Content                                                                                               Page

Title page                                                                                            i

Certification                                                                                       ii

Dedication                                                                              iii

Acknowledgements                                                                            iv

Abstract                                                                      v

Table of Contents                                                                   vi

List of Tables                                                                                     xi

List of Figures                                                                                                 x

Appendices                                                                             xi

Abbreviations                                                                                      xii

CHAPTER ONE: INTRODUCTION                                                       

1.1    Background to the Study                                                                      1

1.2    Statement of the Problem                                                                      3

1.3    Significance of the Study                                                                                  4

1.4    Scope of the Study                                                                                            4

1.5    Objective of the Study                                                                                      4

1.6    Research Questions                                                                                            5

1.7    Hypotheses                                                                                                        5

1.8    Operational Definition of Terms                                                            6


2.0    Introduction                                                                                                       7

2.1    Concept of Postpartum Haemorrhage                                       7

2.2    Relationship between Postpartum Haemorrhage and Maternal Mortality         7

2.3    Classification of Postpartum Haemorrhage                                      8

2.3.1 Blood loss Quantification                                                                                  8 Blood loss during and after Delivery                                8 Hematocrit Changes                                                                          9 Blood Loss Rate                                                                                             9 Blood volume insufficiency                                                           9

2.4    Etiology of Postpartum Haemorrhage                                                   10

2.4.1 Atonic uterus                                                                                        10

2.5    Pathophysiology of Postpartum Haemorrhage                                      12

2.6    Evidence based Measures for immediate Management of Postpartum

Haemorrhage   12

2.7    Non-Pneumatic Anti-shock Garment, strategy against Postpartum

 Haemorrhage  13

2.8    History of Non-Pneumatic Anti-shock Garment                                   13

2.9    Mechanism of action of NASG                         14

2.10  Application of NASG                14

2.10.1 Procedure of Application                                14

2.10.2 Procedure for   NASG Removal15

2.10.3  Contra-indications to NASG                          15

2.11  Benefits of the NASG                                                                                       15

2.12  Empirical Studies                                               16

2.13  Evidence based  report of NASG for Postpartum Haemorrhage in

University College Hospital, Ibadan, Nigeria                                                  17

2.14  Misoprostol                                18

2.15  Concept of Active Management of third Stage of Labour                   19

2.16  Trends of Uterotonic drugs used in the Prevention of PPH           19

2.17  Reasons why Misoprostol is Preferred  20

2.18  Misoprostol and its Mode of Action     20

2.19  Benefits of Misoprostol over other conventional Uterotonic drugs in management   of postpartum haemorrhage                                                       21

2.20  Empirical Studies on Misoprostol          21

2.21  Expanding Midwives Skills       22

2.22  Theoretical Model          23

2.22.1 Bloom’s Model                                                                                   23

2.22.2The Cognitive Domain                                                                     24

2.22.3  The Psychomotor Domain                                                     25

2.23  Application of Model to the Study                               25

2.24  Application of the Psychomotor Domain in the Application of NASG            26

2.25   Conceptual Model; source; adapted from bloom taxonomy (1956)27


3.0    Introduction                                                        28

3.1    Research Design            28

3.2    Population          28

3.3    Sample size and sampling Technique                                                                 29

3.4    Instrument          30

3.5    Validity and Reliability of Instrument                                      30

3.6    Method of Data Collection                                                                    30

3.7    Method of Data Analysis          31

3.8    Ethical Consideration    32



4.0    Introduction                                                                                  33

4.1    Data Analysis and Result Presentation                                                    33

4.2    Discussion of Findings                                                                          43



5.1    Summary                                                                                                            52

5.2    Conclusion                                                                                             53

5.3    Recommendations                                                                54

5.4    Limitation of the study                                                               54

5.5    Suggestion for Further Studies                                                              54

REFERENCES                                                                                              56

APPENDICES                                                                                               62


Table                                                                                      Page

2.1    Showing Standardized Classification of PPH as described by Benedetti        10

4.1    Showing Frequency and Percentage on participant’s Socio Demographic data 33

4.2    Showing Pre and Post Intervention Knowledge level of Midwives on

Misoprostol usein the Management of PPH in Control and Experimental

groups 35

4.3 ShowingPre and post Intervention Knowledge level of Midwives in the use of NASG in the Management of PPH in the Control and Experimental Groups           36

4.4Showing Application of NASG by the Midwives in the Management of PPH Pre    and Post Intervention in the Control and Experimental group.                                     37

4.5ShowingRemoval   of   NASG by the Midwives in the Management of PPH Pre and post intervention in the Control and Experimental group.                                  38

4.6Showing Inferential Statistics comparing mean scores of Post Intervention BKnowledge of Misoprostol and NASG in the Control and Experimental group         40

4.7Showing Inferential Statistics comparing mean scores of Post Intervention Knowledge of   Misoprostol and NASG in the Control and Experimental group        41

4.8Showing Inferential Statistics comparingKnowledge mean scores of Misoprostol   use in Experimental group Pre and Post intervention                                                      42

4.9Showing Inferential Statistics comparingPre and Post Skills in the Application of NASG                                                                            43


Figure                                                                                                              Page

1        Conceptual Model                                                                                            27

2.       Research Design                                                                                               28


Appendix                                                                                                        Page 

Informed Consent Form                                                                             62

Questionnaire                                                              63

Pathfinder Teaching Package                         68

Pictures from the field work                                                                           73


PPH                             Postpartum Haemorrhage

NASG                         Non Pneumatic Antishock Garment

BUHREC                   Health Research Ethics Committee

OSHREC                    Ondo State Health Research Ethics Committee

SPB                             Systolic Blood Pressure

UNFPA                       The United Nationsfund for population activities

POPPHI                      Prevention of postpartum haemorrhage initiative

AMTSL                       Active Management of Third Stage of Labour

CCT                            Control Cord Traction

ANC                           Antenatal Clinic

CHWs                         Community Health Workers

FMOH                        Federal Ministry of Health

NASA/AMES National Aeronautics and Space Administration/Ames Research Centre

PASG                          Pneumatic Anti Shock Garment

MDG               Millennium Development Goals

FIGO                          International Federation of Gynaecology and Obstetrics

ICM                            International Confederation of Midwives

UNPD                         United Nation Population Division

MMR                          Maternal Mortality Ratio

UNPF                          United Nations Population Funds

HIV                             Human immunodeficiency virus

AIDS                          Acquired Immune Deficiency Syndrome

UNICEF                     United Nations Children’s Emergency Fund



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