TABLE OF CONTENTS
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
CHAPTER TWO: REVIEW OF LITERATURE
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
2.3.1.1 Blood loss during and after Delivery 8
2.3.1.2 Hematocrit Changes 9
2.3.1.3 Blood Loss Rate 9
2.3.1.4 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
CHAPTER THREE: METHODOLOGY
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
CHAPTER FOUR: DATA ANALYSIS, RESULTS AND
DISCUSSIONOF FINDINGS
4.0 Introduction 33
4.1 Data Analysis and Result Presentation 33
4.2 Discussion of Findings 43
CHAPTER FIVE: SUMMARY, CONCLUSION AND
RECOMMENDATIONS
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
LIST OF TABLES
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
LIST OF FIGURES
Figure Page
1 Conceptual Model 27
2. Research Design 28
APPENDICES
Appendix Page
Informed Consent Form 62
Questionnaire 63
Pathfinder Teaching Package 68
Pictures from the field work 73
ABBREVIATIONS
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
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
