INTRODUCTION:

Childbirth is a special journey for every woman. Generation of women have travelled the same route but the journey is unique. Childbirth is most pleasurable event to the mother at the same time it is also a life-threatening event to her. Hence, ensuring safe childbirth is the responsibility of a maternity nurse by promoting and preserving the health of the mother and fetus from conception to childbirth.

To ensure safe delivery, various measures have been used when needed to induce labour. They are two kinds of induction–medical induction and surgical induction.¹

Concept of induction is as old as 16^th Century when Ambroise Pare (1958) first induced premature labour in a patient with antepartum hemorrhage. Since then, various methods have been tried from time to time. People were in search of an ideal inducing agent since a long time back. To achieve this, they had tried many methods like plain rubber catheter, inflated balloon of Foley’s catheter etc. The mechanism behind all this was to release endogenous prostaglandins. The first successful step of this search was achieved in 1955, when syntocinon was introduced. In 1986, Karim introduced prostaglandin PGF₂ infusion for induction of labour. An important milestone was 1986, when prostaglandin PGE₁ cervical gel was introduced, which is to a greater extent close to an ideal “but not ideal” inducing agents. In 1991, Norman introduced a synthetic prostaglandin, PGE1.which was later found to induce cervical softening and produces powerful uterine contractions.²

Induction of labour is the stimulation of uterine contractions before the onset of spontaneous labour. It is an obstetric intervention that can be used when elective birth will be beneficial to mother and baby. The purpose of induction is to effect the birth of the baby, thereby ending the pregnancy. Successful induction depends on adequate contractions which are effective in bringing about progressive dilatation of the cervix. The procedure is likely to be successful when the cervix is said to be ripe, that is, it has undergone structural changes to produce softening, dilatation, and effacement.³

Hospitals and other health care agencies have recognized the importance of ongoing education from the time of Florence Nightingale. Her often quoted statement “let none never consider ourselves as finished nurses”, gave a strong motivation for the continued development of professional standards, as the standard and expectations of care rise it becomes increasingly evident that competent and efficient care cannot be delivered unless the professionals get advanced knowledge in specific fields .Continuing education provides means by which nurses can remain up to date with current development to maintain their competence and meet the standards of nursing practice. This study is intended to assess the knowledge of staff nurses regarding induction of labour and to provide adequate knowledge, through self-instructional module in promoting and preserving the health of the mother by ensuring safe delivery.

NEED FOR THE STUDY:

Childbirth (also called labour, birth, partus or parturition) is the culmination of a human pregnancy or gestation period with the birth of one or more new-born infants from a woman's uterus. Most labours begin naturally. Although it's usually best to let nature take its course, sometimes the birth process may need a little help. Labour is "induced" when it is started artificially. Mother will be offered an induction if the risks of prolonging mother’s pregnancy are more serious than the risks of delivering the baby straight away. Contrary to popular belief, studies prove that induced labour is usually not more painful than spontaneous labour.⁴

Labour induction is being increasingly used (15-30% of pregnancies). The most common indications include late pregnancy preeclampsia, intrauterine foetal growth retardation (IUGR), and hypertension. Preinduction by speeding up the ripening of the cervix increases the chances of successful induction. There are mechanical and pharmacological methods of pre-induction: the Foley catheter hygroscopic dilators, prostaglandin gel, and misoprostol. There are various schemes of labour pre-induction and the differences relate primarily to duration of catheter time, amniotomy or the start of the oxytocin.⁵

Mechanical methods were the ﬁrst methods developed to ripen the cervix or to induce labour (Thiery 1989). Devices which were used in this context include various type of catheters and of laminaria tents, introduced into the cervical canal or, through the cervix, into the extra-amniotic space. Mechanical methods were never completely abandoned, but were substituted by pharmacological methods during recent decades. Potential advantages of mechanical methods over pharmacological ones may include simplicity of use, lower cost and reduction of some side effects. The goals of these interventions are to ripen the cervix through direct dilatation of the canal or, indirectly, by increasing prostaglandin (PG) and/or oxytocin secretion.⁶

Administration of oxytocin to the mother during the first stage of labour need not be a routine procedure but recent trends indicate that oxytocin drugs are used to accelerate the labour process. At the same time health care professionals should bear in mind the serious adverse reaction of oxytocin drugs if they are misused. It is nurses at the bedside of labouring women who make oxytocin titration decisions based on their nursing assessments. Those decisions must be based on a sound knowledge of the pharmacologic properties of oxytocin, the physiology of uterine contractions, and the response of the woman and foetus to contractions. In addition, nurses must be aware of the standards and guidelines of care that govern their actions during induction / augmentation.⁷

A study was conducted in McGill University School of Nursing, Centre for Nursing Research, and Sir Mortimer B. Davis-Jewish General Hospital, Canada on One-to-one nurse labour support of nulliparous women stimulated with oxytocin that were cared by staff nurses. The objective of study was to compare the benefits of one-to-one nurse labour support with the benefits of usual intrapartum nursing care in women stimulated with oxytocin. One hundred nulliparous women 37 weeks or more gestation, carrying singletons, in labour with vertex presentation, stimulated with oxytocin, less than 5 cm dilated at baseline, and not scheduled for caesarean delivery or induction or having paid labour support were included in the study. One-to-one care consisted of the presence of a nurse during labour and birth that provided emotional support, physical comfort, and instruction on relaxation and coping techniques. The result shown that a beneficial trend because of one-to-one nurse support, with a 56% reduction in risk of total caesarean deliveries [RR of experimental vs. control = 0.44 (95% confidence interval = 0.19 to 1.01)]. The study suggests that continuous support by intrapartum nursing staff may benefit women stimulated with oxytocin during labour.⁸

A comparative study was conducted by Department of Obstetrics and Gynaecology, Lady Hardinge Medical College, New Delhi towards a safer motherhood. Out of 100 pregnant, mother 50 mothers were induced by oxytocin (8 units of oxytocin in 540 ml of 5% dextrose solution) and another 50 were laboured spontaneously. It was observed that induced group with controlled labour has many maternal and foetal advantages like undisturbed domestic arrangements, avoidance of fatigue of patients and her relations, short duration of labour and minimal exposure to stress of labour, lower incidence of caesarean section and minimized perinatal morbidity and mortality. Once the study women began active labour, the nurse conducted artificial rupture of membranes. The control group was more likely than the study group to have a fever (i.e., 38 degrees Celsius) (5% vs. 0). Prematurity was more common in the control group than the study group (41% vs. 0). These findings shown that active management of labour by staff nurse reduces caesarean section, forceps delivery, duration of labour, and foetal/new-born morbidity and mortality.⁹

A prospective multicentre study was conducted by Public health unit and institute of topical medicine in three developing countries (Benin, Congo and Senegal) to analyze oxytocin use during labour. The objective was to assess the possible negative effects of the treatment regimens instituted during the labour monitoring phase. Four health districts participated in the study. All women who gave birth in one of the participating health facilities over a 6-month period in Benin and Congo, and over a 3-month period in Senegal, were recruited. The number of deliveries studied in each district varied from 457 to 1048. Each of the four collaborating centers used oxytocic preferentially to treat dysfunctional labour, but even in normal labour (i.e. with a normal portogram) oxytocic’s were used in 4.4–21.5% of cases. In normal labour the incidence of neonatal resuscitation was higher in cases with than in those without oxytocic use: This studies shows that an obstetric treatment which is safe when used in certain well-defined indications, may have significant negative effects when used in situations where the same technical quality of care cannot be guaranteed.¹⁰

A descriptive study was conducted by obstetrics and gynecological department, Coimbatore on Assessment of Knowledge and Attitude of Antenatal Mothers towards Caesarean Section and Normal Vaginal Delivery at Selected Hospital, Coimbatore. The objective was Assess the knowledge of antenatal mothers towards caesarean section and normal vaginal delivery. Assess the attitude of antenatal mothers towards caesarean section and normal vaginal delivery. The study was designed to assess knowledge and attitude of antenatal mothers towards caesarean section and normal vaginal delivery. The data was collected from 100 samples by using convenient sampling technique through survey method. Percentage distribution was used to analyze the data. Major findings of the study was majority of antenatal mothers had adequate knowledge on mode of delivery and primi mothers had negative attitude towards caesarean section.¹¹

The study was conducted by Krishna Institute of Nursing Sciences, Karad. Which is under Krishna Institute of Medical Sciences, Deemed University’s Karad on to evaluate the effectiveness of self instructional module on the knowledge of partograph among first year P.B. B.Sc. Nursing student at Krishna Hospital Karad The sample of the study included 40 1^st year P.B. BSc nursing student selected by Purposive sample technique. A evaluativeapproach, one group pretest- post-test (Quasi experimental) design was adopted for the study. The structured knowledge questionnaire was used to assess the knowledge of partograph among 1^st yr PBBSc nursing students To assess the knowledge of partograph among 1^st year P.B. BSc. nursing students. To evaluate the effectiveness of self-instructional module (SIM) on the knowledge of partograph among 1^st year P.B. BSc nursing students. To find an association between pretest knowledge and selected variables. It proved that SIMon partograph was an effective for increasing the student’s knowledge. For an association chi-square test was use there was no statistically significant association found between pre existing knowledge and demographic variables at df (39). The study concluded that SIM on partograph administered to the 1^st year P.B. BSc. Nursing students was effective in increasing the knowledge.¹²A study was conducted by Maternal health division and health ministry at Pacific Northwest medical centre on assessment of knowledge level among 50 staff nurses working in intrapartum nursing unit regarding safe administration of oxytocin. A Descriptive, survey approach used to carry out the study. Out of 50 about 70% of staff nurse did not respond to the structured questionnaire perfectly. It reveal that the inadequate knowledge of staff nurse on the perfect administration of oxytocin. The reasons for improper oxytocin administration according to the investigator may be due to: No availability of protocols in the hospitals. Shortage of nurses in the maternity units. Availability of more technical nurse in comparison to professional nurses in maternity units. Lack of knowledge about administration of oxytocin drugs, its monitoring and serious adverse reactions. Because most of the maternity cases are handled by technical nurse. Inadequate provision for in-service education for the technically qualified nurse.¹³

Brodsky and Pelzer emphasized “a written protocol for the management of oxytocin induction based on current standards of practice should be established in every birth settings and accurate, regular documentation should be made in the woman’s chart and should be made available for nursing personnel. Oxytocin induction protocol can also be useful:

· To secure the maternal and foetal well-being.

· To prevent maternal and foetal complications.

· To ensure safe delivery

· To safeguard the nursing personnel.¹⁴

Nurses, on the frontline, than any other health professionals shoulders an immense responsibility regarding direct care of patients, as also in the case of induction of labour where the nurses participate in the selection of patients in various ways. They are involved in the assessment, planning, administering and evaluating for induction of labour as well as assisting, supporting and educating pregnant women. Unless the nurse has thorough knowledge regarding the theoretical and practical aspects on induction of labour, she may not be able to initiate or render her professional knowledge and skill, act on time and prevent further complications. Hence investigator rightly justifies the need for assessing the effectiveness of self-instructional module on induction of labour among staff nurses with a view to update and improve their knowledge.

MATERIAL AND METHODS:

Objectives:

· To assess the knowledge of staff nurses on induction of labour by pre-test

· To assess the effectiveness of self-instructional module by comparing pre and post-test scores.

· To determine the association between the knowledge scores and selected socio demographic Variables.

Hypothesis:

H₁The post-test knowledge scores of staff nurses exposed to self-instructional module will be significantly higher than their pre-test knowledge scores.

H₂ There will be significant association between knowledge scores of staff nurses and selected variables.

METHODOLOGY:

Pre experimental one group pre-test post-test design was selected for the study. 50 Staff nurses working in selected hospitals, Cuttack, Odisha were taken as subjects. Demographic variables of the above was collected using self-administered questionnaire and the level of knowledge regarding induction of labour among selected subjects was assessed using knowledge questionnaire, following this SIM was administered. After one week of administering SIM, post-test was given

RESULTS:

The paired’t’ test shows that there is significant difference in pre-test and post knowledge score. Chi square test shows that there is significant association of pre-test and post-test knowledge scores with demographic variable (ie Age, Educational Qualification, Type of Educational Institute, Years of Clinical Experience, and Total Years of Clinical Experience in OBG Unit of the subjects) and remaining demographic variables such as Marital Status, Area of Living, and Source of Information on Induction of labour, Recent Exposure of Knowledge on Induction of Labour of the subjects had no significant relationship with knowledge outcomes.

Findings related to demographic variable:

Majority of 50% of subjects were in age group of 20-30 years whereas 26% of Subjects in the age group of 31 to 40 years, 20% in age group of 41-50 Years. Rest of 4% of samples belongs to age group 51-60 years. Based on Marital Status 54% of Subjects were married and rest of 46% were single. Considering area of living 60% of subjects were living in rural area and remaining 40% in urban area. Education wise majority of 50% subjects completed B. Sc. Nursing, followed by 30% GNM and 20% Post Basic B. Sc. Nursing. In relation to type of educational institution maximum of 70% subjects studied in private college where as 20% from Government College, and rest of 10% from trust or mission institute. In the area of clinical experience 36% subjects had 3-8 years of experience similarly more or less 34% subjects had 9-14 years of clinical experience followed by 22% with 0-2 years of experience and remaining 8% of subjects had 15 or more years of experience. Categorising subjects based on total years of professional experience in OBG unit, majority of 44% subjects had 0-2 years of experience in OBG unit whereas 40% had 3-8 years followed by 10% with 9-14 years and rest of 6% had 15 or more years of clinical experience in OBG unit. In-service training program was a source of information on induction of labour for majority of 40% of subjects followed by in-service education for 30% of subjects, continuing education for 20% and rest of 10% had seminar as a source of information on induction of labour .Recent exposure for induction of labour through workshop, in-service education program and seminar was attended by 60%, 30% and 10% of subjects respectively.

Findings related to pre-test and post-test mean Knowledge scores and effectiveness of SIM in improving knowledge of the Staff Nurses:

Knowledge score during pre-test was inadequate with mean score of 37.68% for majority of 90% of subjects, whereas only 10% subjects had moderately adequate knowledge with mean knowledge score of 53.2%. Overall pre-test obtained mean knowledge score was 19.62±2.996 (39.24%) which shows that subjects had inadequate knowledge on induction of labour. Following administration of SIM, maximum of subjects (74%) had obtained moderately adequate knowledge with mean knowledge score of 62.28%, whereas 16% of subjects had adequate knowledge with mean score of 78.5% and remaining 10% of subjects still had inadequate knowledge with mean score of 46.8. overall post-test mean knowledge score obtained was 31.66±5.085 (63.32%) which indicate marked improvement in level of knowledge.

In order to prove the effectiveness of SIM on improvement on knowledge score of subjects paired ’t’ test was calculated which shows that obtained ‘t’ value (24.413) was significantly higher than the table value (2.680) at the level of 0.01 which is proves that SIM was an effective tool in improving knowledge score of the subjects on induction of labour hence stated statistical hypothesis, H_1:The post-test knowledge scores of staff nurses exposed to self-instructional module will be significantly higher than their pre-test knowledge scores, was found to be true and accepted.

Findings related to association of knowledge score with selected demographic variable:

Obtained data shows that there is significant association of knowledge score with certain demographic variable such as age, educational qualification, type of educational institutions, years of clinical experience and total years of professional experience in OBG unit. Hence research hypothesis H₂for above mentioned variable was accepted that there will be a significant association between knowledge score of the Staff Nurses and selected variables.

Whereas few demographic variables, such as marital status, area of living, source of information on induction of labour and recent exposure for induction of labour, had no significant association with knowledge score. Hence stated research hypothesis H₂ rejected and restated for above mentioned demographic variables, that there is no significant association between knowledge scores of the Staff Nurses and demographic variables.

CONCLUSION:

The study findings concluded that staff nurses had average knowledge regarding induction of labour before SIM. After SIM staff nurses have improve knowledge. The study was concluded the administration of self-instructional module on induction of labour is an effective technique.

REFERENCE:

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2. Nalini Neelam, Rani Usha, Role of misoprostol (intravaginal) in cervical ripening and induction of labour, Obs. and Gynae. Today, 2006; 11(5): 258- 261.

3. Myles, Textbook for midwives, 13^th edition, London; Harcourt Publishers Ltd, 1999, P 492-497.

4. Journal of Obstetrics and Gynaecology and Neonatal Nursing.199 Nov 6; 20(6): P 440-44.

5. Mukharjee S, Sood M. Towards Safe Motherhood: J. Indian Medical Association; 93(3):98-100, 89.

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7. Polit DF, Hungler BP. Nursing research Principles and methods. 5^th edition. Philadelphia: JP Lippincott Company; 2003. P. 378 and 201.

8. Sathyalatha R. A study to assess present knowledge of staff nurses on oxytocin induction to mother during 1^st stage of labour in view of developing a protocol for better management in maternity wards at selected hospitals, Chennai. Unpublished Master of Nursing Thesis; 2001.

9. http://www.ncbi.nlm.nih.gov /pubmed/8543106

10. Kavitha V, Karpagam. Assessment of Knowledge and Attitude of Antenatal Mothers Towards Caesarean Section and Normal Vaginal Delivery at Selected Hospital, Coimbatore. Asian J. Nur. Edu. and Research 3(3): July-Sept., 2013; Page 190-191.

11. Jyoti A. Salunkhe, A study to evaluate the effectiveness of self instructional module on the knowledge of partograph among first year P.B. B.Sc. Nursing student at Krishna Hospital Karad. Asian J. Nur. Edu. and Research 2(1): Jan.-March 2012; Page 18-20.

12. http://www.ncbi.nlm.nih.gov /pubmed/8543106

Received on 31.08.2019 Modified on 27.10.2019

Int. J. Nur. Edu. and Research. 2020; 8(2):166-170.

DOI: 10.5958/2454-2660.2020.00037.X