PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

Miss R.K. MIRNALINI

I YEAR M.Sc NURSING
OBSTETRICS AND GYNAECOLOGY NURSING
YEAR 2010-2012

PADMASHREE COLLEGE OF NURSING

GURUKRUPA LAYOUT, NAGARBHAVI
BANGALORE-5600072

0
 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PERFORMA FOR REGISRATION OF SUBJECT FOR

DISSERTATION

1. NAME OF THE CANDIDATE MISS R.K.MIRNALINI

AND ADDRESS I YEAR M.Sc NURSING

PADMASHREE COLLEGE OF

NURSING, GURUKRUPA LAYOUT,

NAGARBHAVI, BANGALORE
560072.

2. NAME OF THE INSTITUTE Padmashree College of Nursing,

Bangalore

3. COURSE OF THE STUDY I Year M.Sc Nursing

AND SUBJECT
Obstetrics and Gynaecology Nursing

4. DATE OF ADBMISSION 03-05-2010

5. TITLE OF THE STUDY A Study To Assess The Knowledge And

Practice Of Staff Nurses Regarding
Management Of Third Stage Of Labour
In Selected Maternity Hospitals,
Bangalore, With A View To Develop
Informational Protocol.

1
6. BRIEF RESUME OF THE INTENDED WORK:
6.1. INTRODUCTION:

Parturition is derived from the Latin word “parturire” which means the
act of bringing forth or being delivered. Parturition or labour is a physiological
process during which the products of conception that is the fetus, membranes,
umbilical cord and placenta, are expelled outside of the uterus. Labour is
achieved with changes in the biochemical connective tissue and with gradual
effacement and dilatation of the uterine cervix as a result of rhythmic uterine
contractions of sufficient frequency, intensity, and duration.1

Labour is divided into four stages. The first stage starts from the onset of
true labour pains and ends with full dilatation of the cervix. The second stage
starts from the full dilatation of cervix and ends with expulsion of the fetus
from the birth canal. The third stage begins after the expulsion of fetus and
ends with expulsion of the placenta and membranes. The fourth stage is the
stage of early recovery, it begins after the expulsion of placenta and
membranes lasts for one hour.2

Third stage of labour is mainly concerned with the delivery of the placenta
and prevention of complications like postpartum haemorrhage, uterine
inversion, etc. The management of third stage is broadly classified into-
expectant management and active management.

Expectant management of the third stage of labour is also called the

physiologic method and is best described as a “hands off” approach. The
umbilical cord is not clamped or cut until the cessation of pulsating, separation
of the placenta occurs without intervention and the placenta is delivered
spontaneously or aided by gravity.3

Active management of labour has been defined in many ways and

current definition comprises of three components, administration of uterotonic
soon after delivery of the baby, controlled cord traction and uterine massage

2
after delivery of placenta. In previous active management of the third stage of
labour the cord was clamped as soon as possible usually within one minute.
However trails of cord clamping timing have shown beneficial effects on
newborn haematological indices leading to the recommendation to clamp the
cord at around 3 minutes.4

Active management of the third stage of labor is an evidence-based,

low-cost intervention used to prevent postpartum hemorrhage. In response to
the growing evidence supporting the use of active management of the third
stage of labor for the prevention of postpartum haemorrhage, the International
Confederation of Midwives (ICM) and the International Federation of
Gynecology and Obstetrics (FIGO) issued a joint statement. The November
2003 joint statement promotes Active management of labour to save mother’s
lives. International Confederation of Midwives and International Federation of
Gynecology and Obstetrics further state:"Every attendant at birth needs to
have the knowledge, skills and critical judgment needed to carry out active
management of the third stage of labour for preventing postpartum
haemorrhage”.5

The World Health Organisation (WHO) defines postpartum

haemorrhage as vaginal bleeding in excess of 500ml after childbirth. Globally
postpartum haemorrhage occurs in 10.5% of live births. It is the leading cause
of maternal mortality worldwide. Experts recommend that all women should
benefit from active management of the third stage of labour, the only
intervention known to prevent postpartum haemorrhage.6

Care of the baby in the third stage of labour includes clearing of airway,
APGAR rating, birth kangaroo care that is initiation of skin to skin contact of
the mother and the baby immediately after birth that helps in early initiation of
breastfeeding, early separation of placenta, and mother and infant bonding.

Mothers and babies should be together, in skin to skin contact

immediately after birth. The baby is happier, the baby's temperature is more

3
stable, the baby's heart and breathing rates are more stable and more normal,
and the baby's blood sugar is more elevated. Not only that, skin to skin contact
immediately after birth allows the baby to be colonized by the same bacteria as
the mother and are thought to be important in the prevention of allergic
diseases. When a baby is put into an incubator, his skin and gut are often
colonized by bacteria different from his mother’s.7

Skin to skin contact in the third stage also benefits the mother ,massage
of the breast by the baby induces a large oxytocin surge from the mother’s
pituitary gland into her bloodstream. Close emotional interaction coupled with
cutaneous, visual and auditory stimuli from the baby when placed in prone
position in skin to skin contact also help oxytocin release. This oxytocin helps
to contract the uterus, expelling the placenta and closing off many blood
vessels in the uterus, thus reducing blood loss and preventing anaemia.
Pressure of the infant’s feet on the abdomen may also assist in expelling the
placenta.8

In third stage the midwives and the mother may be relaxed with the safe
arrival of baby and lured to a false sense of security however complications
may arise in this stage and hence skilled care must be provided to both the
mother and baby to avoid complications.

6.2 NEED FOR STUDY:

Insufficient maternal care during pregnancy and delivery is largely
responsible for the staggering annual toll of more than half a million maternal
deaths and the estimated 4 million newborn deaths that occur within the first
month of life. Indeed, roughly three quarters of all maternal deaths occur
during delivery and in the immediate post-partum period.9

All women and babies need maternity care in pregnancy, childbirth and
after delivery to ensure optimal pregnancy outcomes. Although all women and
babies need pregnancy care, care in childbirth is most important for the
survival of pregnant women and their babies.10

4
 An estimated 358,000 maternal deaths occurred worldwide in 2008.
This means that each day about thousand women die worldwide because of
complications related to pregnancy and childbirth. Developing countries
account for 99% of the deaths. Two regions, Sub-Saharan Africa and South
Asia accounted for 87% of global maternal deaths.11

In 2008 India had an MMR of 230 and ranked 166th among 171
countries for which estimates were available.12

Bleeding after childbirth, postpartum haemorrhage is an important cause

of maternal mortality, accounting for nearly one quarter of all maternal deaths
worldwide. Atonic postpartum haemorrhage is the most common cause of
postpartum haemorrhage and the leading cause of maternal death. One
intervention that has been promoted as an effective intervention in preventing
atonic Postpartum haemorrhage is the active management of the third stage of
labour.13
Evidence shows that management of the third stage of labour can
directly influence important maternal outcomes such as blood loss, need for
manual removal of the placenta, and postpartum hemorrhage. Most of the large
trials have compared active management of the third stage to expectant
management. On the basis of current evidence, if a decrease in postpartum
bleeding or avoidance of manual removal is desired, an active approach to third
stage is the one that should be adopted until and unless contradictory findings
are published. 14

A study was conducted to assess the effects of active versus expectant

management on blood loss, post partum haemorrhage and other maternal and
perinatal complications of the third stage.The study findings showed that
compared to expectant management, active management was associated with
the following reduced risks: maternal blood loss (weighted mean difference -
79.33 millilitres, 95% confidence interval -94.29 to -64.37); post partum
haemorrhage of more than 500 millilitres (relative risk 0.38, 95% confidence

5
interval 0.32 to 0.46); prolonged third stage of labour (weighted mean
difference -9.77 minutes, 95% confidence interval -10.00 to -9..15

A cross-sectional survey to assess the use of active management of the

third stage of labour in 15 university-based obstetric centres in ten developing
and developed countries and to determine whether evidence-based practices
were being used. Data on approximately 30 consecutive vaginal deliveries in
each centre (452 in total) were included. Significant intracountry and
intercountry variation in the practice of the active management of the third
stage of labour was found (111/452 deliveries used active management), which
confirmed the existence of a large gap between knowledge and practice. 16

Studies have shown that during skin to skin contact immediately after
birth, newborns have better temperature regulation , higher blood sugars,
lowers breathing rates and less crying ,compared to babies who are separated
and wrapped. One study shows that newborns who had enjoyed early skin to
skin contact had warmer hands and feet – a sign of lower levels of stress
hormones upto two days later. Skin to skin contact also benefits the mother
who releases high levels of oxytocin which helps the uterus to contract and
heps in preventing excessive bleeding.17

A descriptive study was conducted to determine whether breastfeeding

behaviors, skin temperature, and blood glucose values could be influenced
through the use of kangaroo care at the time of birth in healthy full term infants
. Nine full term neonates were given kangaroo care beginning within 1 minute
of birth. Infant skin temperature was taken at 1 and 5 minutes after birth and
every 15 minutes thereafter. Blood glucose level was taken 60 minutes after
birth and breastfeeding behaviour were observed during the first breastfeeding.
Skin temperature rose during birth kangaroo care in eight of the nine infants,
and temperature remained within neutral thermal zone for all infants. Blood
glucose levels varied between 43 and 85 mg/dL for infants who had not already
fed and between 43 and 118 mg/dL for those who had fed. Physicians noted

6
 that mothers were distracted from episiotomy or laceration repair discomfort
during birth kangaroo care18

A descriptive survey was conducted to assess practice, knowledge,

barriers, and perceptions regarding birth kangaroo care among staff nurses in
selected hospitals in the United States (N=1,133). A response rate of 59% (N =
537) was achieved. Nurses were knowledgeable about birth kangaroo care.
Major barriers to practicing birth kangaroo care for certain types of infants
were infant safety concerns, as well as reluctance by nurses, physicians, and
families to initiate or participate in birth kangaroo care. The findings suggest
that in order to overcome barriers to the practice of birth kangaroo care, nurses
need educational offerings highlighting the knowledge and skills needed to
provide birth kangaroo care safely and effectively.19

During the clinical posting the investigator found that active

management of third stage of labour was familiar but poorly understood
concept among the staff nurses and also the babies were separated from the
mother instead of giving the much needed and beneficial immediate skin to
skin contact. Thus the investigator felt the need to assess the knowledge and
practice of staff nurses regarding management of third stage of labour and to
provide informational protocol.

6.3 STATEMENT OF THE PROBLEM:

A Study To Assess The Knowledge And Practice Of Staff Nurses
Regarding Management Of Third Stage Of Labour In A Selected Maternity
Hospital , Bangalore With A View To Develop Informational Protocol

6.4OBJECTIVES:
1. To assess the existing knowledge of staff nurses regarding management of
third stage of labour.
2. To assess the practice of staff nurse regarding management of third stage of
labour.

7
3. To co-relate knowledge and practice of staff nurses regarding management
of third stage of labour.
4. To associate knowledge and practice of staff nurses regarding management
of third stage of labour with their selected demographic variables.
6.5 OPERATIONAL DEFINITIONS:
1. Knowledge:
Refers to the level of awareness and understanding of the staff nurses
regarding management of third stage of labour.

2. Practice:
Refers to the ability of the staff nurses to carry out the management of
third stage of labour in terms of providing competent care to both the
mother and the baby.

3. Staff nurses:
Refers to registered nurses (ANM. GNM. Bsc(N), P. Bsc) who are
working in the selected maternity hospitals
4. Management:
Refers to planning, organizing, leading and controlling the efforts to
prevent the complications in the third stage of labour. It includes active
management of third stage of labour for prevention of postpartum
haemorrhage and care of the baby which includes birth kangaroo care.

5. Third stage of labour:

Refers to the stage of labour in which separation and expulsion of
the placenta and membranes occurs and its extends from the delivery of
the baby to the delivery of the placenta and last for about 15 minutes.
6.6 ASSUMPTIONS:
1. Staff nurses may have inadequate knowledge regarding management
of third stage of labour.
2. The knowledge level of staff nurses may have influence on their
practice.

8
 3. Administration of protocol on management of third stage of labour
may help to improve knowledge and practice of staff nurses

6.7 HYPOTHESES:
H1 - There will be significant co-relation between knowledge and
practice of staff nurses regarding management of third stage of
labour
H2 - There will be significant association between knowledge and
practice of staff nurses with their selected demographic variables.

6.7 REVIEW OF LITERATURE:

Review of literature is an extensive, systematic selection of
potential sources of previous work acquainted with facts findings after
securitization and location of reference to the problem under study. It is
helpful in understanding and developing insight into the selected problem
understanding and also in developing conceptual framework for the
study.20

The literature review is sectioned under the following headings:

i. Literature related to knowledge of active management of third stage of
labour.
ii. Literature related to practice of active management of third stage of
labour.
iii. Literature related to effectiveness of active management of labour in
preventing postpartum haemorrhage.
iv. Literature related to birth kangaroo care, skin to skin contact
immediately after birth.

I. Literature related to knowledge of active management of third stage of

labour:
A questionnaire based cross sectional survey of 361 labour and delivery
professionals in public tertiary obstetric centres was done in Southwest Nigeria
to assess their knowledge on active management of third stage of labour .

9
 Female nurses at different cadres accounted for most of the respondents.
Majority (90.6%) of the respondents reported being aware of active
management of labour as an obstetric intervention. Out of 13 potential third
stage interventions,102 respondents (28.3%) correctly identified the
components of active management of labour . The study concluded that active
management of labour was a familiar but poorly understood intervention
among obstetric care providers in this region21

II. Literature related to practice of active management of third stage of

labour
A descriptive study was done to assess the practice of active
management of third stage of labour and barriers to its effective use in
Tanzania. A national representative sample of 251 facility based vaginal
deliveries was observed for active management of third stage of labour. 71% of
the observed deliveries were conducted by midwives and 11% by staff nurses.
Correct practice of active management of third stage of labour was observed in
7% of the deliveries. The study also observed harmful practices in 1/3 of the
deliveries. The study concluded that the knowledge and practice of active
management of third stage of labour is very low and strategies are not updated
on correct active management of third stage of labour. 22

A descriptive study was done to assess the practice of active

management of third stage of labour in Zambia. Midwives employed in five
public hospitals were interviewed (N=62), and 82 observations were
conducted during the second through fourth stages of labour. However active
management was conducted in strict accord with the currently recommended
protocol in only 25 (40.4%) of births.23

A descriptive study was done to assess the normal labor practices in an

Egyptian teaching hospital, where postpartum hemorrhage is the leading cause
of maternal mortality. 176 normal births were directly observed. Women were
interviewed postpartum and study findings were shared with providers. Third-

10
stage active management was correctly done for 15% of women observed.
Most common deviations for the remaining 85% were, giving uterotonic drugs
after placental delivery (65%) and without cord traction (49%). The preventive
role actively managing the third stage can provide against postpartum
hemorrhage was lost in the majority of the deliveries observed. Obstacles to
adopting protocols shown to reduce hemorrhage should be explored, given the
contribution of postpartum hemorrhage to maternal death in Egypt.24

An intervention study with post-test-only design was conducted among

health maternity wards using a data collection sheet to obtain information
regarding the practice of active management of labour. All pregnant women
attending Vanga Health maternity wards constituted the study population. From
April 2007 to March 2008, 6339 deliveries took place at Vanga Health
maternity wards, representing 71% of the institutional delivery rate. The
number of deliveries realised with the practice of active management of labour
were 5562; 366 cases of PPH were reported, making an incidence of 5.77%,
which means there was a decline of 70% compared with the previous two
years. The extension of active management of labour practice, combined with
the assurance of better supplies of oxytocin to enhance drug management, is
strongly advised/suggested.25

A prospective single blind study was conducted to find the quality of

service incorporated in the active management of third stage of labour in
Maternity Hospital, Thapathali, Kathmandu, Nepal. 325 labouring women were
randomly selected . Loading of the oxytocin was correctly done immediately
when the women were seen to bear down at second stage in 99.5% of the cases.
In 5.8% of cases, the oxytocin doses were different from the standard 10 units.
The possibility of second baby was not ruled out in 81.9% of the cases before
the administration of 10 units of IM oxytocin. Moreover the study revealed that
controlled cord traction was applied in 56% of the cases without confirming
uterine contractions. The study concluded that improvement in the standard of

11
 active management of third stage of labour is still needed in the training
providing institutions.26

An observational study was conducted to document the use of active

management of the third stage of labour for preventing postpartum
haemorrhage and to explore factors associated with such use in seven
developing countries - Benin, El Salvador, Ethiopia, Honduras, Indonesia,
Nicaragua and the United Republic of Tanzania First, a sample of health
facilities with one to three deliveries per day was chosen. Then all deliveries in
the facility were observed for two 8-hour periods over 2 days to select a sample
of deliveries within that facility. 200 facility-based vaginal deliveries was
selected by a two-stage, probability sampling factor. The study findings
showed that correct use of active management of the third stage of labour was
found in only 0.5% to 32% of observed deliveries due to multiple deficiencies
in practice. Developing countries have not targeted decreasing postpartum
haemorrhage as an achievable goal; there is little use of active management of
the third stage of labour. 27

A project was conducted in rural Tamil Nadu to promote the practice of

active management of third stage of labour. Interviews were held with
providers delivering pregnancy-related services to women in the project area. A
self-administered questionnaire focusing on current practice. A total of 15
TBAs were identified and interviewed to understand their practices, especially
related to the third stage of labour. Interviews were conducted by project field
staff and followed an interview guide developed as part of the project. Findings
reiterated the limited awareness of active management of labour.28
III. Literature related to the effectiveness of active management of third stage
of labour in preventing postpartum haemorrhage:
A randomized control trial was conducted to test the hypotheses that
active management of the third stage of labour lowers the rates of primary
postpartum haemorrhage (PPH) and longer-term consequences compared with
expectant managemen . 1512 women judged to be at low risk of PPH (blood

12
loss >500 mL) were randomly assigned active management of the third stage
or expectant management. The rate of PPH was significantly lower with active
than with expectant management. 29

A randomized trial was conducted to judge whether active management

of the third stage of labor is as effective in reducing maternal blood loss among
rural American Indian women. Retrospective data was collected on a cohort of
largely multiparous American Indian women having singleton vaginal births at
a rural hospital in 2000-2001, comparing measures of blood loss among women
receiving active (n=62) versus routine (n=113) management of the third stage
of labour. Active management was associated with reduced maternal blood loss
on several measures when compared to routine management. Compared to
women who received routine management, women who received active
management had 3 g/dl or greater postpartum hemoglobin . The findings
suggest that active management of the third stage is effective in reducing
maternal blood loss among rural American Indian women30

A hospital based descriptive, observational study was carried out from

1st July 2005 to 30th June 2006 at department of Obstetrics and Gynaecology,
Kathmandu Medical College Teaching Hospital (KMCTH) to see effects of
active management of third stage of labour on the incidence of Post-Partum
Haemorrhage (PPH), length of 3rd stage, incidence of retained placenta and
average blood loss. Total number of deliveries during the study period was 530.
There were 13 cases of PPH. Incidence of PPH was 2.4%. One case was of
retained placenta requiring Manual Removal . Average third stage duration was
less than 5 minutes. The study concluded that active management of 3rd stage
of labour reduces the incidence of PPH from uterine atony, reduces the
duration as well as average blood loss during third stage.31

A quasi-experimental study was conducted to assess the effectiveness of

active management of third stage labour in preventing postpartum haemorrhage
, active management of third stage of labour was introduced for all births

13
 attended by government midwives (at home, community, and district levels) in
one district while standard practice without active management of labour was
continued in three neighboring districts (with a 1:2 ratio of participants). A
total of 3607 women participated (1236 in the intervention district and 2371 in
the comparison districts). Active management of third stage of labour was
associated with reduced risks for prolonged third stage beyond 30 min , 34%
reduction in PPH incidence This study supports the value of active
management in reducing the incidence of postpartum haemorrhage, shortening
the third stage of labor, and reducing the need for additional treatments32

IV. Literature related to birth kangaroo care, skin to skin contact

immediately after birth
A randomized control trial was conducted in Meyer Children’s Hospital,
Israel to assess the effect of skin to skin contact shortly after birth on the
neurobehavioral response of the term newborn.47 healthy mother – infants was
selected by using a table of random numbers. After consent the mothers were
assigned one of the two groups, skin to skin contact immediately after birth or a
no-treatment standard care (control group). During a one hour long
observation, starting at four hours postnatally , the infants in skin to skin
contact slept longer, were mostly in a quiet sleep state and exhibited more
flexor movements. The study concluded that skin to skin contact influence state
organisation and motor system modulation of the newborn infant shortly after
delivery. Medical and nursing staff may be well advised to provide this kind of
care shortly after birth.33

A longitudinal study was conducted in Chiba Children’s Hospital, Japan

to determine the effects of mother -infant skin to skin contact immediately after
birth on infant recognition of their own mother’s milk odour and breastfeeding
duration until one year of age. Sixty healthy, full term neonates were randomly
assigned to group A with skin to skin contact and group B without skin to skin
contact. Infants in group A demonstrated a larger difference in mouthing
movements between their own and another mother ‘s milk odour at four days

14
of age compared to infants in group B. Infants in group A were breastfed an
average of 1.9 months longer than the others in group B.34

Randomized and quasi – randomized clinical trials comparing early skin

to skin contact with usual hospital care was reviewed. Thirty studies involving
1925 participants (mother and infant ) were included. Statistically significant
and positive effects of early skin to skin contact on breastfeeding at one to four
months post birth( 10 trails ;552 participants) and breastfeeding duration( seven
trails ;324 participants), maternal affectionate love/ touch observed during
breastfeeding ( 4 trails;314 participants). Skin to skin contact infants cried for a
shorter length of time (one trial; 44 participants)35

A prospective cohort was conducted to study the influence on

breastfeeding of skin-to-skin contact after birth. A group of 1250 Polish
children was investigated with 3 years follow-up. The infants kept with the
mothers for at least 20 min were exclusively breastfed for 1.35 months longer
and weaned 2.10 months later than those who had no skin-to-skin contact after
delivery. The study concludes that extensive mother-infant skin-to-skin contact
lasting for longer than 20 min after birth increases the duration of exclusive
breastfeeding36

An exploratory study was done to assess the perceptions among post

delivery mothers regarding skin to skin contact in St. Francis Hospital,
Nsambya, Uganda.30 postnatal mothers were purposively sampled from 249
mothers in the poatnatal ward. Mothers expressed varying opinions about the
opinions about the usefulness of skin to skin contact. Some knew about its use
to reduce the risk of hypothermia , others were ignorant. The study concluded
that the best informants for helping mothers understand the skin to skin
intervention were the health care providers. Health care providers need to be
encouraged to continuously advocate for , educate and implement regular skin
to skin contact.37

15
7 MATERIALS AND METHODS:
7.1 SOURCE OF DATA:
Staff nurses who are working in selected maternity hospitals.
7.2 METHODS OF DATA COLLECTION:
i. Research design
Non-experimental descriptive design will be used to assess the knowledge, and
practice of staff nurses regarding management of third stage of labour.

ii. Research variables:

a. Study variable:
Knowledge and practice of staff nurses regarding management of third
stage of labour.

b. Extraneous variables:
Demographic variables of the staff nurses such as age, sex, designation,
qualification, working experience and previous exposure to any information.

iii. Setting
The study will be conducted in the selected maternity hospitals,
Bangalore.

iv. Population
Staff nurses who are working in selected maternity hospitals.
v. Sample
Staff nurses who fulfill the inclusion criteria will be the sample.
Sample size will be 60.
vi. Criteria for sample selection
a. Inclusion criteria:
The study includes those who are:
 Staff nurses (ANM, GNM, B.Sc., P.B.Sc) working in selected
maternity hospitals, Bangalore.
 Staff nurses who are willing to participate in the study.

16
 b. Exclusion criteria
The study excludes
 Staff nurses who are not available at the time of data
collection.
vii. Sampling technique
Non probability convenient sampling technique

viii. Tool for data collection

The tool consists of the following sections:

Section A: A self administered structured questionnaire to assess the

demographic profile consisting of Age, sex,
designation ,qualification, working experience in ward and
previous exposure to any information .

Section B: A self administered structured questionnaire to assess the

knowledge regarding management of third stage of labour.

Section C: Non-observational checklist will be used to assess the practice of

staff nurses regarding management of 3rd stage of labour.
ix. Method of data collection:

Phase 1: After obtaining the permission from the concerned authorities and
informed consent from the samples the investigator will collect the
baseline demographic data.
Phase 2: Self administered structured questionnaire will be administered to
assess the knowledge of staff nurses regarding management of third
stage of labour.

17
Phase 3: Non observational checklist will be used to assess the practice of staff
nurses regarding management of third stage of labour regarding
management of third stage of labour.
Duration of the study : 4 weeks

x. Plan for data analysis:

The data will be analyzed by using descriptive and inferential statistics:
Descriptive statistics:
 Frequency and percentage distribution will be used to study the
demographic variables of the staff nurses.
 Mean and standard deviation will be used to determine the level
of knowledge and practice of staff regarding management of 3 rd
stage of labour.

Inferential statistics :
 Co-rrelation co-efficient will be used to determine the correlation
between the knowledge and practice of staff nurses regarding
management of 3rd stage of labour.
 Chi-square test will be used to determine the association of
knowledge and practice of staff nurses regarding management of 3 rd
stage of labour with the demographic variables.

xi. Projected outcome:

After the study the investigator will know the level of existing
knowledge and practice regarding management of 3 rd stage of labour among
the staff nurses who are working in the selected maternity hospitals and will
develop a protocol to improve the knowledge and practice of staff nurses
regarding management.

7.3 Does the study require any investigation or intervention to the staff
nurses or other human beings or animals?

18
 Yes the study requires minimum investigation to assess the knowledge
and practice of staff nurses regarding the management of third stage of labour.
No other investigations which can cause any harm to the subjects will be done.

7.4 Has ethical clearance obtained from your institution?

Yes permission will be obtained from the institution and informed
consent will be obtained from the staff nurses. Privacy and confidentiality of
the data will be maintained.

19
8. REFERENCES:

1. Yvonne Cheng, Aaron B Caughey. Normal Labor and Delivery. 2009 Oct 26.
Available at http://en  emedicine.medscape.com

2. Diaa M El. Obstetrics Simplified Available online on http://www.gfmer.ch/.

3. Karen L.Maughan , Steven W Heim, Sim S Galazka. Preventing Postpartun

Haemorrhage: Managing the third stage of labour. American Family
Physician.2006 March 15;73(6)

4. A Metin Gulmezogula, Mariana Widmer, Mario Merialdi, Zahida Qureshi,

Gilda Piaggio, Diana Elbourne et al. Active management of third stage of
labour without controlled cord traction: randomized non- inferiority control
trial. Reproductive Health 2009.
5. Postpartum Haemorrhage.
Available on http://www.internationalmidwives.org/
6. E.J. Kongnyuy , N.v. Broek. A clinical audit of the management of
postpartum haemorrhage in Malawi. The Internationl Journal of Gynaecology
and Obstetrics. 2008;7(2)
7. Jack Newman. The Importance of skin to skin contact. Available online
on:http://www.naturalchild.org/.

8. Prashant Gangal, Kartikeya Bhagat, Sanjay Prabhu, Rajlakshmi Nair.

Initiation of breastfeeding by breast crawl. Available online at :
http://breastcrawl.org/.

9. Childinfo. Monitoring the Situation of Children and Women Available

online on http://www.childinfo.org/l

10. WHO. Making Pregnancy Safe. Available online at:

http://www.who.int/making_pregnancy_safer/

11. Childinfo.org.statistics by area _trends in maternal mortality. Available

online at: www.childinfo.org/maternal_mortality.html

12. Indo- Asian News Service. September 21,2010 Available online

at:http://www.ndtv.com/article/india

20
13. WHO Recommendations for the Prevention of Postpartum Haemorrhage
Department of Making Pregnancy Safer. Available online on
http://whqlibdoc.who.int/

14. .Brucker MC. Management of the third stage of labor: an evidence-

based approach. Journal Of Midwifery Womens Health. 2001 Nov-
Dec;46(6):381-92.

15. Prendiville WJ, Elbourne D, McDonald S. Active versus expectant

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9. Signature of the candidate :

10. Remarks of the guide : The study is researchable and

appropriate. It has implication in
clinical nursing practice.

11. Name and designation of :

11.1 Guide : Ms. Subhashini G.

11.2 Signature :

11.3 Co guide (if any) : Mrs. Dhanalakshmi

11.4 Signature :

11.5 Head of the department : Ms. Subhashini G.

11.6 Signature :

12.1 Remarks of the principal :

25
12.2 Signature :

26