JE, Rajaratnam, George, Mathai M (2007) conducted a

study on compare two WHO partographs, a composite partograph including
latent phase with a simplified one without the latent phase. The main result
of this study is that the simplified WHO partograph was more user-friendly,
was more to be completed than the composite partograph, and was
associated with better labour outcomes. Result: Eighteen physicians
participated in this trial. One or the other partograph was used in 658
parturients.
 The mean (SD) used- friendliness score was lower for the composite
partograph (6.2(0.9) vs. 8.6 (1.0); P = 0.002). Most participant (84%)
experienced difficulty “sometimes” with the composite partograph, but no
participant reported difficulty with the simplified partograph. While most
maternal and perinatal outcomes were similar, labour values crossed the
action line significantly more often when the composite partograph was
used, and the women were more likely to undergo cesarean deliveries.5

Lavendert T, Alfirevic Z, Walkinshaw S (2007) conducted a study

on to assess the effect of different partogram action lines on birth outcomes.
The main result of this study is a total of 3000 women were randomly
assigned to groups, 99.2% were available for analysis. Questionnaires were
completed by 1,929 (65%) women. In this birth setting, for primi gravid
women selecting low intervention care, the 2 hour partogram increases the
need for intervention without improving maternal or neonatal outcomes,
compared with the 4 hour partogram, advocated by the World Health
Organization.6

Azandeybe N, Testa J, Makoutode M (2006) carried out a study on

assessment of partogram utilization in Benin. The findings revealed that one
of the methods used to decrease maternal mortality and morbidity was the
partogram. Partograms were used in 89% of all cases, in 13.3% of files all in
rural areas partogram completion stopped before delivery. Over all
completion was less good, of the 984 partograms examined, administration
data were complete on only 20% and medical delivery data on 50% action
taken before the alert line was crossed was incorrect in 48% of cases.
(particularly oxytocin use). The aert line was crossed in 13.5% of the cases
but correct action always followed (artificial rupture of membranes,
oxytocin administration). These results show very high coverage of
partogram use.7

Soni BL (2006) carried out a study on the effect of partogramme

use on outcomes for women in spontaneous labour at term. The finding
revealed in reduction of caesarean section rate, instrumental delivery and
APGAR score more then 7 at one minute.8

Fahdhy M (2005) carried out a study on assessing the

effectiveness the effectiveness of promoting the use of the World Health
Organization (WHO) partograph by midwives for labour in a maternity
home by comparing outcomes after birth. The findings revealed that the
WHO partograph should be for use by midwives who care for laboring
women in a maternity home. 9

Lavender T (2003) carried out a study on NCT evidence based

briefly use of the partogram in labour. The finding revealed that the action
line allowed 50% women whose rate of dilation crossed the alert line to
avoid being given oxytocin stimulation. It also showed a lower incidence of
prolonged labour and reduction in caesarean sections

The partogram can be used as a means of monitoring and imposing

routine interventions on those women whose labour does not conform with
pre-set time on measurable progress, with the objective of preventing
prolonged labour as a result of “inefficient uterine action”. Alternatively, it
can be used as a tool for recording observation of clinical significance with
the objective of reducing lengthy note taking, thus enabling midwives to use
their time effectively.10
 Lennox EC, Kwast EB, Farley MMT (1998) carried out a
study on assessing the impact of breech labour management using the WHO
partograph on fetal and maternal outcomes of labour method. The findings
revealed that the use of the WHO partograph in the management of breech
labour reduces prolonged labour and (among multigravida) cesarean sections
and improve fetal outcomes.11

6.3 OBJECTIVES OF THE STUDY

1. To assess the level of knowledge and practice among third year Bsc.
Nursing students on partogram
2. To identify the effect of structured teaching programme on
knowledge and practice among third year BSc. Nursing students on
partogram.
3. To co-relate the findings with selected demographic variables.

6.4 HYPOTHESIS

H1: There will be a significant difference in the level of knowledge and

practice among third year BSc. Nursing students regarding partogram
before and after administration of structured Teaching Programme.

H2: There will be a significant co-relation between the level of

knowledge and their selected demographic variables.
 H3: There will be a significant co-relation between practice and selected
demographic variables.

6.5 OPERATIONAL DEFINITIONS

6.5.1: Knowledge

It is the awareness gained by experience of a person (such as nurses and

midwives) fact or thing and, true justified belief, a theoretical or practical
understanding of a subject, language and the sum of what is known.

6.5.2 Skill

Experiences, practiced ability, facility in an action

6.5.3 Partogram

The depiction of the progress of labour in the form of graphs.

6.5.4 Labour

The process of child birth.

6.5.5 Nursing students

The students that trained to care for the sick nursing students will learn to
give medical attention to an illness carefully.
6.6 ASSUMPTIONS

1. third year Bsc. Students may have previous knowledge on partogram

2. structured Teaching programme will enhance the level of knowledge
and practice among third year Bsc. Students.

6.7 LIMITATION

Only those students are available at the time of data collection

7. MATERIALS AND METHODS

7.1 SOURCE OF DATA

Bsc. third year BSc. Nursing students

7.2 METHODS OF COLLECTION OF DATA

Structured questionnaire method

7.2.1 RESEARCH DESIGN

One group pretest post test design.

7.2.2 SETTING

Selected College of Nursing in Bangalore

7.2.3 POPULATION

Third year Bsc. Nursing students of selected College of nursing,Bangalore

7.2.4 SAMPLE SIZE

50 BSc. Nursing students of selected College of nursing

7.2.5 SAMPLING TECHNIQUE

Non-probability convienent sampling technique

7.2.6 DATA COLLECTION TOOL

Tool-I: Demographic data

Tool-II: Information to assess the knowledge and practice on the partogram

7.2.7 DATA ANALYSIS

Descriptive and inferential statistics

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR

INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER
HUMANS OR ANIMALS? IF SO DESCRIBE BRIEFLY.
______________ No ____________
7.4 HAS ETHICAL CLEARENCE BEEN OBTAINED FROM YOUR
INSTITUTION IN CASE OF 7.3?
 Yes, ethical clearance will be obtained from research committee of the
Jupiter College of Nursing.

8. LIST OF REFERENCES
1. Bo O. “Improving intrapartum care with better use of the partogram”. In:
Brown HC, paranjothy S, Dowswell T, Thomas J. Package of care for
active management in labour for reducing caesarean section rates in
low-risk. Cochrane Database Syst Rew. 2008; (4): CD004907

2. Cochrane Database Systematic Review. “Effect of Partogram Use on

Outcomes for women in spontaneous labour at term”. 2008. Available
from: http://www:nursing.manchester.ac.uk/research/pubDetails

3. Kwast EB, Poovan P, Vera E, Kohis E. “Modified WHO partograph: do

we need a latent phase?” 2008; 2(3): 143-148.

4. Orji E. “Evaluation progress of labor in nulliparas and multiparas using

the modified WHO partograph”. International Journal of Gynecology
& Obstetrics. 2008; 102(3): 249-252.

5. Mathews JE, Rajaratnam, George, Mathai M. “Comparison of two World

Health Organization Partograph”. International Journal of Gynecology
& Obstetrics. 2007; 96(2): 147-150.

6. Lavendert T, Alfirevic Z, Walkinshaw S. “Effect of different partogram

action lines on birth outcomes: a randomized controlled trail. Evid
Based Med”. 2007; 12(2): 46. Available from: http://www.controlled-
trials.com/isrctn/trial/l/0/78346801.html
7. Azandeybe N, Testa J, Makoutode M. “Assessment of partogram
utilization in Benin”. Gynecol. 2004; 108(2): 295-302

8. Soni BL. “Effect of Partogram use on outcomes for women in

spontaneous labour at term”. 2008. Available from:
http://apps.who.int/rhl/pregnancy_
childbirth/routine_care/cd/cd005461

9. Fahdhy M. “Evaluation of World Health Organization partograph

implementation by midwives for maternity home birth in Medan,
Indonesia”. The Australian Journal of midwifery, 2005; 14(3), 22-27.

10. Lavender T. “NCT Evidence Based Briefing Use of the Partogram in

Labour”. In: National Childbirth Trust. Early days- life with a new
baby. London, National Childbirth Trust. (2003) and Brown S,
Lumley J. Maternal Health after childbirth: results of an Australian
population based survey. Br J Obset Gynaecol. 1998; 105(2): 156-61.

11. Lennox EC, Kwast EB, Farley MMT. “Breech labor on the WHO
partograph”. International Journal of Gynecology & Obstetrics. 1998;
62(2): 117-127
9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE

11. NAME AND DESIGNATION OF THE GUIDE

11. 1 SIGNATURE OF THE GUIDE

11. 2 HEAD OF THE DEPARTMENT

11. 3 SIGNATURE OF HOD

12. REMARKS OF THE PRINCIPAL

13. SIGNATURE OF THE PRINCIPAL