Rajiv Gandhi University of Health Sciences Karnataka



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

|1. |NAME OF THE CANDIDATE AND ADDRESS |SOUMYA GEORGE |

| | |GOLDFINCH COLLEGE OF NURSING, |

| | |NO:150/24,KODIGEHALLI MAIN ROAD, |

| | |MARUTHI NAGAR, |

| | |BANGALORE-560092. |

|2. |NAME OF THE INSTITUTION |GOLDFINCH COLLEGE OF NURSING, |

| | |MARUTHI NAGAR, |

| | |BANGALORE-560092. |

|3. |COURSE OF STUDY AND SUBJECT |MSc NURSING |

| | |OBSTETRICS AND GYNECOLOGIC NURSING |

|4. |DATE OF ADMISSION TO COURSE |30-06-2012 |

| |

|5. STATEMENT OF THE PROBLEM |

|A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING CTG MONITORING AMONG STAFF NURSES IN A SELECTED MATERNITY |

|HOSPITAL AT BANGALORE |

6.0 BRIEF RESUME OF INTENDED WORK

INTRODUCTION

‘Making childbirth safer, Reducing avoidable harm in childbirth’

Birth is the end of the pregnancy. It encompasses two major phases, referred to as

labour and delivery21. Every pregnant woman expects to have a safe delivery and a healthy baby. Unexpected maternal and fetal complications may occur during labour or delivery or postpartum, even in women without risk factors. About 30% of hospital deliveries involve an obstetric complication. So it is important that the wellbeing of both mother and her baby is carefully monitored during labour.

The midwife plays a significant role in monitoring the health and well-being of the woman and her family during their labour and birth journey. This journey is a significant life event as the woman evolves from Womanhood to Motherhood and the foetus leaves the uterus to join the family. Evidence supports monitoring both foetal and maternal health status during this journey to enhance birth outcomes that impact on the health of families and society as a whole. The midwife supports the woman to enhance the natural processes of labour, monitors the maternal and foetal heart rates, the uterine contraction pattern and minimises unnecessary interruptions to these processes. Continuous foetal monitoring (CEFM) is one intervention that can potentially help detect foetal complications.1

Recording the foetal heart rate has been standard practice for more than 159 years. The wooden Pinard’s stethoscope was the first technology to be introduced and its modern version is still in clinical usage in under developed countries. However, it only provides information on the number of heart beats per minute. Electronic foetal monitoring was developed with the introduction of Cardiotocography (CTG) technology, 1 which rapidly gained clinical acceptance. It was believed that the provision of continuous information would enable clinicians to detect babies exposed to oxygen deficiency. For many years it was assumed that birth asphyxia was the principle cause of cerebral palsy [CP]. Indeed when CTG was introduced in late 1960s it was hoped that this technique would reduce the incidence of CP and mental retardation by 50 %. 2

The Cardiotocography was invented in early 1960’s by Hammacher, working closely with Hewlett Packard. Its introduction into the clinical setting was surrounded by great fanfare and before the end of the decade continuous electronic fetal monitoring (EFM) was in widespread clinical use23 .The general expectation was that within a short time cerebral palsy (CP) would be virtually eliminated. At the time obstetricians felt that the fetal monitor had given them, for the first time, a window through which they could monitor the wellbeing of the fetus antenatal and during labour. Since caesarean section (CS) had become a relatively safe procedure by this time they thought that they had the power to save babies from the potentially catastrophic effects of hypoxia during labour. CTGs have a high degree of sensitivity but a low level of specificity which means that they are very good at telling us which foetuses are well but are poor at identifying which foetuses are unwell. The differences in individual foetal responses to a decrease in oxygen (and therefore differences in heart rate changes) mean that the positive predictive value of CTG for adverse outcome is low and the negative predictive value high. The increased intervention rates associated with EFM can be reduced with the use of foetal blood sampling. 2

The main purpose of modern obstetrics is to reduce maternal and foetal perinatal risk and to ensure complete integrity of the mother and foetus during labour by increasing security in these respects. Cardiotocography (CTG) is the most common method of foetal monitoring both during and before labor. Cardiotocography is a modern non-invasive means of ante partum and intrapartum fetal status monitoring method that strongly impacts on obstetric practice. The CTG output is influenced by all hypoxic, metabolic or qualitative maternal blood alterations, showing besides Bradycardia and tachycardia suggestive hypoxic injury alterations: lack of variability, flat/smooth fetal heart rate (FHR) baseline, accelerations and decelerations.CTG monitoring during labour may be continuous or intermittent (at every 15 minutes). 3

We know that misinterpretation of CTGs, poor documentation and failure to refer to a doctor are key trends in adverse neonatal outcomes. Some trusts have implemented a 'fresh eyes' approach to CTG interpretation ensuring that CTG traces are interpreted by more than one person24. A fresh eyes approach recognizes that factors such as fatigue, familiarity and limited knowledge can lead to lack of objectivity and this can impede accurate interpretation of a CTG. We decided to take this a stage further and implement a CTG categorization buddy system where midwives on the delivery suite are paired together to make assessments of each other’s CTG traces. 3

6.1 NEED FOR THE STUDY

Poor standards and training of foetal monitoring during labour are a major cause of avoidable perinatal deaths. The issue has been highlighted repeatedly by reports of the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI). Many obstetricians and midwives state they have commenced working on labour wards without formal CTG training 4.

Continuous EFM only provides a printed recording of the FHR pattern. The interpretation of the FHR record is subject to human error. Education and training improve standards of evaluating the FHR. Trusts should ensure that staff with responsibility for performing and interpreting the results of EFM should receive annual training with assessment to assure that their skills are kept up-to-date21.

Using CEFM in the case of a complicated (high risk) labour and birth journey is known to improve foetal outcomes, justifying its use. For uncomplicated (low risk) journeys, however, intermittent auscultation (IA) is the recommended method to monitor the foetus during labour and birth. Using CEFM in low risk labour and birth offers no improvement in long term foetal outcomes, restricts the woman’s comfort choices, interrupts natural birthing behaviours and often leads to increased medical interventions 5.

Monitoring the baby's heartbeat is one way of checking babies' well-being in labour. By listening to, or recording the baby's heartbeat, it is hoped to identify babies who are becoming short of oxygen (hypoxic) and who may benefit from caesarean section or instrumental vaginal birth. A baby's heartbeat can be monitored intermittently by using a fetal stethoscope, Pinard (special trumpet shaped device), or by a handheld Doppler device 2. The heartbeat can also be checked continuously by using a CTG machine. This method is sometimes known as electronic fetal monitoring (EFM) and produces a paper recording of the baby's heart rate and their mother's labour contractions 2. It also means that some resources tend to be focused on the needs of the CTG rather than the woman in labour20.

During childbirth, the fetal heart rate is considered a valuable indicator of how the fetus is tolerating labour. It is normal to observe a slight deceleration in the fetal heart rate during labour contractions as the uterine muscles temporarily restrict blood flow to the fetus. The reduced blood flow results in decreased oxygen delivery to the fetus, an event referred to as hypoxia. When the uterine muscles relax at the end of the contraction, normal blood flow resumes, oxygen delivery increases and the fetal heart rate rebounds. This cycle is a considered a normal part of the birth process and causes no identifiable harm to the fetus.

On rare occasions, if the blood flow is too restricted or is restricted for an extended period of time, the oxygen supply to the fetus may decline more than is normal. When this happens the fetal heart rate decreases significantly and the fetal heart rate may rebound slowly or not at all. Prolonged depressions and certain types of decelerations of the fetal heart rate can signal that the fetus is in distress and might possibly suffer permanent neurological damage or even die from oxygen deprivation. If the fetal heart rate measurements indicate extreme distress, immediate intervention is necessary to save the fetus.

EFM records what happening in real time with the contractions, it graphically establishes a notion of antagonism between the mother and fetus, as each of the mother’s contractions is shown to cause fetal stress. Though physicians knew of this phenomenon from manual auscultation, the EFM displays the correlation in a more tangible, dramatic way. The output of the EFM demonstrates direct opposition between the woman’s body and the fetus’ well-being in compelling graphic form. The presentation of information in this way solidifies the perception of labour as dangerous and reinforces the idea that the obstetrician must protect the fetus from the risks created by the maternal body during labour.

A Cochrane Collaboration review has shown that use of Cardiotocography reduces the rate of seizures in the newborn. The false-positive rate of Cardiotocography for cerebral palsy is given as high as 99%, meaning that only 1-2 of one hundred babies with non-reassuring patterns will develop cerebral palsy. When introduced, this practice was expected to reduce the incidence of fetal demise in labor and make for a reduction in cerebral palsy (CP). 8

All evidences show that continuous fetal monitoring has major role to play in modern obstetrics. At the core of a safe team is a well-trained and skilled workforce. This could not be more essential in identifying and responding to emergency situations within maternity. Both midwives and junior doctors can often feel ill-equipped or lacking in confidence when presented with an emergency situation in the hospital or the community. Indeed, with childbirth taking place at home, in midwifery-led units, or out of hours, staffs need to be effectively prepared for any eventuality25.

‘Staffs who work together must train together’22. This approach not only helps staff to recognize their unique but complementing roles but also helps to remove barriers to effective communication and teamwork. The Safe Births report recommended the use of simulation-based training, which assesses clinical skills as well as communication and team working. Skills and drills training within the staff’s own unit would be most beneficial. Therefore in this research the researcher plan to do experimental study to assess the effectiveness of teaching staff nurses about CTG monitoring.23

6.2 REVIEW OF LITERATURE

Review of literature is considered as the most important pre requisite to actual planning and conduct of study. Review of literature involves systematic identification, location, scrutiny and summarization of written materials that contain information regarding research problem. Literature review is the sources that are an effective in providing the in depth knowledge that the researcher needs to study the selected problem .In addition, referring to Fain (2009) says that the major purpose of the literature review is to find out what is already known and unknown about the problem. This section provides the detailed information that is relevant and related to my research topic.

The related literature has been categorized and discussed on the basis of their priority and contribution to the study under the following

1) Studies related to Fetal heart rate monitoring during labour

2) Studies related to CTG monitoring during labour

3) Studies related to Knowledge of staff nurses regarding CTG monitoring

6.2.1 Studies related to Fetal heart rate monitoring during labour

A study conducted by experts on Development, evaluation and validation of an intelligent system for the management of labour. This study involved 17 experts from UK. Each expert and the system reviewed 50 cases twice, at least one month apart which contained those CTGs considered most difficult to interpret selected from a database of 2400 high-risk labours. The CTG information, together with the patient information and labour events, are collectively passed to an expert system for processing. The expert system interprets this combined data using a database of over 400 rules which are used to recommend action. Importantly, as the knowledge is rule-based, it allows the system to explain the reasoning which led it to recommend a certain action. After two internal evaluations had found the system obtained a performance comparable with local experts, an extensive external validation was undertaken. This study found that the majority of experts agreed well and were consistent in their management of the cases. The system obtained a performance that was indistinguishable from the experts, except it was more consistent, even when used by an engineer with little knowledge of labour management. This study demonstrates the potential for intelligent systems to transform the Cardiotocography from a difficult-to-use, ineffective recorder of fetal heart rate, to an interactive and effective decision support tool capable of raising the skills of staff13.

A comparative study on Efficacy and safety of intrapartum electronic fetal monitoring: The study included 58,855 pregnant women and their 59,324 infants in both high- and low-risk pregnancies from ten clinical centers in the United States, Europe, Australia, and Africa. A statistically significant decrease was associated with routine EFM for 1-minute Apgar score less than 4 and neonatal seizures No significant differences were observed in 1-minute Apgar scores less than 7, rate of admissions to neonatal intensive care units, and perinatal death. An increase associated with the use of EFM was observed in the rate of caesarean delivery. Risk of caesarean delivery was greatest in low-risk pregnancies the only clinically significant benefit from the use of routine EFM was in the reduction of neonatal seizures18.

A survey study conducted in Canada related to Electronic fetal monitoring to determine the current status of electronic fetal monitoring (EFM) in Canadian teaching and nonteaching hospitals, to review the medical and nursing standards of practice for EFM and to determine the availability of EFM educational programs. The directors of nursing at the 737 hospitals providing obstetric care were sent a questionnaire and asked to have it completed by the most appropriate staff member. However, 21.6% of the hospitals with monitors had no policy on EFM practice. The availability of EFM educational programs for physicians and nurses varied according to hospital size, type and region. Most Canadian hospitals providing obstetric services have electronic fetal monitors and use them frequently. Although substantial research has questioned the benefits of EFM, further definitive research is required16.

A study done on Electronic fetal heart rate monitoring and its relationship to neonatal and infant mortality in the United States. The researchers reviewed 1,732,211 singleton live births (elective C-sections and congenital anomalies were excluded). Of these births; 89% involved EFM while 11% did not. The risk of corrected mortality rate was different between those with or without EFM during the early neonatal period. The secondary analysis also indicates that the rate of neonatal seizure was significantly lower only among high-risk women who had EFM. EFM appears to save lives by decreasing the risks of hypoxic brain injuries associated with low Apgar scores (‹4). The study did not include intrapartum deaths (Apgar 0), where the benefits of EFM are similar or even larger. The bottom line is that the largest study of electronic foetal monitoring to date shows that EFM cuts the rate of early neonatal death in half. That is a dramatic benefit. 15

6.2.2 Studies related to CTG monitoring during labour

A prospective study evaluated sensitivity and specificity of presently used methods for intrapartum monitoring and their mutual comparison of pregnancy. Study conducted on 114 pregnant women with high-risk or pathological course and researcher evaluated the capability of individual methods to predict intrapartum hypoxia, determined on the basis of postnatal evaluation of parameters observed (Apgar score in 1st minute, pH from umbilical artery, lactate levels in fetal blood, base excess (BE) and postpartum condition of fetus evaluated by a neonatologist). A similar or different prediction of the condition of the newborn by these individual methods was evaluated by the McNamara test of symmetry. In that 50 deliveries performed by Caesarean section and 24 forceps deliveries the researcher evaluated postnatal pH from umbilical artery and evaluation by Chi-square test. The best balanced evaluation of the newborns is provided by FpO2 and there was a significant difference between CTG and FpO2. The occurrence of emergencies in the course of a pathological delivery in individual methods is as follows: CTG, FpO2 and STAN .the study concludes CTG draws attention of the obstetrician very early to the possibility of developing hypoxia12.

A comparative study was conducted on performance by medical and midwifery students in multiprofessional teaching. 13 Midwifery and 38 medical students of Dundee University participated in the study they were taught obstetrics together in a 2-week intensive course. They tested the students before and after a timetabled computer-assisted learning (CAL) session focusing on how to interpret a Cardiotocography (CTG). Also, half of each student group was given extra CTG teaching before the CAL session. The medical students increased their median score from 9 to 17 but the midwifery students only increased their median score from 12 to 14 after the CAL. However, when given a tutorial and CAL, the post-test scores for both medical and midwifery students were similar and significantly higher than pre-test scores. This study concludes that shared resources could be used by medical and midwifery students to reach equivalent levels of skill in CTG interpretation19.

A study was conducted using a multicentre randomized clinical trial. This is the first time that computer analysis of intrapartum fetal monitoring with real-time alerts is being compared with conventional fetal monitoring in a randomized trial, so there is no prior evidence of benefit for the reduction in the incidence of adverse neonatal outcomes. However, there are observational data to suggest that computer analysis of fetal monitoring signals has a higher validity in prediction of adverse outcomes. Inclusion criteria are, women aged ≥ 16 years, able to provide written informed consent, singleton pregnancies ≥ 36 weeks, cephalic presentation, no known major fetal malformations, in labour but excluding active second stage, planned for continuous CTG monitoring, and no known contra-indication for vaginal delivery. Eligible women will be randomized using a computer-generated randomization .The addition of fetal electrocardiogram analysis has increased the potential to avoid adverse outcomes, but CTG interpretation remains its main weakness. A program for computerized analysis of intrapartum fetal signals, incorporating real-time alerts for healthcare professionals, has recently been developed. The addition of fetal electrocardiogram ST waveform analysis to conventional has been shown to increase the identification of fetuses with metabolic acidosis. A systematic review of the first three trials comparing CTG+ST monitoring with conventional CTG showed that the former significantly decreases the rates of fetal blood sampling, neonatal encephalopathy and operative delivery, and is associated with a borderline reduction in the incidence of umbilical artery metabolic acidosis. It has recently been documented that adverse neonatal outcomes continue to occur with routine use of the technology, because of human errors, such as poor CTG interpretation, delay in taking appropriate action, or failure to follow clinical guidelines, as well as non-occurrence or very late occurrence of ST events .

6.2.32 Studies related to Knowledge of staff nurses regarding CTG monitoring

A descriptive study was conducted on Midwives' and doctors' attitudes towards the use of the Cardiotocography machine. The purpose of the research was to provide a new insight into the attitudes of doctor and midwives towards the use of CTG. Participants undergone a semi-structured interview .A valid and reliable tool designed by Sinclair (2001) was used to measure the attitudes of doctors and midwives towards CTG usage. The study was conducted on 56 midwives and 19 doctors who worked in the labour ward within the last year. Six midwives and two doctors were randomly selected to participate in the interviews. The majority of the respondents 24 (60.0%) felt that their training adequately prepared them for using CTGs. The illustrative accounts provided by the respondents demonstrated a predominant belief that CTG technology continues to have a role in monitoring and detecting abnormalities in the fetal heart rate but this role is limited by how well the CTG is used and interpreted. The interviews confirmed the data obtained from the questionnaires and revealed a number of professional needs and concerns relating to CTG usage10.

A study was conducted on deceleration. The aim of this to study assess Cardiotocography (CTG) interpretation by midwives and trainee obstetricians using the standard and a modified definition of fetal heart rate deceleration compared with consultant interpretation as the Gold Standard. It was conducted at a tertiary obstetric unit, UK by using a randomized survey by online tool between 4 January and 24 April 2009, a total of 104 (54%) health professionals responded, providing 1,118 responses with respect to the presence of decelerations on 13 anonymised CTGs. Five obstetric consultants (62.5%) provided expert opinion. Midwives and trainee obstetricians were more likely to concur with Consultant opinion when using the modified definition of fetal heart rate deceleration compared with the standard definition. Larger scale studies may be needed to further evaluate the usefulness of the modified definition21..

Descriptive correlational study was conducted on midwifery attitudes on CTG monitoring. The aim of study to identify the midwives' attitudes and practices related to intrapartum fetal monitoring. All midwives were invited to participate. The study were administered on 242 midwives in UK and 117 were returned (48% response rate).The information was collected by using a questionnaire on professional/demographic details, education and practices related to intrapartum fetal monitoring, together with a 20-item attitude scale which encompassed attitudes towards fetal monitoring and related issues. The findings suggest that midwives' preferred methods of fetal monitoring varied with the client's risk category. However, midwife preference did not necessarily match actual choice of method. There are many factors influencing choice, not least of which is confidence in ability. Significant differences were found between midwives the findings highlight some of the issues relating to individual confidence. The midwives (97%) felt they would benefit from in-service training in CTG interpretation. The findings support the development of continuing in service education programmes for midwives. 22

A study conducted on Midwives' visual interpretation of intrapartum Cardiotocography: intra- and inter-observer agreement. This study aims validity of electronic fetal heart rate monitoring and subsequent decisions on intrapartum management of midwives' by interpretations of CTG tracings. 28midwives independently interpreted three intrapartum CTG tracings on two separate occasions using a self-administered Cardiotocography Interpretation Skills Test. Efforts are needed to reduce inter- and intra-observer variation in interpretation of intrapartum CTG tracings. , this research suggests focusing on the development and evaluation of non-invasive, low observer variability methods of intrapartum assessment of fetal well-being. The subjectivity of CTG interpretation and inconsistencies in interpretation should also be considered in intrapartum management, clinical audit and in medico-legal settings21.

6.3 PROBLEM STATEMENT

“ A study to assess the effectiveness of structured teaching programme on knowledge regarding CTG monitoring among staff nurses in selected maternity hospital in Bangalore ’’

6.4 OBJECTIVES OF THE STUDY

1) To assess the pre-test level of knowledge of staff nurses regarding CTG

2) To assess the post-test level of knowledge of staff nurses regarding CTG

3) To compare the Pre-test & Post -test level of knowledge of staff nurses regarding CTG

4) To associate the Post-test level of knowledge with selected demographic variables

6.5 OPERATIONAL DEFINITIONS

Effectiveness: It refers to the extent to which the desired improvement achieved in knowledge after using structured teaching programme among staff nurses.

Structured teaching programme: it is a planned, well organised educational tool intended to provide information (or) knowledge for staff nurses on CTG.

CTG: It is an electronic device that monitors and record uterine contractions and foetal heart beat.

Staff Nurses: A graduate nurse who has been legally authorized (registered) to practice after examination by a state board of nurse examiners or similar regulatory authority, and who is legally entitled to use the designation Registered Nurses.

6.6 ASSUMPTIONS

It is assumed that:

1. Staff nurses may have inadequate knowledge regarding CTG monitoring.

2. Demographic variables may have influence on Staff nurses knowledge regarding CTG monitoring.

3. Structured teaching programme may enhance knowledge of staff nurses regarding CTG monitoring.

6.7 HYPOTHESES

H1: There will be a significant difference between Pre-test and post-test level of knowledge of staff nurses regarding CTG monitoring.

H2: There will be significant association of post-test level of knowledge with selected demographic variables.

6.8 DELIMITATIONS

The study is delimited to:

• Period of 4 weeks.

• Nursing staff working in maternity ward.

• Selected settings only at Bangalore.

6.9 PROJECTED OUTCOME

There will be a significant improvement on knowledge regarding CTG monitoring and it improves patient safety. Nurses able to identify the importance of CTG and enhance the proper management in acute settings. It improves confidence level of staffs who are dealing with maternity patient. They can put their knowledge in practice and play a major role in teamwork.

7.0 MATERIALS AND METHODS

7.1 SOURCE OF DATA

RESEARCH DESIGN AND APPROACH

An evaluative research approach is used for this study.

The research design adopted for present study is pre-experimental one group pre- test & post test design. The design can be represented as:

| | | |

|Pre-test |Manipulation |Post-test |

| | | |

|O1 |X |O2 |

Fig.1 Schematic representation of research design

Key:

O1. Pre test.

X. Structured teaching programme on CTG monitoring

O2. Post test.

7.1.2 SETTING OF THE STUDY

The study will be conducted at selected maternity settings

7.1.3 POPULATION

Population included in this study is staff nurses of selected settings

7.2 METHOD OF COLLECTION OF DATA

7.2.1 SAMPLING PROCEDURE

Non probability sampling technique

2. VARIABLES OF STUDY

Independent variable

Structured Teaching Programme.

Dependent variable

Knowledge of staff nurses.

Demographic variables

Age, education, total years of experience, total years of experience in maternity area, etc

7.2.3 SAMPLE SIZE

40 staff nurses from a selected maternity setting at Bangalore.

4. DURATION OF THE STUDY

4 weeks.

7.2.5. INCLUSION CRITERIA FOR SAMPLING

The subjects will be selected based on predetermined criteria.

Staff nurses who are

❖ Working in selected maternity hospital

❖ Engaging in direct maternity care

❖ Able to understand Kannada or English language

7.2.6 EXCLUSIVE CRITERIA

❖ Staff nurses who working in administrative level.

❖ Staff nurses not willing to participate in this study

❖ Staff nurses and student nurses.

7. INSTRUMENT INTENDED TO BE USED

• Section A: Demographic data

• Section B: Knowledge questionnaire

METHOD OF DATA COLLECTION

Knowledge will be assessed personally using structured questionnaire from staff nurses before and after administering a structured teaching programme.

8. LIMITATIONS

The study is limited to staff nurses:

1. Who are working in the selected maternity hospitals Bangalore.

2. Sample size is limited to 40 staff nurses.

7.2.9 METHOD OF DATA COLLECTION

After obtaining the official permission from concerned hospital management, informed consent from the samples, the investigator personally collect the base line demographic data. After which the data will be collected in the following:

Phase1: Assess the existing knowledge regarding CTG monitoring with the help of structured questionnaire.

Phase 2: Structured Teaching programme regarding CTG monitoring and interactive discussion with staff to make CTG interpretation by giving sample exercises.

Phase 3: After Structured teaching, there will be assessment of post test knowledge regarding CTG monitoring will be assessed within the same group using same knowledge questionnaire

7.2.10 METHOD OF DATA ANALYSIS

The investigator will analyze the data obtained by using descriptive and inferential statistics. The plan of data analysis as follows:

← Organize the data in a master sheet/computer.

← Descriptive statistics:

Mean, Mode, Median, Percentage and Standard Deviation will be used for assessing their demographic characteristics

← Inferential statistics:

‘t’-test will be used to compare the pre-test and post-test level of knowledge.

Chi square test will be used to establish association between, knowledge with selected demographic variables.

2. Dose the study require any investigation or intervention to be conducted on patients or other humans or animals? If so please describe briefly.

-YES-Structured teaching programme will be administered to staff nurses in selected maternity settings at Karnataka.

7.4 ETHICAL CLEARANCE

• Yes, the ethical clearance will be obtained, from the concerned Authorities.

• Permission will be obtained from the Principal and from the concern authority of selected setting, Bangalore, to conduct the study.

• Written consent will be received from the subjects after explaining the purpose of the study.

• Confidentiality of the subjects will be maintained for the study.

7.5 ETHICAL COMMITTEE

|Title of the topic |“A study to assess the effectiveness of structured teaching programme on |

| |knowledge regarding CTG monitoring among staff nurses in selected |

| |maternity hospital in Bangalore’’ |

|Name of the candidate |Ms. Soumya George |

|Course and the subject |MSc Nursing in Obstetrics and Gynecological Nursing |

|Name of the guide |Mrs. Kalaivani |

|Ethical committee |Approved |

8.0 LIST OF REFERENCES

1. Cydney Afriat Mennihan, Ellen Kopal.CTG monitoring. Assessment of foetal heart rate, ,Lippincott.2002June;17-59.

2. Thomas P.sartwelle,LL.B, A Bridge to Far. Electronic foetal monitoing.The Journal Of legal medicine,2012 Jan;33:313-378.

3. American College of Obstetricians and Gynecologists. Intrapartum foetal heart rate monitoring: nomenclature, Interpretation, and General Management Principles. ACOG practice Bulletin No. 16: Obstetric Gynecol. 2009;114(1):192-202.

4. Graham EM, Peterson SM, Christo DK, Fox HE. Intrapartum electronic foetal heart rate monitoring and the prevention of perinatal brain injury. Obstetric Gynecol. 2006;108(3Pt1):656-666.

5. Chauhan SP, Klauser CK, Woodring TC, Sanderson M, Magann EF, Morrison JC. Intrapartum nonreassuring fetal heart tracing and prediction of adverse outcomes: Interobserver variability. 2008;199(6):623.e1-e5.

6. Larma JD, Silva AM, Holcroft CJ, Thompson RE, Donohue PK, Graham EM. Intrapartum electronic fetal heart monitoring and the identification of metabolic acidosis and hypoxic-ischemic encephalopathy. Am J Obstet Gynecol. 2007;197(3):301.e1-e8.

7. Macones GA, Hankins GD, Spong CY, Hauth J, Moore T. The 2008 National Institute of Health and human Development Workshop report on electronic foetal monitoring: update on definitions, interpretation, and research guidelines. Obstetric Gynecol. 2008;112(3):661-666.

8. Costa A, Ayres-de-Campos D, Costa F, Santos C, Bernardes J. Prediction of neonatal acidemia by computer analysis of foetal heart rate and ST event signals. Am J Obstetric Gynecol. 2009;201(5):464.e1-e6.

9. Fedorka P. Electronic foetal monitoring: an update. J Legal Nurse Consulting. 2010;21(1):15-18.

10. Parer JT& Ikeda T. A framework for standardized management of the intrapartum foetal heart rate patterns. Am J Obstetric Gynecol. 2007;197(1):26.e1-e6.

11. Lewis, L., & Rowe, J. (2004b). Focus on the beat: current foetal monitoring practice in low-risk labour. Australian Midwifery Journal, 17(4), 6–10.

12. Feinstein, N., Sprague, A., & Trepanier, M. (2000). Foetal heart rate auscultation:comparing auscultation to electronic foetal monitoring. AWHONN Lifelines, 4(3),35–44.

13. Flood-Chez, B., Harvey, M., & Harvey, C. (2000). Intrapartum foetal monitoring: Development, evaluation and validation of an intelligent system for the management of labour.Journal of Perinatal and Neonatal Nursing, 14(3), 1-18.

14. Foley, L., & Faircloth, C. (2003). Medicine as discursive resource: legitimation in the work narratives of midwives. Sociology of Health & Illness, 25(2), 165-184.

15. Goodwin, L. (2000). Intermittent auscultation of the foetal heart rate: a review of general principles. Journal of Perinatal Nursing, 14(3), 53–61.

16. Kennedy, G. (1998). Electronic foetal heart rate monitoring: retrospective reflections on a twentieth-century technology. Journal of the Royal Society of Medicine, 91, 244 –250.

17. Greenhalgh, T. (1997). (systematic review and meta-analyses). British Medical Journal, 315, 672–675.

18. Guilliland, K., & Pairman, S. (1995). The midwifery partnership: a model for practice.Wellington: Department of Nursing & Midwifery, Victorian University of Wellington.

19. A comparative study was conducted on performance by medical and midwifery students in multi-professional teaching Retrieved from ncbi.nlm.

20. A study conducted on Midwives' visual interpretation of intrapartum cardiotocographs Retrieved from

21. A study was conducted on Intrapartum cardiotocograph interpretation by midwives and trainee obstetricians using a modified definition of a foetal heart rate deceleration Retrieved from riskmanagement

22. A prospective study evaluated sensitivity and specificity of presently used methods for intrapartal monitoring and their mutual comparison of pregnancy Retrieved from .

23. A survey study conducted in Canada related to Electronic foetal monitoring

24. A study conducted by experts on Development, evaluation and validation of an intelligent system for the management of labour

| | | |

|9 |SIGNATURE OF THE CANDIDATE | |

| | |The study will enable the staff nurses to update their knowledge in |

|10 |REMARKS OF THE GUIDE |CTG monitoring which helps them to monitor the fetal well being |

| | |effectively. |

| | | |

|11 |NAME &DESIGNATION OF THE GUIDE | |

| |NAME & DESIGNATION OF THE | |

|11.1 |THE GUIDE | |

| | | |

| |SIGNATURE | |

|11.2 |NAME &DESIGNATION OF | |

| |THE CO-GUIDE | |

| | | |

| |SIGNATURE | |

|11.4 | | |

| |12.1 REMARKS OF THE CHAIRMAN OR PRINCIPAL |The study is feasible and can improve the knowledge of staff nurses |

| | |regarding CTG monitoring |

| | | |

| |12.2 SIGNATURE | |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download