SYNOPSIS ON A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED VIDEO TEACHING PROGRAMME ON NEONATAL RESUCITATION OF NEWBORNS DEVELOPING NEONATAL ASPHYXIA

CONDUCTED AMONG STAFF NURSES WORKING IN SVS HOSPITAL. BY

SUBMITTED TO DR. NTR UNIVERSITY OF HEALTH SCIENCES, VIJAYAWADA, IN PARTIAL FULFILLMENT OF THE REQUREMENT FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATIN

Name of the candidate and address

Name of the Institution

Course of Study and Subject

M Sc Nursing First Year Pediatric Nursing

Date of admission to course

Title of the study

A study to evaluate the effectiveness of structured video teaching programme on neonatal resuscitation of newborns developing perinatal asphyxia conducted among staff nurses working in SVS Hospital, Mahabubnagar, AP

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION Minds are like parachutes. They only function when they are open Sir James Dewar

The birth of an infant is one of the most awe-inspiring and emotional events that can occur ones lifetime. After nine months of anticipation and preparation, the neonate arrives amid a flurry of excitement of parents and also the other family members. But if the neonate is not the healthy robust infant who was expected it creates problem

. Perinatal asphyxia is a common neonatal problem. The World Health Organization has defined birth asphyxia as failure to initiate and sustain breathing at birth and based on Apgar score as an Apgar score of <7 at one minute of life. Birth asphyxia may result in adverse effects on all major body systems. Many of these complications are potentially fatal. In a term infant with perinatal asphyxia renal, neurological, cardiac and lung dysfunction occurs in 50%, 28%, 25% and 23% cases respectively.

Early initiation of basic resuscitation interventions within 60 seconds in apneic newborn infants is thought to be essential in preventing progression to circulatory collapse based on experimental cardio-respiratory responses to asphyxia. Basic resuscitation would substantially reduce itrapartum-related neonatal deaths. Where births occur in facilities, it is a priority to ensure that nurses attending the births and also those working in the neonatal

units are competent in resuscitation. Strategies to address the gap for home births are urgently required. Fetal surveillance and attention to signs of asphyxia must be improved; there should be cooperation between professionals in the labour unit and, to create security barriers. Even though all nurses are trained in cardiopulmonary resuscitation, or CPR, they may not realize that newborns have different needs. American Heart Association recently issued guidelines that effective chest compressions are far more important than ventilations for adult victims while newborns primarily need ventilation. Suction devices are not necessary to remove mucus from the newborn nose and throat. The lungs of the rescuer can remove such secretions or they can be allowed to drain naturally by tipping the baby's face down and holding the baby's body aloft on one arm. Vigorous babies can clear their own airways. Such measures should be considered by the nurse while resuscitating a newborn with asphyxia. Chinas Neonatal Resuscitation Program (NRP), also known as Freedom of Breath, Fountain of Life launched in 2004. Since the program neonatal mortality caused by birth asphyxia has declined in China by more than 53 percent, based on evaluated program sites in 20 target provinces (each of which has more than 20,000 hospitals). The success of the program has led to a policy change in China. Now, neonatal resuscitation certification is a professional requirement for nurses, midwives and obstetricians working in labor and delivery.

6.2 NEED FOR THE STUDY

The National Neonatology Forum of India has defined asphyxia as gasping or ineffective breathing or lack of breathing at one minute of life. . In India, between 250,000 to 350,000 infants die each year due to birth asphyxia, mostly within the first three days of life. The National Neonatal Mortality Rate is 44 per 1000 live births per year. The Neonatal Mortality Rate in the A P state is between 45 and 50.

Perinatal asphyxia is a serious neonatal problem and contributes significantly to neonatal morbidity and mortality. It ranks as the second most important cause of neonatal death after infections accounting for around 30% mortality worldwide. Each year approximately 10 million babies do not breathe immediately at birth, of which about 6 million require basic neonatal resuscitation. The major burden is in low-income settings, where health system capacity to provide neonatal resuscitation is inadequate.

Between 5%10% of all babies born in all facilities need some degree of resuscitation, such as tactile stimulation or airway clearing or positioning and approximately 3%6% require basic neonatal resuscitation, consisting of the simple initial steps and assisted ventilation. Delays in assisting the non-breathing newborn to establish ventilation may exacerbate hypoxia, increase the need for assisted ventilation, and contribute to neonatal

morbidity and mortality. Each year there is an estimated 904000 neonatal deaths immediately after birth due to lack of proper resuscitative measures. Experience over the last century has demonstrated that perinatal mortality can be reduced by improved obstetrical and neonatal care. With the aim to avoid errors in care by implementing system-based changes, a systematic review of the pitfalls and mistakes in the clinical practice of perinatal medicine can be useful.

An evaluative study was conducted by Sophie Berglund and Mikael Norman of Department of Clinical Science and Education, Stockholm, (2008), on neonatal resuscitation after sever asphyxia in selected hospitals, Sweden among 177 cases. The results showed that there are possibilities for improvement in the immediate neonatal resuscitation within labour units. The most important contributions may be made by improving compliance with the guidelines concerning ventilation, and the paging for the early assistance of skilled personnel in cases of imminent asphyxia. The researchers concluded that it is crucial that all of the staff on the labour ward is familiar with how to initiate extensive neonatal resuscitation. Every case of unexpected asphyxia, also those that recover without sequelae, should be scrutinized to enable the creation of security barriers and improvements in each labour unit, concerning both obstetrical care and neonatal resuscitation. They also stress the importance of improving the documentation of neonatal resuscitation to enable accurate and reliable evaluation.

Vinod Paul of the All India Institute of Medical Sciences in New Delhi presented a perspective on birth asphyxia in India. As in some other developing regions, birth

asphyxia is the cause of 20% of neonatal deaths in India. Dr. Paul referred to the studies of Bang et al who found that the incidence of severe birth asphyxia (no cry or breath absent, slow or gasping at five minutes) was 4.6% of all births. He described Dr.Bangs studies of community-based interventions that involved training health workers in neonatal resuscitation. These interventions resulted in a significant reduction of asphyxia-related deaths.

When the necessary skills are learned, the attending nurse can approach any resuscitation with a good comprehension of transitional physiology and adaptation, as well as an understanding of the infant's response to resuscitation. Resuscitation involves much more than possessing an ordered list of technical skills and having a resuscitation team; it requires excellent assessment skills and a grounded understanding of physiology. Competency in neonatal resuscitation should be developed and maintained by every practicing nurse-midwife, although it is difficult to obtain the necessary experience. Thus training the nurses on neonatal resuscitation can contribute a lot in reducing mortality and morbidity due to birth asphyxia.

The above facts and findings along with the personal clinical experience motivated the researcher to plan an educational programme on neonatal resuscitation for staff nurses, helping them to give better care to their little clients; so that the mortality and morbidity due to birth asphyxia can be reduced.

6.3 STATEMENT OF THE PROBLEM

A study to evaluate the effectiveness of structured video teaching programme on neonatal resuscitation of newborns developing birth asphyxia conducted among staff nurses working in SVS Hospital, Mahabubnagar, AP

6.4 OBJECTIVES OF THE STUDY

To assess the existing knowledge of staff nurses on neonatal resuscitation of newborns developing birth asphyxia by pretest on staff nurses at SVS Hospital, Mahabubnagar, AP.

To develop and implement structured video teaching programme on neonatal resuscitation of newborns developing birth asphyxia to staff nurses working in SVS Hospital, Mahabubnagar, AP.

To analyze the effectiveness of structured video teaching programme on neonatal resuscitation of newborns developing birth asphyxia in terms of gain in knowledge scores in post-test on staff nurses at SVS Hospital, Mahabubnagar, AP.

To determine the association between the pretest knowledge on neonatal resuscitation of newborns developing birth asphyxia of staff nurses working in SVS Hospital, Mahabubnagar, AP, with their selected demographic variables.

6.5 OPERATIONAL DEFINITIONS Evaluate: It refers to grading based on statistical scale the knowledge of staff nurses ,to determine the significance, importance or value of knowledge on neonatal resuscitation of newborns developing birth asphyxia by a structured questionnaire among the staff nurses. Effectiveness: It refers to determine the extent to which the video teaching programme has achieved the desired effect in terms of gain in knowledge scores obtained on a structured questionnaire among the staff nurses. Structured video teaching programme: It refers to planned video teaching on neonatal resuscitation of newborns developing birth asphyxia by health education and by using various teaching aids. Knowledge:It refers to information or skills acquired through education or experiences. Neonatal resuscitation: Neonatal resuscitation refers to the set of interventions at the time of birth to support the establishment of breathing and circulation of a newborn Newborns: Babies of age from birth to 28 days. Birth asphyxia: In this study, birth asphyxia refers to the failure of newborn to initiate

breathing within one minute of birth.

Staff nurses: In this study, staff nurses refers to those who have completed a nursing course conducted by a registered university or board, registered as nurse midwives and working in labour room, gynecology operation theatre and maternity wards.

6.6 ASSUMPTIONS
1. 2. Birth asphyxia is one of the primary causes of early neonatal mortality. Staff nurses can manage birth asphyxia by improving their knowledge & skill in neonatal resuscitation. 3. Staff nurses possess some knowledge regarding neonatal resuscitation of newborns developing birth asphyxia. 4. Structured video teaching programme is an accepted strategy to improve the knowledge. 5. Staff nurses have a need to acquire information regarding the neonatal resuscitation of newborns developing birth asphyxia.

6.7 HYPOTHESES
1. H1: There will be a significant difference between pre test knowledge score and post test knowledge scores of staff nurse working in SVS Hospital, Mahabubnagar, regarding the neonatal resuscitation of newborns developing birth asphyxia.

2. H2: There will be a significant association in the knowledge levels of staff nurse working in SVS Hospital, Mahabubnagar, regarding the neonatal resuscitation of newborns developing birth asphyxia, with selected demographic variables such as 10

nursing education status (BSc or GNM), years of experience, clinical area of experience etc.

6.8 REVIW OF LITERATURE

A randomized, controlled trial was conducted by Opiyo et al.(2008), on health workers receiving early training on newborn resuscitation (n = 28) or late training (the control group, n = 55) in Pumwani Maternity Hospital in Nairobi, Kenya. The aim of the study was to test resuscitation training on practices by randomly assigning labour ward and theatre staff to either early or late training, considering the health worker as a unit of clustering. Data were collected on 97 and 115 resuscitation episodes over 7 weeks after early training in the intervention and control groups respectively. The results showed that the trained providers demonstrated a higher proportion of adequate initial resuscitation steps compared to the control group (trained 66% vs control 27%; risk ratio 2.45, [95% CI 1.753.42], p<0.001, adjusted for clustering). The study concludes that implementation of a simple one day newborn resuscitation training can be followed by significant, short-term improvement in health workers' practices. An evaluative study was conducted by Deorarai et al on the impact of a neonatal resuscitation programme on staff nurses in fourteen Indian teaching hospitals. The purpose of the study was to evaluate the impact of a training programme for a rational approach to neonatal resuscitation. The results showed that there was a statistically significant

reduction in the use of chest compression and medications ( p < 0.001) and an increase in the use of bag mask ventilation and asphyxia related deaths declined significantly (p

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<0.01). The researchers concluded that the study reflected a more rational approach to neonatal resuscitation with more effective and appropriate use of bag and mask ventilation leading to less need for chest compressions and resuscitation drugs.

A randomized, controlled trial study was conducted on immediate effect of training of nurses on newborn care at birth and implications for management of asphyxia by Ayesha Sania et.al on 26 nurses of obstetric unit in a tertiary-level sub-urban hospital in central Bangladesh during November 2005January 2006. The objective of the study was to assess the immediate newborn care practices pertaining to recognition and management of birth asphyxia in delivery room prior to, and following, training of nurses of delivery room. The results showed that before the training, only 5 babies were assessed to identify the need for resuscitation, whereas 17 babies were assessed during the post-training period. The study concluded that a wide gap existed between the evidence-based standard of immediate newborn care and the actual practices. Need-based training of staff in delivery rooms is needed for timely recognition and management of asphyxiated births in hospital deliveries.

A multicentric trial study was conducted by Ramji S et. al on resuscitation of asphyxiated newborn infants with 21% or 100% Oxygen: Follow-Up at 18 to 24 Months. The aim of the study was to follow-up children who had been resuscitated at birth with either 21% or 100% oxygen (O2). 410 infants for whom resuscitation was performed with either 21% or 100% O2 were selected as samples for the study. A follow-up between ages 18 and 24 months was performed. A simple questionnaire was filled out and neurologic

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assessment was performed in addition to measuring anthropometric data. The results showed that there were no significant differences in weight, height, or head circumference between the 2 groups. The researchers concludes that there were no significant differences in somatic growth or neurologic handicap at an age of 18 to 24 months in infants resuscitated with either 21% or 100% O2 at birth. A multicentric quasi randomized control trial was conducted by J A Dawson et.al, (2006), on oxygen saturation and heart rate during delivery room resuscitation of infants <30 weeks gestation with air or 100% oxygen. The aim of the study was to describe changes in preductal oxygen saturation (Spo2) and heart rate (HR) in the first 10 min after birth in very preterm infants initially resuscitated with 100% oxygen (OX100) or air (OX21). There were 20 infants in the OX100 group and 106 in the OX21 group. The results showed that in the OX100 group, Spo2 had risen to a median of 84% after 2 min and 94% by 5 min. In the OX21 group, median Spo2 was 31% at 2 min and 54% at 5 min.The study concludes that most very preterm infants received supplemental oxygen if air was used for the initial resuscitation. A prospective descriptive observational study was conducted by Ersdal HL et. al among 5845 newborns born in a rural hospital in Tanzania. The aim of the study was to assess the effectiveness of early initiation of basic resuscitation interventions including face mask ventilation in reducing birth asphyxia related mortality in low-income countries. The results were the risk for death or prolonged admission increases 16% for every 30s delay in initiating resuscitation up to six minutes (p=0.045) and 6% for every minute of applied resuscitation (p=0.001). The researchers concluded that infants who required resuscitation were more likely to die particularly when ventilation was delayed or prolonged.

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A monocentric randomized controlled trial was conducted by Vento M et al, (2001), in Spain comparing the use of air versus 100% oxygen for the resuscitation of 40 term infants with clinical and biochemical evidence of asphyxia. The results showed that the time to establish regular respirations was significantly less in the room air group (p<0.05). They concluded that there were no apparent disadvantages to resuscitation with room air and potentially significant advantages.

A comparative study was conducted to assess the functionality and acceptability of selected neonatal resuscitation devices in Durban, South Africa (2008) on 34 health workers. The goal of this study was to reduce neonatal mortality and childhood disability in South Africa by ensuring that health care providers have access to affordable, high-quality neonatal resuscitation devices and have appropriate skills in neonatal resuscitation. This study used a participatory methodology to engage users and potential users within the health system in the evaluation of the functionality and acceptability of a select group of resuscitators. Participants recorded their observations about individual devices using a structured 5-point Likert-type scale instrument The study concluded that the Laerdal device was universally evaluated as superior, and most of the participants chose the Besmed resuscitator as their second choice. The researchers recommended that comprehensive neonatal resuscitation training is essential for all new staff and for all staff when a new resuscitator is introduced. A retrospective study was conducted in neonatal unit of National Institute of Child Health (NICH) from 1st January to 31st August, 2001. The objective of the study was to look for risk factors leading to birth asphyxia in new borns admitted in a tertiary

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care unit. Patients and Methody Records of 235 new borns admitted with birth asphyxia during this period were analyzed. The results showed majority (71%) of mothers were booked and had antenatal care, similarly most (88%) of the babies were born at term and 75.3% were delivered in maternity homes or hospitals. Caesarian sections were performed in 14% cases and rest was all vaginal deliveries. The study concluded that birth asphyxia occurring in such a high number of booked cases delivered at term with good weight, reflects the poor perinatal services offered in those maternity homes or hospitals. It recommended that trained personnel and neonatal resuscitation equipment should be made mandatory in all maternity homes/hospitals. A comparative study was done by Abhay T B et. al on effectiveness of two types of birth attendants and of resuscitating with mouth-to-mouth, tube mask or bag-mask in management of birth asphyxia in home deliveries in Rural Gadchiroli. Trained birth attendants used mouth-to-mouth resuscitation in the baseline year (1993-1995). Additional village health workers only observed in 1995-1996. In the intervention years (1996-2003) they used tube-mask and bag-mask. The incidence case fatality (CF) & asphyxia specific mortality rate (ASMR) were compared. The results of the study showed decrease in incidence of mild birth asphyxia by 60% from 14% in the observation year to 6% in the intervention year (P< 0.0001). The incidence of severe asphyxia did not change significantly.

A meta-analysis was conducted on neonatal resuscitation and immediate newborn assessment and stimulation for the prevention of neonatal death of 3 studies of neonatal

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resuscitation studies examining the effect of resuscitation training on intrapartum-related neonatal deaths .The results showed that immediate newborn assessment and stimulation would reduce both intrapartum-related and preterm deaths by 10%, facility-based resuscitation would prevent a further 10% of preterm deaths, and community-based resuscitation would prevent further 20% of intrapartum-related and 5% of preterm deaths. The study concluded that neonatal resuscitation training in facilities reduces term intrapartum-related deaths.

7.0 MATERIALS AND METHODS

Research methodology involves the systematic process, which the investigator starts from the initial identification of the problems to its final conclusion. It is a science of study how research is done scientifically. It is a backbone of the study. So methodology is a significant part of an investigator under which the investigator is able to project conclusion of the research undertaken. This chapter includes description of research approach, research design, study setting, sampling technique, development and description of the tool, data collection technique and plan for data analysis. 7.1 Research Approach Research Approach is a systemic, objective method of discovery with empirical evidence and rigorous control. Research Approach spells out the basic strengths that the researcher adopts to develop information that is accurate and interpretable. The control is achieved by holding conditions constant and varying only the phenomenon under study.

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Evaluative research was considered as an appropriate approach for the present study. Quasi experimental research design is used for the present study.

7.2 Source of data / Subjects Staff nurses working in labour room, gynecology operation theatre and maternity wards in SVS Hospital, Mahabubnagar, AP.

7.3 Population Population selected for the study is working staff nurses working in SVS Hospital, Mahabubnagar, AP.

7.4 Sample Sample size of 20 staff nurses that are randomly grouped as 10 experimental group and 10 control group working in SVS hospital, Mahabubnagar, A.P.

7.5 Sampling technique In this study the researcher will use convenient sampling technique.

7.6 Method of data collection A structured Questionnaire with Interview method consists of two parts namely section A& B. Section A represents the demographic data, Section B represents the knowledge on neonatal resuscitation of newborns developing birth asphyxia. A structured

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questionnaire consists 30 questions will be given to the subjects. After obtaining the consent and prior permission from the subjects and significant others, data will be collected back immediately from the subjects after making sure about their completion.

7.7 Does the study require any investigation or interventions to conducted on patients or other humans or animals? If so, please describe briefly. Yes, the study will be conducted on staff nurses working in SVS hospital, Mahabubnagar, AP.

7.8 Has ethical clearance being obtained from your institution in case of 7.7? Yes, ethical approval has obtained from the ethical committee.

7.9 Plan for data analysis The data obtained will be analyzed in terms of objectives of descriptive and inferential statistics.

8.0 List of references

1. Lawn J.E,Haws R.A,Darmsatdt L.G.Reducing one million child deaths from birth asphyxia.Biomed Central Ltd.2007;22(4):314-317 2. WHO (2005) The world health report: 2005: make every mother and child count 3. Department of Reproductive health and Research. Basic new born resuscitation; a practical guide.WHO.Geneva;1997 4. www.pubmed.com. 18

5. 6.

www.google.com. Sophie Berglund, Mikael Norman, Charlotta Grunewald, Neonatal resuscitation after severe asphyxia a critical evaluation of 177 Swedish cases.Acta Paediatrica. 2008 June; 97(6): 714719.

7.

N Opiyo, Newton .O, Fred.W, Fridah.G, Grey.F .Effect of newborn resuscitation training on health worker practices. PLoS Clinical trials.2008 Oct; 16 (10): 1886-97.

8.

Deorari AK, Paul VK, Singh M, Vidasagar D. Impact of education and training on neonatal resuscitation practices in 14 teaching hospitals in India. Annals of Tropical Paediatrics: International Child Health. March 30, 20122001; 21 (1): 29-33

9.

Ramji S, Rasaily R, Mishra PK, Narang A, Jayan S, Kapoor AN, Kambo I, Mathur A, Saxena BN. Resuscitation of asphyxiated newborns with 21% or 100% oxygen at birth: a multicentric trial. Indian Pediatr. 2003 Jun;40(6):507-9

10. Dawson JA, Yam CH, Schmlzer GM, Morley CJ, Davis PG. Heart rate changes during resuscitation of newly born infants <30 weeks gestation: an observational study.Arch Dis Child Fetal Neonatal Ed. 2011 Mar;96(2):F102-7. 11. Ersdal HL, Mduma E, Svensen E, Perlman JM. Early initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality. Journal of Paediatr Child Health 2002 Jan;38: 241245 12. Vento M, Asensi M, Sastre J, Carcia-Sala F, Pallardo F, Vina J. Resuscitation with room air instead of 100% oxygen prevents oxidative stress in moderately asphyxiated term neonates. Pediatrics. April 2001;107(4):642-647 13. Elwyn C, ElIzebeth M.M, Linda L.W,WalderA.L . Effect of WHO Newborn care training on neonatal mortality by education. Ambulatory Pediatrics.2006 September;8(5) 19

14. OHare B.A, Nakakeeto M,Southhall D.P.A study to determine if nurses trained in basic neonatal resuscitation would impact the outcome of neonates delivered in Kampala.Tropical pediatrics Advance 2006 June; 52(2):376-379. 15. Raina N, Kumar V. Management of birth asphyxia by traditional birth attendants. World Health Forum. 1989;10(2):243-6 16. Abhay T.B,Rani A.B,Sanjay B.BHanimi M.R, Management of birth asphyxia in home deliveries in rural Gadchiroli.Journal of tropical pediatrics Advance.2006June 25 (2): 130 41 17. Linn S, Theresa A.S, Meta analysis on neonatal resuscitation and immediate newborn assessment and stimulation for the prevention of neonatal death Midwifery.2004 March;20(1):51-60

18. Rose marie nieswiadong. Foundation of nursing research. 2nded appketion and lange; Norwalk 9us).2008 Aug; 100(8):625-9.

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9.0 Signature of the Candidate

10.0 Remarks of Guide 11.0 Name and Designation Of 11.1 Guide 11.2 Signature

: :

11.3 Head of the department . 11.4 Signature

12.1 Remarks of the Chairman and Principal:

12.2 Signature of the principal

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Principal S.V.S. College of Nursing Mahabubangar.

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