BACKGROUND OF THE STUDY

“WOMEN’S HEALTH IS THE EFFECT OF GENDER ON DISEASE AND

HEALTH THAT ENCOMPASSES A BROAD RANGE OF BIOLOGICAL AND

PSYCHOSOCIAL ISSUES”.

-The Second National Conference of the Society of Midwives,

2003.

Introduction

Childbirth is one of the most marvelous and memorable segment in a

woman's life. It does not really matter if the delivery is first, second or the

third. Each experience is unique and calls for a celebration. The fear and

anxiety about childbirth and the maternal care often prevents most women

from enjoying this experience. Adequate and appropriate care during intra natal

period results in a good outcome of the labour which can impart a feeling of

confidence and sense of emotional wellbeing ensuring a successful labour.1

Labor is a physiologic process during which the products of conception i.e.

the foetus, membranes, umbilical cord and placenta are expelled outside from

the uterus into the outer world. The process of labour is an enormous

emotional and physiologic accomplishment for the women and her support

person. Inadequate care during labour results in threats to the life of the

mother and the foetus. In order to prevent complications during labour and

for a better outcome, it is essential to follow the simple and effective tool

such as a partograph, by the health care providers with an adequate

knowledge and skill.2

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Labor has been termed the most dangerous journey a human ever under takes.

The reason being that although it is a natural process but complications can arise

at any time during its course. One of the tools used to monitor labor and prevent

prolonged and obstructed labor is the partograph, a preprinted one-page form on

which labor observations are recorded. The purpose of the partograph is to help

health care providers record, interpret, analyze, and use data to make clinical

management decisions while labor is in progress. The form provides a graphic

overview of the progress of labor and records information about maternal and

fetal condition during labor.3

The partograph provides information about deviations from the normal progress

of labor and about abnormalities of maternal or fetal condition during labor. It

alerts providers when a woman may need an intervention and facilitates ongoing

evaluation of the effects of those interventions.4

An important development in the management of labour was the introduction of

the partogram. A partograph is a representation of the changes that occur in

labour, including cervical dilatation, fetal heart rate, maternal pulse, blood

pressure and temperature. It also shows a numerical record of features such as

urine output and the volume and type of intravenous infusions (including

oxytocin drips). It is therefore possible at a glance to identify deviations from

normal in any of this variable.5

The partograph has following advantages:-

 It depicts the progress of labor at a glance.

 It enables failure to progress to be readily recognized.

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 It is simple to use.

 It provides a practical teaching aid.

 It is an efficient means of exchange of technical information about labor

progress between teams of care givers.5

The partograph can be used by midwives personnel to assess the progress of

labor to identify when intervention is necessary. Studies have shown that using

the partograph can be highly effective in reducing complications from prolonged

labor for the mother such as postpartum hemorrhage, sepsis, uterine rupture and

its sequelae and for the newborn like death, anoxia, infections, etc. It is very

useful to assist in make the correct decision about transfer, Caesarean birth, or

other life-saving interventions. Partograph is one of the very important tools for

monitoring the labor. This helps in identifying the prolonged labor, decision for

augmented labor and for the operative birth. This make to reduce the maternal

mortality rate during the intranatal period.6

The World Health Organization modified partogram is widely used under

resourced setting as a simple and affordable tool to monitor labor. The

partograph is legal record and may be examined by any court up to a period

of twenty five years and is developed for usage in hospital setting. The use of

partograph modified by the WHO significantly improves the maternal and

neonatal outcome of labor and is therefore recommended worldwide.7

Around 97% of still birth and 98% of neonatal deaths occur in under

developed countries due to the inadequate care and failure to identify the

complications at early hours of intra natal period. In 1954, Friedman

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introduced the concept of a partogram by graphical representation of the

dilation of the cervix during labour. In 1972, Philpot and Castle

developed Friedman’s concept for monitoring labour by adding the “action”

and “alert” line to the graph. The current partograph is designed to monitor

not only the progress of labor, but also the condition of the mother and foetus

during the process labor8.

Although the partograph is viewed as an important tool during labor, its level

of awareness, application, knowledge and uses are low in developing countries.

The tool itself may present difficulties for health providers as they lack

underlying knowledge and the skills required. Hence many researcher have

recommended that health education by any tool needs to be significantly

made awareness of to all health care providers mainly nurses who care all the

time during labor.9

A partograph is one of the valuable appropriate technologies in use for

improved monitoring of labour progress, maternal and fetal wellbeing. It is

an important tool for managing labour. This is through enabling clinicians

(midwives and doctors) to plot examination findings from their assessment

on the partograph. The belief that its use was applicable in developing

settings leads to its introduction worldwide. A number of common partogram

designs incorporate an alert and action line. The partograph provided

pictorial overview to health professionals about the labour progress, maternal

and foetal condition to allow early identification and diagnosis of

pathological labour. Its use is critical in the prevention of maternal and peri

natal morbidity and mortality.10

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The majority of the deaths and complications could be prevented by cost

effective and affordable health interventions like the partograph and indeed

the measures that would prevent maternal deaths and also prevent morbidity

and improve neonatal outcome. The partograph is an effective tool for

monitoring labour, and when used effectively, will prevent prolonged labour,

which accounts for about 8% of maternal deaths. The partograph thus serves

as an early warning system and assist in early decision on transfer,

intervention decision in hospital and ongoing evaluation of the effect of

interventions.11

Increasing the effectiveness and efficiency of health services is important

everywhere but particularly in developing countries with limited resources. It

is estimated that 97% of reported of still births and 98% of reported neonatal

deaths occurs in less developed countries. In Sub Saharan Africa, women

face a 1 in 22 chance of dying during child birth whereas corresponding

deaths in industrialized countries is 1 in 8000. Continuous monitoring of

labor and provision of rapid care to deal with problems are most crucial for

preventing adverse obstetrics outcomes related to the child birth.12

WHO reports that the partograph is a vital tool for health care providers who

need to be able to identify complications in child birth in a timely manner

and refer the women to an appropriate facility hospital for treatment. The

normal pattern of partograph including latent and active phases of cervical

dilation. The WHO has been modified the partograph by removing the latent

phase of labour. This WHO modified partograh was found to be simple and

efficient in labour management by preventing prolonged labour and its

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complication. The use of modified WHO partograph significantly improves

neonatal perspective. So it is recommending that the WHO partograph be

used in all maternity units. The partograph should be enlarged to full size

before use. The record of the modified partograph consist of the patient

information – name, Para, gravida, hospital member, date and time of

admission and time of ruptured membranes or time elapsed since rupture of

membrane.13

The WHO recommended that the modified partograph be used in monitoring

all labour to identify abnormal progress and women who might need further

intervention. It records the information about the progress of labour and the

condition of a woman and her baby during labour. It is a key for the

appropriate prevention and treatment of labour complication. The use of this

partograph improves the management of labour and to support the decision-

making regarding interventions. When used appropriately, the modified

WHO partograph helps the health care providers identify the complications

of labour and know when to take the appropriate actions.14

Need of the study

The physiological transition from being a pregnant woman to becoming a

mother means an enormous change for each woman both physically and

psychologically. It is a time when each and every system in the body is

affected and the experience, though unfortunately not joyous for all,

represent a major occurrence in a women’s life. Labour, purely in the

physical sense, may be described as the process by which the foetus, placenta

and membranes are expelled through the birth canal. Of course, labour is

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much more than a purely physical event.15

Labour is a physiological process which is complicated in the majority

throughout the world. Maternal mortality and neonatal deaths occur in India

every year. The health and survival of mothers and their newborns are

intrinsically linked, and many of the same interventions that save maternal

lives also benefit their infant’s”, said UNICEF India Representative, Karin

Hulshof.16

Maternal mortality ratio continues to be the major index of the widening

discrepancy in the level of care and the outcome of reproductive health

between the advanced and developing countries which is supported by the

global maternal mortality pattern. The current estimated maternal mortality

rate globally is 0.4% in South East Asia region, the maternal mortality rate is

0.83% in India and the maternal mortality rate is 0.3%, in the southern states

is 7.7%. The maternal mortality rate in Karnataka is 2.28% and in Bangalore

it is 0.15%. Many countries have documented clinical standards to guide and

care. Every nation and every facility should have a clearly articulated

pantograph protocol for care during labour and delivery. The pantograph

should specify the function provided for different type of persons and the

competencies and pantograph needed to perform those functions.17

Tools and techniques to monitor labour thus play an important role in saving

woman’s lives. The partogram or partograph is an inexpensive tool to

provide a continuous pictorial overview of labour and is essential to monitor

and manage labour. The partogram is a single sheet of paper from which all

information related to labour is obtained. Partograph is designed for all

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maternal setting, and has different levels of functions at different levels of

health care. It serves as an “early warning system” and assists in an early

decision making on referral, augmentation and termination of labour.

Partograph also increases the quality and regularity of all observations of the

fetus and the mother in labour and aids in early recognition of problems with

either.18

The partograph can enhance the communication, interaction between health

care providers and the laboring women, promote the continuity of care across

the providers and encourages team work. The partograph provides

information about deviation from the normal progress of labor and about the

abnormalities of maternal or fetal conditions during labor. It alerts providers

when women may need an intervention and facilitates ongoing evaluation of

the effects of those interventions.19

A descriptive study was conducted to determine the uses of modified WHO

partograph. The emergency caesarean section rate was reduced from 44% to

21%. None of the cases had labour beyond 12 hours. Neonatal intensive care

admissions decreased from 17 % to 6 % indicates an improved maternal and

neonatal outcome.20

Against this back ground, there was also a need for a study on the use of the

pantograph by nursing students. Since it is one of the tool used 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 modified pantograph among

nursing students because of the reasons given above.

The investigator from her personal experience during clinical postings had seen

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inadequate care of mothers in intra natal periods at maternity units. Most of the

staff nurses and nursing students are unaware and are having inadequate

knowledge and unsatisfactory practices regarding the modified WHO partograph.

Maternal mortality rate increases because of insufficient facilities in the health

care setting, careless practice and inadequate knowledge of plotting the

interventions in the partograph.

Hence, keeping the above points in mind the investigator felt the need for

assessing the nursing students’ knowledge regarding the partograph. She also

realized that there is an immense need for issuing an instructional module on the

partograph and would like to assess its effectiveness. Through this she can

enhance the knowledge and adequate practices of the nursing students regarding

the partograph and can prevent maternal and foetal complications associated with

the process of labour.

Problem Statement

To Assess the Effectiveness of Computer Assisted Teaching on Knowledge and

Practices Regarding Partograph: An Experimental study on Nursing Students of

Selected Colleges of Ludhiana, Punjab.

Scope

The scope of the present study is to focus on the effectiveness of computer

assisted teaching on knowledge regarding partograph among nursing students

and improve their knowledge and also develop the practices about partograph

which can further reduce the risk of complications.

Aim of the study

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The aim of the study is to explore the knowledge and practices among the

nursing students regarding partograph with a view to improve their existing

knowledge and link it with the practices by computer assisted program and

giving pamphlets, so that after completion of their course they can use the

knowledge and practice for the maintenance of partograph in the labour room

and prevent further complications during labour.

Objectives of the Study

The objectives of the study are to:-

1.To assess the pre-test knowledge and practices regarding partograph

among nursing students.

2.To assess the post-test knowledge and practices regarding partograph

among nursing students.

3.To find out the correlation between pre-test knowledge and practices

regarding partograph among nursing students.

4.To find out the correlation between post-test knowledge and practices

regarding partograph among nursing students.

5.To find out the association between pre-test knowledge regarding

partograph and selected demographic variables.

6.To find out the association between pre-test practices regarding partograph

and selected demographic variables.

7.To prepare pamphlet regarding partograph among nursing students.

Operational Definitions

1. Effectiveness: It refers to the extent to which the nursing students gain

knowledge regarding partograph after computer assisted programme.

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 2. Computer Assisted Programme: It refers to the slides regarding partograph

to provide information regarding it.

3. Knowledge: It refers to the range of factual information of nursing students

regarding partograph assessed by computer assisted programme.

4. Practice: It refers to the range of factual practices of nursing students

regarding partograph assessed by computer assisted programme.

5. Partograph: It is a graphical representation of the changes that occur in the

labour for monitor the fetal and maternal well-being to reduce the maternal

morbidity and mortality rate.

6. Nursing Students: It refers to the students who are studying in GNM and

B.Sc. nursing.

7. Nursing College: An institution providing medical and surgical knowledge

and develop skills regarding

Research Hypothesis

H0: There will be no significant difference between mean pretest and posttest

knowledge score after computer assisted teaching programme regarding

partograph.

H1: There will be significant increase in posttest knowledge and practice score as

compare to pretest knowledge and practice score after computer assisted teaching

programme regarding partograph.

H2: There will be positive correlation between posttest knowledge and practice score

after computer assisted teaching programme regarding partograph.

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 H3: There will be significant association between the pretest knowledge of nursing

students regarding partograph with selected demographic variables.

H4: There will be significant association between the pretest practices of nursing

students regarding partograph with selected demographic variables.

Delimitations

 The study was delimited to 500 samples only.

 Non- standardized tool was used for this study.

 The study was delimited to nursing students studying in selected nursing colleges.

Summary

This chapter dealt with the background of the study, need of the study, statement of

the problem, objectives on which the study based, purpose of the study, research

hypothesis, delimitations and operational definitions of the some of the common

terminology, conceptual framework and organization of the report.

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 CONCEPTUAL FRAMEWORK

A conceptual framework broadly presents an understanding of the phenomenon of interest

and reflects the assumptions and philosophic views of the model’s designer. Conceptual

models can serve as springboards for generalizing research hypotheses.

- POLIT AND BECK,

2008.21

Theory is the basis of all scientific work. Theorizing is a central process in all scientific

endeavors. Theoretical thinking is essential to all professional understanding.

In the current study, King’s theory of Goal Attainment was applied to investigate the

phenomenon of interest.

APPLICATION OF THEORY OF GOAL ATTAINMENT TO THE CURRENT

STUDY

King (1997) stated that communication is the interchange of thoughts and opinions

among individuals. Communication is the main key for facilitating mutability and

trust between the nurse educator and the nurse. “Computer assisted teaching on

Partograph serves this purpose, through which the nurse educator and the

nursing students communicate with each other and exchange their ideas

regarding Partograph.”22

King’s concept of nursing is applied to this study as follows; “Nursing is an interpersonal

process of action, reaction, interaction and transaction, whereby the nurse educator and

the nursing student share information about their perceptions in the nursing situation”.

King added, “Nursing is a process of human interaction, between the nursing students and

the nurse educator whereby each perceives the other and the situation, and through

communications, they set goals, explore means and agree on means to achieve goals”.

King put particular emphasis on the nursing student’s ability for critical thinking,

observation of behavior, and the collection of specific information essential for

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 decision- making, to meet the needs of individuals at a particular point of time.

Computer assisted teaching on partograph serves this purpose, by explaining about

the importance of “Alert and Action lines”. The delivery of nursing care to patients

therefore becomes a process of thinking as well as doing, as nursing students

continuously maintain Partograph and makes decision based on it to prevent

complications. Thiscan be measured by monitoring patient outcomes.

King’s (1996) perspective of the process of nursing reflects the science of nursing,

which enables critical thinking to discover the rationale for actions taken. Computer

assisted teaching on Partograph provides such qualities.22

Goal attainment needs ongoing evaluation. According to king (1996), goal attainment

leads to effective nursing care. In this study, “Enhancing the knowledge and linked

it with the practices of the nursing students on Partograph” is the goal established

by the nurse educator and the nursing students. If this goal is attained, it ensures safety

of the mother and fetus during labour, and enhances the labour outcomes. If goals are

not attained, the nurse educatorand the nursing students need to re-examine the

process of educating, critical thinking and transaction.22

Perceptions

Perceptions refer to each person’s representation of reality. Perceptions are related to

experiences, concept of self, socioeconomic group, biological inheritance, and

educational background. In this study, the nurse educator perceives the inadequacies

of the situation and analyzes the maternal mortality and morbidity rates. The nurse

educator also perceives the need to educate the nursing students on Partograph. The

nursing student perceives the need to update their knowledge and link it with the

practices on Partograph.

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Judgement

Judgement is defined as “a dynamic and systematic process by which goal- directed

choice of perceived alternatives is made and acted upon by individuals or groups to

answer a question and attain a goal”. In this study, judgement by the nurse educator is

deciding to teach about Partograph and judgement by the nursing students is deciding

to learn about Partograph.

Action

Communication between the nurse educator and the nursing students occurs, thus

creating action. In this study, action by the nurse educator refers to the pretest

conducted by the nurse educator to assess the knowledge by self- administered

questionnaire and practices by check l ist of nursing students.

Reaction

Reaction occurs as a result of action. In this study, reaction is that the nursing

students lack knowledge and unsatisfactory practices on Partograph.

Disturbance

Inadequate knowledge and unsatisfactory practices of the nursing students, are the

disturbance felt in this study.

Mutual Goal Setting

The nurse educator and the nursing students mutually decide to enhance the

knowledge and development of practices on Partograph, and to attain this goal, the

nurse educator prepares the computer assisted teaching on Partograph.

Interaction

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Interaction is “a process of perception and communication between person and

environment, between person and person, represented by verbal or non- verbal

behaviors that are goal- directed. In this study, interaction is the computer assisted

teaching on Partograph by the nurse educator to the nursing students.

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