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					     PROFORMA FOR REGISTRATION OF SUBJECT FOR
                     DISSERTATION




               DISSERTATION PROPOSAL




A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED
 TEACHING PROGRAMME REGARDING PAIN MANAGEMENT
 DURING LABOUR AMONG NURSES WORKING IN SELECTED
               HOSPITALS BANGALORE




                SUBMITTED BY


                          ASWATHI.YASODHARAN M.SC.
                          NURSING 1ST YEAR
                          OBSTETRICS AND
                          GYNECOLOGY NURSING
                          JOSCO COLLEGE OF NURSING
                          NELAMANGALA
                          BANGALORE
    RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
            BANGALORE, KARNATAKA


      PROFORMA FOR REGISTRATION OF SUBJECTS FOR
                    DISSERTATION



1   NAME OF THE CANDIDATE ASWATHI YASHODHARAN
    AND ADDRESS                    M.SC. NURSING 1ST YEAR
                        :          JOSCO COLLEGE OF NURSING
                                   NELAMANGALA
                                   BANGALORE


2   NAME OF THE INSTITUTION        JOSCO COLLEGE OF NURSING
                         JOSCO     NELAMANGALA
                                   BANGALORE


3   COURSE   OF   THE       STUDY M.SC NURSING 1st YEAR
    AND SUBJECT                    OBSTETRICS AND
                                   GYNECOLOGICAL NURSING


4   DATE OF ADMISSION              01/06/2009




5   TITLE OF THE TOPIC
                                      A STUDY TO EVALUATE THE
                                   EFFECTIVENESS OF STRUCTURED
                                        TEACHING PROGRAMME
                                    REGARDING PAIN MANAGEMENT
                                    DURING LABOUR AMONG NURSES
                                         WORKING IN SELECTED
                                        HOSPITALS BANGALORE
6. BRIEF RESUME OF THE INTENDED WORK

6.1 NEED FOR STUDY

        Pain is a normal part of labour and the degree of pain experienced varies from
person to person. It may help you to attend antenatal/ parent education classes where you
will be taught about the process of labour. At these classes the midwife or a professionally
trained teacher (eg: The National Childbirth Trust) will also discuss with you ways of
managing the labour pain and this will include self help, non pharmacological (not using
medication) and pharmacological (use of medication) methods. Understanding how you
can manage the pain of labour will make you feel more confident, relaxed and less anxious.
It will also help you to make informed choices during your. You may prefer to have some
idea of how you would like to manage your labour pain or alternatively you may wish to
wait and see how your labour progresses1.

        According to a latest claim by an associate professor in midwifery in the University
of Nottingham, women must bear labour pain, as pain-relieving drugs including epidural
injections, can lead to serious medical complications2.

        The medical chief Dr. Denis Walsh asserted on the need to take the help of yoga,
birthing pools and hypnosis, to strengthen the bond between the child and the mother.
Walsh said that "it's beneficial for women to suffer the labour pain of a natural birth."
An increasing number of pregnant women try avoiding labour pain caused due to natural
birth, by taking pain-killers and injections, to get relief from the pain3.

        Latest statistics reveal that there has been an increase in the women-in-labour
receiving epidural or spinal anesthesia. In 2007-08, nearly 33 percent women opted for
pain-relieving and spinal anaethetising including injections to ease the pain as compared to
17 percent women in 1989-904.

        This study conducted on US midwives' knowledge and use of sterile water
injections for labor pain. The purpose of this research study was to identify and describe
US midwives' knowledge and use of sterile water injections to relieve pain during labor.
Research studies have shown that injections of sterile water to relieve low back pain during
labor are effective with good maternal satisfaction. Questionnaires were mailed to a
random sample of 450 midwives who were members of the American College of Nurse-
Midwives (ACNM). While sterile water injections are a good treatment for back pain
during labor, there is a lack of knowledge among midwives about this method of pain relief
during labor and an interest in knowing more5.


       This study examines the perceptions of labour pain by mothers and their attending
midwives. The aim of the current study was to examine the perception of pain by labouring
women and their attendant midwife, from the onset of labour to delivery. The short form
McGill Pain Questionnaire (SF-MPQ), routinely used to assess pain in obstetric
environments was used to determine pain perception. Thirteen labouring women and nine
midwives completed the SF-MPQ every 15 minutes beginning at the time of admittance to
the delivery suite. On each measure of pain on the SF-MPQ, the midwives scores
correlated with the mothers' scores across the entire pain range. Further analysis showed
that mothers' and midwives' pain scores were similar at mild-moderate pain levels6.


       The activities are useful in alleviating pain are Learning to relax helps to promote
calmness, Antenatal classes place the emphasis on being fit and what choices there are,
offering more control in labour, Position during the birth can also make a difference. Some
women like to kneel, walk around or rock backwards and forwards, Feeling in control of
what is happening is important. Don’t hesitate to ask questions or to ask for anything at any
time, having a partner, friend or relative to ‘lean on’ who can provide support during labour
helps. If this is not possible, don’t worry, as the midwife will give support and Warm water
and baths can reduce pain7.


        So nurses have an important role in controlling the labour pain. Lack of study
conducted among nurses regarding knowledge of labour pain motivated the researchers to
do this study
6.2 REVIEW OF LITERATURE


         Review of literature provides basis for future investigations, justifies the need for
replication, throws light up on feasibility of the study, and indicates constraints of data
collection and help to relate findings of one another.


             A. Studies related to importance of education regarding pain management
                 during labour
             B. Studies related to the importance of pain management during labour


       A. Studies related to importance of education regarding pain management
                 during labour


       This study conducted on Knowledge and decision-making for labour analgesia of
Australian primiparous women to assess and investigate knowledge of labour pain
management options and decision-making among primiparous women in a major tertiary
obstetric hospital in metropolitan Sydney, Australia.. A semi-structured guide was used in
focus groups to gather pregnant women's knowledge concerning labour analgesia. There
was a large discrepancy between perception and actual knowledge. The main source of
knowledge was anecdotal information. Late in pregnancy was considered the ideal time to
be given information about labour analgesia. Women described their labour pain relief
plans as flexible in relation to their labour circumstances; however, most women wanted to
take an active role in decision-making8.


         This study determined women's knowledge of and attitudes to pain relief during
labour. This descriptive study included 151 women, 18 years or older, attending the
antenatal clinic of Cecilia Makiwane Hospital. Women were interviewed using a
questionnaire that determined their knowledge of and attitudes regarding pain relief. Half
the women (51.7%) believed that they should experience mild pain, however, while 55.7%
had experienced severe pain during previous labour and 65.3% of these had found the
experience to be unacceptable. Most women (59.8%) who had been pregnant were not told
what to expect when in labour. Even though the few women who received information
about what to expect during labour found the information useful, most expressed little
confidence in labour pain relief9.


         B.     Studies related to the importance of pain management during labour



       This study examines the labor pain at the time of epidural analgesia and mode of
delivery in nulliparous women presenting for an induction of labor. The objective of the
study is to assess whether the degree of labor pain at the initiation of neuraxial analgesia is
associated with mode of delivery. Nulliparous women who presented to the labor
department for an induction of labor, who were between 37 and 41 weeks of gestation, and
who requested labor epidural analgesia with a pain score of 0-3 (low pain) and a cervical
dilatation less than 4 cm were assessed retrospectively. We found 185 nulliparous women
with low pain and compared them with a randomly selected equal number of women in
each of the other pain groups. There was no significant association between pain groups in
terms of duration of the first or second stage of labor or mode of delivery10.



       This study conducted on mathematical modeling of the pain and progress of the first
stage of nulliparous labor. The authors retrospectively studied 100 sequential deliveries
from each of five self-reported ethnic groups (Asian, Black, Hispanic, Other, and White).
Demographic variables, cervical dilation, and numerical rating scores for pain before
analgesia and cervical dilation were abstracted from the automated medical record.
Mathematical models can be used to detect subtle effects of patient covariates on the
progress and pain of the first stage of labor. Asian women and heavier women had slower
labor and slower onset of labor pain than others. These effects were modest compared with
the substantial remaining unexplained subject-to-subject variability in labor progress and
labor pain11.



       This study conducted on time and obstetric anesthesia from chaotic cosmology to
chronobiology. Temporal cycles (dark/light; birth/death; etc.), along with environmental
conditions (synchronizers), influence labor physiology because of the presence of
endogenous clocks (oscillators) that interact with social diuturnal clues. In this review, the
most important cyclic anesthetic-obstetric parameters in parturient care are listed. This
study concluded that the chronobiological approach of labor anesthesia emphasizes the
obstetric importance of circadian rhythmicity in labor humanization and safety12.


        This study examines the effects on mother and fetus of epidural and combined
spinal-epidural techniques for labor analgesia. The objective of the study is Epidural (EA)
and combined spinal-epidural (CSE) techniques have both been utilized for labor analgesia.
This study compared the effects on the mother and newborn of these techniques in labor
analgesia and anesthesia. Forty pregnant women received epidural analgesia with 15 mL of
0.125% ropivacaine (EA group) and 5 microg of sufentanil plus 2.5mg bupivacaine in the
subarachnoid space (CSE group). Epidural (EA) and combined spinal-epidural (CSE)
analgesia relieved maternal pain during obstetric analgesia13

       This study explain that the epidural Analgesia in the Latent Phase of Labor and the
Risk of Cesarean Deliver. The objective of this trial was to test the hypothesis that patient-
controlled epidural analgesia given at cervical dilation of 1.0 cm or more does not increase
the risk of prolonged labor or Cesarean delivery. After institutional review board approval
and patient consent, 12,793 nulliparous patients requesting neuraxial analgesia were
enrolled and randomized to an early epidural (cervical dilation at least 1.0 cm) or delayed
epidural (cervical dilation at least 4.0 cm) group. Epidural analgesia in the latent phase of
labor at cervical dilation of 1.0 cm or more does not prolong the progression of labor and
does not increase the rate of Cesarean in nulliparous women compared with the delayed
analgesia at the cervical dilation of 4.0 cm or more14.


       This study conducted on hypnosis for pain relief in labour and childbirth. Reference
lists from retrieved papers and hypnotherapy texts were also examined. There were no
language restrictions. Our primary outcome measures were labour analgesia requirements
(no analgesia, opiate, or epidural use), and pain scores in labour. Suitable comparative
studies were included for further assessment according to predefined criteria. Meta-
analyses were performed of the included randomized controlled trials (RCTs), assessed as
being of ‘good’ or ‘adequate’ quality by a predefined score. This study concluded that the
risk/benefit profile of hypnosis demonstrates a need for well-designed trials to confirm the
effects of hypnosis in childbirth15.


       This study examines the analgesia for labour pain by analysis of the trends and
associations in the Grampian region of Scotland between 1986 and 2001. The rates of the
use of epidural, opioid and Entonox or no analgesia for pain relief in labour in each year
were calculated. Maternal, pregnancy, labour and delivery characteristics were compared
among the users of three different analgesics by univariate and multivariate analyses. This
study highlight the non epidural analgesia was found to be the most popular choice for pain
relief in labour in the Grampian region between 1986 and 2001, although an increase in the
uptake of epidural services is starting to occur. The type of labour analgesia used is
associated with the epidemiological characteristics of the women's pregnancy, labour and
delivery16.


       A study conducted on Lesotho midwives' utilization of non-pharmacological pain
management methods during the first of stage labour. The purpose of this study was to
determine the use of non-pharmacologic methods of pain management used by midwives in
Lesotho. The research design was non-experimental and of a descriptive nature. The data
was obtained by means of a structured questionnaire which was compiled after a thorough
literature analysis was done. According to the results, the midwives indicated that they
were taught non-pharmacologic methods of pain management, however they expressed that
they inadequately use these methods during the first stage of labour due to shortage of staff,
lack of privacy and space, a high midwife-mother ratio, culture and hospital policies. In the
light of these findings, recommendations were made of maximizing the use of non-
pharmacologic methods during the first stage of labour17.
STATEMENT OF THE PROBLEM


A study to evaluate the effectiveness of structured teaching programme regarding
pain management during labour among nurses working selected hospitals Bangalore


6.3 OBJECTIVES OF THE STUDY


   1. Assessing the knowledge on pain management during labour among nurses in the
       terms of pretest
   2. Evaluate the effectiveness of structured teaching programme regarding pain
       management during labour by comparing pretest score on post test knowledge score
   3. Find out the association between knowledge score on post test knowledge score and
       selected demographic variables.


6.4 OPERATIONAL DEFINITIONS


1) Effectiveness: Refers to the extent to which the structured teaching programmes on pain
management during labour has achieved the desired effect in improving the knowledge of
patients as assessed by structured questionnaire
2) Structured Teaching Programme: Refers to systematically planned group instructions by
lecture cum discussion method designed to provide information regarding pain
management during labour.
3) Pain management during labour: Refers to managing the labour pain by using a
supportive Birth Partner, Relaxation, Movement and Position, Breathing, Massage,
Complementary Therapies like homeopathy, acupuncture, reflexology, and aromatherapy
and water tub.
4) Nurses: Refers to a woman skilled in aiding the delivery of babies
6.5 HYPOTHESIS


 H1 : There is a significant deference in the knowledge score on pain management
 during labour in the post test knowledge score than the pretest knowledge score among
 nurses
 H2 : There is a significant association between knowledge score and demographic
 variables

 6.6 ASSUMPTION

   The nurses will have inadequate knowledge regarding pain management during
      labour

   The planned teaching programme improves the knowledge of nurses regarding
      pain management during labour


 6.7 PROJECTED OUTCOME

      The structured teaching programme will enhance nurse’s knowledge regarding
  pain management during labour

 6.8 DELIMITATION

 The data collection period is limited to 6 weeks

     Assessment of knowledge is measured by one observation only

     Teaching strategy is delimited to lecture method only
6.9 VARIABLE
 Dependent variables of this study are Knowledge of nurses regarding pain management
 during labour
Independent variables are structured teaching programme on pain management during
labour
Demographic variables in this study are Age, Gender, education, occupation, religion,
and Family income, Type of family and Source of information


7. MATERIALS AND METHODS

The study is designed to determine the effectiveness of structured teaching programme

Programme on pain management among nurses in selected hospitals.



                             Data will be collected from nurses in selected hospitals,
  7.1 Source of data
                             Bangalore


7.1.1 Research design         Research design adopted for the present study is pre-
                              experimental, one group pre test- post test design


7.1.2Research                 The research approach used in this study is Evaluative
approach                      approach



7.1.3 Setting    Of    The    Setting of the study will be in selected hospitals,
         Study
                              Bangalore.


7.1.4    Population
                              The population of present study comprises the registered
                              nurses in selected Hospitals Bangalore

7.1.5    Sample size          The proposed sample size of the study is 60 qualified
                              nurses

7.1.6    Sampling             Sampling technique using in this study is Simple
         technique            random sampling
 SAMPLING
 CRITERIA
                                1. Nurses who are working in labour ward
 7.1.7 Inclusion criteria       2. Nurses who are willing to participate
                                3. Nurses who are willing to participate



7.1.8 exclusion criteria     Nurses who are taking leave/absent at the time of data
                             collection



7.2 METHOD     OF
    DATA
    COLLECTION

7.2.1. Tool     for   data   Self administered questionnaire
collection


7.2.2 procedure for data     The data will be collected with the prescribed time
collection
                             period in selected hospitals.

                                 Permission will be obtained from higher

                                    authorities

                                 Purpose of the study will be explained to the

                                    respondents

                                 Pre test will be conducted using structured

                                    knowledge questionnaire. Subsequently planned

                                    teaching programme will be given on the day.

                                 On the seventh day post test will be conducted.

                                    Proposed data collection period will be 30 days.
7.2.3   data   analysis
                               The data analysis through descriptive and inferential
        method
                               statistics

    descriptive
     statistics                Frequency, mean, mean percentage, and standard
                               deviation of described demographic variables.


                               Paired t test to compare pre and post test knowledge
    Inferential
     statistics                score.
                               Chi-square test will be used to find out association
                               between selected demographic variables



7.3 Does the study require any investigation to be conducted on the

patient or other human beings or animals?

NO. This study does not have any investigation



7.3 ETHICAL CLEARANCE

    The main study will be conducted after approval of the research committee.

    Permission will be obtained from the concern head of the institution. The purpose

    and after details of the study will be explained       to the study subjects and as

    informed concerned will be obtained from them. Assurance will be given to the

    study subject on the confidentiality of the data selected from them.

    Information consent will be taken from nurses who are willing to participate in the

    study
 8. LIST OF REFERENCE

1. URL : http://indiwo.in.com/india/features/childbirth-pregnancy/how-painful-is-labour-
   pain/6443/0
2. URL : http://en.wikipedia.org/wiki/Pain
3. Sunanda, Anand, Hemesh. Acute pain-labour analgesia. Indian J. Anaesth. 2006; V50
   (5), P363 -9
4. URL : http://www.themedguru.com/20090713/newsfeature/it-s-good-women-undergo-
   labour-pain-professor-denis-walsh-86124593.html
5. Mårtensson L, McSwiggin M, Mercer JS. US midwives' knowledge and use of sterile
   water injections for labor pain. J Midwifery Womens Health. 2008 Mar-Apr; V53 (2):
   P115-22.
6. Sally A. Ferguson, Gregory D. Roach, Drew Dawson. Perceptions of labour pain by
   mothers and their attending midwives. Journal of Advanced Nursing. 2001 Jan; V35(2),
   P171-9.
7. URL : http://birthingoptions.suite101.com/article.cfm/managing_pain_in_labour
8. Camille H. Raynes-Greenow, Christine L. Roberts. Knowledge and decision-making
   for labour analgesia of Australian primiparous women. Elsevier. June 2007; V 23(2),
   P.139-45
9. Mugambe.JM, Nel.M,Hiemstra. L, ASteinberg W.J. Knowledge of and attitude towards
   pain relief during labour of women attending the antenatal clinic of Cecilia Makiwane
   Hospital, South Africa. South African Family Practice, 2007 May; V49 (4), P.16.
10. Beilin Y, Mungall D, Hossain S, Bodian CA. Labor pain at the time of epidural
   analgesia and mode of delivery in nulliparous women presenting for an induction of
   labor. Obstet Gynecol. 2009 Oct; V114 (4), P.764-9.
11. Debiec J, Conell-Price J. Evansmith J.Mathematical modeling of the pain and progress
   of the first stage of nulliparous labor. Anesthesiology. 2009 Nov; V111 (5), P.936-7.
12. Vale NB, Vale LF, Cruz JR.Time and obstetric anesthesia: from chaotic cosmology to
   chronobiologyRev Bras Anestesiol. 2009 Sep-Oct; V.59 (5), P.624-47.
13. Nakamura G, Ganem EM, Rugolo LM, Castiglia YM. Effects on mother and fetus of
   epidural and combined spinal-epidural techniques for labor analgesia. Rev Assoc Med
   Bras. 2009 Jul-Aug; V.55 (4), P.405-9.
14. Wang F, Shen X, Guo X. Epidural Analgesia in the Latent Phase of Labor and the Risk
   of Cesarean Delivery: A Five-year Randomized Controlled Trial. Anesthesiology. 2009
   Sep 7.
15. M. Cyna, G. L. McAuliffe, M. I. Andrew.Hypnosis for pain relief in labour and
   childbirth: a systematic review. British Journal of Anaesthesia. 2004; V. 93(4), P.505-511


16. Sohinee Bhattacharya, Tao Wang, Fiona Knox. Analgesia for labour pain – analysis of
   the trends and associations in the Grampian region of Scotland between 1986 and 2001.
   Clin Effect Nurs 2000; V4 (1), P.11-9


17. Roets L, Moru MM, Nel M.Lesotho midwives' utilization of non-pharmacological pain
   management methods during the first of stage labour. Curationis. 2005 Aug; V.28(3),
   P.73-7
9    SIGNATURE OF CANDIDATE


10   REMARKS OF THE GUIDE


11   NAME AND DESIGNATION
     OF (IN BLOCK LETTERS

                              MRS. ABHIRAMI..P
     11.1 GUIDE
                              ASSOCIATE PROFFESSOR
                              JOSCO COLLEGE OF NURSING




     11.2 SIGNATURE




     11.3 CO-GUIDE (IF ANY)




     11.4 SIGNATURE



                              MRS. ABHIRAMI..P
12                            ASSOCIATE PROFFESSOR
     12.1 HEAD OF THE
                              JOSCO COLLEGE OF NURSING
     DEPARTMENT




     12.2 SIGNATURE
13
     13.1 REMARKS OF THE
     CHAIRMAN OR PRINCIPAl


     13.2 SIGNATURE

				
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