A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE OF STAFF NURSES REGARDING

SELECTED ALTERNATIVE AND CONTEMPORARY MODALITIES OF PAIN RELIEF DURING

FIRST STAGE OF LABOUR IN SELECTED MATERNITY

HOSPITALS, BANGALORE

By

SHANTI SONU SAM

Dissertation Submitted to

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

IN PARTIAL FULFILLMENTOF THE REQUIREMENTS FOR THE DEGREE OF

MASTER OF SCIENCEIN

OBSTETRICS AND GYNAECOLOGICAL NURSING

Under the guidance ofMrs. Gowri Sayee

Associate Professor & HODDepartment of Obstetrics and Gynaecological Nursing

FORTIS INSTITUTE OF NURSING20/5, Yelachenahalli, Kanakapura road, Bangalore-560078

YEAR2010-2012

1

Rajiv Gandhi University Of Health Sciences, Bangalore, Karnataka.

DECLARATION BY THE CANDIDATE

I hereby declare that this thesis entitled “A STUDY TO

ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING

PROGRAMME ON KNOWLEDGE OF STAFF NURSES

REGARDING SELECTED ALTERNATIVE AND CONTEMPORARY

MODALITIES OF PAIN RELIEF DURING FIRST STAGE OF

LABOUR IN SELECTED MATERNITY HOSPITALS,

BANGALORE.” is a bonafide and genuine research work carried out by me

under the guidance of Mrs. Gowri Sayee, Associate professor and HOD,

Department of obstetrics and gynaecology, Fortis institute of nursing,

Bangalore.

Signature of Candidate

SHANTI SONU SAM

Date:

Bangalore:

2

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation titled “A STUDY TO

ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING

PROGRAMME ON KNOWLEDGE OF STAFF NURSES

REGARDING SELECTED ALTERNATIVE AND CONTEMPORARY

MODALITIES OF PAIN RELIEF DURING FIRST STAGE OF

LABOUR IN SELECTED MATERNITY HOSPITALS,

BANGALORE.” is a bonafide research work done by Ms. Shanti Sonu

Sam in partial fulfilment of the requirement for the degree of Masters of

Science in Nursing (Obstetrics and Gynaecology).

Signature of Guide:

Mrs. Gowri SayeeAssociate professor& HODObstetrics and gynaecological nursingFortis institute of nursingBangalore- 560078

Date:

Bangalore

3

ENDORSEMENT BY THE

HOD, PRINCIPAL/ HOD OF THE INSTITUTION .

This is to certify that the dissertation entitled “A STUDY TO

ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING

PROGRAMME ON KNOWLEDGE OF STAFF NURSES

REGARDING SELECTED ALTERNATIVE AND CONTEMPORARY

MODALITIES OF PAIN RELIEF DURING FIRST STAGE OF

LABOUR IN SELECTED MATERNITY HOSPITALS,

BANGALORE.” is a bonafide research work done by Ms. Shanti Sonu

Sam under the guidance of Mrs. Gowri Sayee, Department of Obstetrics

and Gynaecological Nursing, Fortis institute of nursing, Bangalore.

Signature of the HOD Signature of the Principal

Mrs. GOWRI SAYEE Prof. SRIDHAR K.V

Associate Professor

Date: Date:

Bangalore Bangalore

4

COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University of Health

Sciences, Karnataka shall have the right to preserve, use and disseminate this

dissertation thesis in print or electronic format for academic or research

purposes.

Signature of the candidate:

Shanti Sonu Sam

Date:

Bangalore

© Rajiv Gandhi University of Health Sciences, Karnataka

5

ACKNOWLEDGEMENTS

“Every good thing given and every perfect gift is from above, coming down

from the Father of lights, with whom there is no variation or shifting

shadow”.

(James 1: 17)

  First and foremost I would like to thank the supreme teacher of all:

God. I know that I am here and that I am able to write all of this for a

reason. I will do my best in never forgetting what a great fortune I have had

in just being here, and that it comes with a lesson and a responsibility. I

hope I am doing the work you have planned me to do.

I extend my heartfelt thanks to my respected

teacher and guide Mrs. Gowri Sayee Associate professor,

HOD, Department of Obstetrics and gynecological nursing,

Fortis Institute of Nursing, Bangalore. Her appropriate

guidance, even support, encouragement, priceless

suggestions and co-operation has continually motivated me

for the successful achievement of this dissertation.

I express my profound and sincere thanks to our

beloved principal Prof. Shridhar K.V, Principal, HOD,

Department of Medical Surgical Nursing, Fortis Institute of

6

Nursing, Bangalore. His encouragement, guidance, valuable

suggestions and untiring effort which has motivated me

throughout the study. His personal interest, endless

patience, love and blessing have been the foundation of this

study.

I owe my earnest gratitude and sincere thanks

to my teacher and co-guide Mrs. Sabitha Sibbala

Associate professor, Department of Obstetrics and

gynecological nursing, Fortis Institute of Nursing, Bangalore.

I am thankful for her valued guidance, kind support and

judicious help which enabled me to complete my study

successfully.

My heartfelt gratitude to our class coordinator,

Dr. Mrs. Thressiamma P.M, vice principal HOD,

Department of Community health Nursing, Fortis Institute of

Nursing, Bangalore. I am thankful for her venerated

guidance and constant support which enabled me to

complete my study successfully.

A word of thanks to Mr. Prabhuswamy A C,

associate professor, Department of medical surgical nursing,

7

Fortis Institute of Nursing, Bangalore, for his help in

completing my study.

With great proud and privilege, I express my

profound sense of

gratitude and heart full thanks to all my P.G. Faculty,

Fortis Institute of

Nursing, Bangalore for the fathomless guidance, constant

availability,

intuitive suggestions, motivation and support rendered

throughout my

study.

I am deeply indebted to all the experts who

contributed the time and effort towards validating and

refining the tools used in the present study.

I owe my gratitude to all the subjects who

enthusiastically participated in carrying out the research

project.

I express my sincere thanks to the Nursing

Superintendent, Fortis hospitals, Bangalore Mrs.

Kavitha Biswas for giving me the authorization to conduct

8

the study among staff nurses in their revered institution. I

thank the nursing in-charges of LDRP ward and 6th level of

Fortis hospital for their help in arranging the classes.

A word of acclamation is to Mr. Arun, Asst.

Professor, Manjunath college of arts and science, a

prominent statistician who has helped me in the analysis of

data of my research study.

I pay my obliged salutations to my parents Rev. Fr

K. P. Sam and Mrs. Anitha Sam for their prayers and

blessings. I extend my love to my siblings Ms. Shalin

mary sam and Mr. Alwin sam for their support and best

wishes that helped me to carry out my study successfully.

There are many more people who have worked behind

the screen in their own loving way to help me accomplish

this task. Special word of thanks to my classmate and

dear friend Mrs. Reena stephen for her sensible help and

suggestions. I thank all my friends especially my friends

Ms. Navreet Virk and Mrs. Bincy Thomas for their

support and prayers.

9

There are many to whom I am yet to show gratitude

because all those who have helped in time have become

priceless charms.

Signature of the

candidate

(Ms.

Shanti Sonu Sam)

Date:Bangalore.

10

LIST OF ABBREVIATIONS USED

GNM GENERAL NURSING AND MIDWIFERY

B.Sc BACHELOR OF SCIENCE

STP STRUCTURED TEACHING PROGRAMME

SD STANDARD DEVIATION

S SIGNIFICANT

NS NON-SIGNIFICANT

df DEGREES OF FREEDOM

PPT POWER POINT PRESENTATION

11

ABSTRACT

“It is refreshing to know that for all the billions of times it has occurred,

the birth of a child, like the wonder inspired by a sunset, can never be

tarnished by repetition”

Background

Motherhood is one of life’s greatest blessings. It is a lifelong event

that forever changes woman into a mother. But the mother also has to go

through enormous pain during this process of transition from a woman to a

mother. As an expectant mother reaches her due date, a concern that looms

large in her mind is the pain that she will experience during labour.

Childbirth is a significant, though stressful event. A woman who is able to

cope with the stress of the labour tends to feel more satisfied with her

experience; an experience that is positive and has satisfying perceptions of

childbirth.

An ideal labour pain relief method should meet the following criteria:

having the least possible side effects for mother and fetus, having permanent

effect, could be administered easily, having appropriate sedative effect

without intervening the uterine contractures. Alternative and contemporary

12

modalities during delivery would lead to relaxation and consequently, a

rapid and easy delivery.

Midwives are the primary care takers who are with the labouring

woman throughout the process of labour. Hence they should be educated

about these alternative modalities and it should be applied in our hospitals.

A teaching programme on selected alternative modalities can promote the

use of these modalities during first stage of labour.

Statement of the problem

“A STUDY TO ASSESS THE EFFECTIVENESS OF

STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE OF

STAFF NURSES REGARDING SELECTED ALTERNATIVE AND

CONTEMPORARY MODALITIES OF PAIN RELIEF DURING FIRST

STAGE OF LABOUR IN SELECTED MATERNITY HOSPITALS,

BANGALORE”

Objectives of the study

1. To assess the pre-test knowledge scores of staff nurses regarding

alternative and contemporary modalities of pain relief during first

stage of labour.

13

2. To find out the effectiveness of structured teaching programme regarding

alternative and contemporary modalities of pain relief during first

stage of labour by assessing post-test knowledge scores of staff

nurses.

3. To find out the association between pre-test knowledge scores and

selected demographic variables.

Methods

Conceptual framework of the study is based on Von Ludwig

Bertalanaffy’s general system’s theory. Based on the problem selected and

objective of the study quasi-experimental one group pre-test post-test design

without control group was selected.

A sample of 60 staff nurses working in OBG department of Fortis

hospital, Bangalore were selected by non-probability sampling technique.

Data was collected by administering structured questionnaire before and

after the implementation of structured teaching programme. Data were

analysed using descriptive and inferential statistics and represented in graphs

and tables.

14

Results

In the present study 86.7% of the respondents had inadequate

knowledge regarding alternative and contemporary modalities before the

implementation of structured teaching programme. But after the

implementation of structured teaching programme 15% of them had

moderately adequate knowledge and 85% of them had adequate knowledge

The mean pre-test scores of 40.42% was higher than the mean post-

test scores of 80.50% which was significant at P-value of 0.001 level which

showed significant increase in knowledge and thus it proves the

effectiveness of the structured teaching programme.

In the preset study the knowledge scores of staff nurses were found to

be non-significant with the demographic variables i.e. age, qualification,

experience, religion. Hence it indicates that there is no association between

the knowledge scores of nurses and the selected demographic variables.

Interpretation and conclusion

The study showed that there was a significant improvement in the

knowledge scores after the administration of structured teaching programme.

Hence it can be concluded that the structured teaching programme was

15

effective in improving the knowledge of staff nurses on alternative and

contemporary modalities of pain relief during first stage of labour.

KEY WORDS: Structured teaching programme, effectiveness,

knowledge, alternative and contemporary modalities

16

TABLE OF CONTENTS

NO. CHAPTER PAGE

1. INTRODUCTION 1-9

2. OBJECTIVES 10-15

3. REVIEW OF LITERATURE 16-24

4. METHODOLOGY 25-40

5. RESULTS 41-64

6. DISCUSSION 65-68

7. CONCLUSION 69-72

8. SUMMARY 73-77

9. BIBLIOGRAPHIC REFERENCES 78-81

10. ANNEXURES 82-137

LIST OF TABLES

17

TABLE NUMBE

RTITLE OF TABLE PAGE

NUMBER

1. Design chosen for the study. 26

2. Distribution of respondents according to age. 43

3. Distribution of respondents according to qualification. 45

4. Distribution of respondents according to experience. 47

5. Distribution of respondents according to religion. 49

6. Distribution of respondents according to pre-test and post-test knowledge scores 51

7.Area wise distribution of mean, mean percentage and standard deviation of pre-test knowledge scores of the respondents.

54

8.Area wise distribution of mean, mean percentage and standard deviation of post-test knowledge scores of the respondents.

57

9.Paired ‘t’ test showing the significant difference between mean pre-test and mean post-test knowledge scores of the respondents

60

10.Association between pre-test knowledge scores of the respondents with selected demographic variables.

63

LIST OF FIGURES

18

FIGURE NUMBER

TITLE OF FIGURE PAGE NUMBER

1. Conceptual framework of the study 15

2. Schematic representation of research methodology 28

3. Cylindrical diagram showing distribution of respondents according to age. 44

4. Pie chart showing distribution of respondents according to qualification 46

5. Pyramid diagram showing distribution of respondents according to experience 48

6. Pie chart showing distribution of respondents according to religion 50

7.Cylindrical diagram showing distribution of staff nurse according to pre-test and post-test knowledge scores

53

8.

Bar diagram showing area wise distribution of mean, mean percentage and standard deviation of pre-test knowledge scores of staff nurses.

56

9.

Bar diagram showing area wise distribution of mean, mean percentage and standard deviation of post-test knowledge scores of staff nurses.

59

10.Cylindrical diagram showing the significant difference between mean pre-test and mean post-test knowledge scores of staff nurses

62

19

LIST OF ANNEXURES

ANNEXURE NO. TITLE OF ANNEXURE PAGE

NO.

A Ethical clearance certificate 82

B Letter seeking permission to conduct the study 83

C Letter requesting consent to validate the tool 84

D Acceptance form for tool validation 86

E Content validation certificate 87

F Letter to the participants requesting consent to participate in the study 88

G List of experts for tool validation 90

H Blue print of distribution of items 92

I Tool for data collection 93

J

Structured teaching programme on alternative and contemporary modalities of pain relief during first stage of labour.

109

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1. INTRODUCTION

“To her who loves us before she meets.”

-An inscription in Mexico City.

The foundation for the whole humankind is the art of motherhood. Mother is the

greatest gift to the world.1 Every woman is a mother and she should be respected.

Childbirth is an intense event and strong emotions both positive and negative can be

brought to the surface. Childbirth is a divine process and women should be supported

during labor.2

Genesis 3:16 says, “I will greatly multiply your sorrows and your conception, in

pain you shall bring forth children” as said to eve the first woman created. This was the

background of labor pain in biblical terms.

Childbirth is a magnificent event with meaning far beyond the actual physiologic

process. Normal labour can be defined as a series of events that take place in the genital

organs in an effort to expel the viable products of conception out of the womb through

the vagina into the outer world. Normal labour occurs between 37 and 42 weeks of

gestation.3

Conventionally, the events of labour are divided into four stages. First stage starts

from the onset of true labour pain and ends with full dilatation of cervix. It is in other

words, the “cervical stage” of labour. Second stage of labour starts with full dilatation of

cervix and ends with the expulsion of fetus. Third stage begins after the expulsion of

21

fetus and ends with the expulsion of placenta and membranes. Fourth stage is the stage of

observation of at least one hour after the expulsion of placenta and membranes.3

The first symptom to appear in first stage of labour is intermittent painful uterine

contractions followed by expulsion of bloody mucous per vagina. The first stage of

labour is characterized by noticeable cervical changes as a result of uterine contractions.

The cervix softens, thins, shortens and opens to a diameter of 10 cm. These changes are

referred to as effacement and dilatation. The first stage is characterized by several

physical and psychological changes of which the most important one to be managed is

the pain due to intermittent uterine contractions.4

During the process of giving birth to new life, the mother has to undergo

enormous pain. Labor pain is an unpleasant, complex, highly individualized phenomenon

with both sensory and emotional components. Childbirth while primarily a joyful event

predisposes the mother to one of the most severe form of pain ever reported.5

The causes of labor pain can be either physical or psychological. Physical factors

include uterine contractions, cervical dilatations, cervical effacements etc. Psychological

factors include fear and anxiety, previous experiences, inadequate support, inadequate

knowledge. Pain perceived during labor may be different for each woman.4

Pain relief is the way in which women feel that they have coped with pain during

labor. It is an essential part in good obstetric care. This involves the use of

pharmacological and non-pharmacological or alternative methods of pain relief. Some of

them are sedatives and analgesics, inhalation agents, general anesthesia, epidural

analgesia, alternative and contemporary modalities. Due to its widespread popularity and

22

proved effectiveness alternative and contemporary modalities should be made available

to every mother.

Alternative and contemporary modalities are simple, safe and inexpensive. It

considers the human body as the sum total of its physical, mental, social and spiritual

dimensions. It has no side effects. Remedies are based on natural ingredients thereby

advocating a drugless cure. Alternative modalities are simple to practice and easily

affordable. Preventive and promotive aspects are accorded equal emphasis in alternative

modalities.6

Midwifery, a field where the mother is viewed as a whole being requires the

practice of alternative and contemporary modalities in reducing labor pain. The

effectiveness of alternative modalities is proved by various studies. Alternative

modalities help the woman to maintain a sense of personal control over birth process.7

Alternative and contemporary modalities include a wide variety of techniques to

address not only the physical sensations of pain but also to prevent suffering by

enhancing psycho-emotional and spiritual components of care.8 Rather than making the

pain disappear, these modalities build self confidence and maintain a sense of well being

in the mother. The mother can attain mastery over pain management with these

modalities.9 The woman is supported and guided in using these modalities to minimize

pain and enhance the progress of labor.

Alternative and contemporary modalities offer lots of possibilities for relieving

pain and can be combined with each other. These modalities do not actively interfere

with labor progress but in some cases can enhance progress or effectiveness of pushing.

23

These modalities promote a sense of accomplishment and capability, which can be more

critical to a satisfying childbirth experience than pain relief. Unlike pain medications they

can be discontinued immediately if they don’t help or in the unlikely event that they

cause a problem.9

Different alternative and contemporary modalities used are: continuous labor

support, hydrotherapy, intra-dermal water blocks, positioning and movement, touch and

massage, acupressure, acupuncture, hypnosis, trans-cutaneous electric nerve stimulation,

aromatherapy, hot and cold application, breathing and relaxation, music, audio analgesia,

birth balls.10

A women experiences great pain during labor and she needs physical and

emotional support to pass over this plateau. A midwife is the ideal person to assist the

woman in this crucial period, combining her skills and knowledge with abundant

humanity.2 The topic of labor pain management occupies a unique place in the evaluation

of effectiveness of maternity care.8

The mother should also be provided with evidence based information on all

these alternative modalities during antenatal period itself. Alternative modalities reduce

suffering by empowering the women to utilize her coping strategies.9

Alternative modalities should be adopted according to the women’s need and

expanding options available should be a primary focus of maternity care. The main goal

should be to provide a safe and acceptable alternative to women.

24

In present study five main modalities namely aromatherapy, touch and massages,

breathing exercises, intra-dermal water block, and hydrotherapy are selected and a

structured teaching programme is given to nurses working in the maternity department.

Aromatherapy is the science of using highly concentrated essential oils or

essences distilled from plants in order to utilize their therapeutic properties. Massaging is

a simple technique of rubbing and kneading painful body muscles. Massages relieve

contraction discomfort as well as aches and pains from tension and long hours of labor.

Hydrotherapy is the method of using water to minimize labour pain and ease birth.7

Breathing exercises use learned breathing patterns to aid the woman’s relaxation

efforts and also helps her to distract from the painful response. Breathing exercises allows

her uterus to do its work without any added effort or waste of energy. Intra-dermal water

block is a new technique for non-narcotic pain relief in which four tiny (0.1ml) injections

of sterile water are administered intra-dermally around the sacrum or lower back.7

These modalities are very effective in minimizing pain during first stage of

labour. Midwives are with the mother during the entire process of labour and hence they

are at a position to provide relief to the woman from labour pain. Hence the investigator

wishes to select them to provide an educational programme on the selected alternative

modalities of pain relief with a view of stressing the importance of understanding and

applying these modalities in order to accelerate the standards of midwifery services

provided.

25

Need for the study

Childbirth has a deep significance not only to mother and her partner but also to

the whole family. It is a profound physiological, psychosocial and spiritual event. It is

this joy and expectation from the entire family that drives the mother to face the pain and

all the suffering associated with it.5

The management of labor pain is one of the main goals of maternity care.

Although pain and suffering occur together, one may suffer without pain or have pain

without suffering. The goal of eliminating labor pain not only requires pain medication

but also require other techniques/modalities to preserve health and maintain coping

strategies. This requires highly skilled personnel to control any undesirable side effects.

The effectiveness of most widely used alternative modalities is discussed with a view to

educate the primary care providers, the midwives.8

A systematic review on non-pharmacological approaches to relieve labor pain and

sufferings was conducted in university of Mexico. A systematic review on randomized

trials was conducted and thirteen methods were found to be effective. Systematic review

of randomized controlled trial of methods like continuous labor support, hydrotherapy,

intra-dermal water blocks, movement and positioning, touch and massage, acupuncture,

hypnosis, transcutaneous electric nerve stimulation, aromatherapy, heat and cold,

childbirth education, self-help techniques such as breathing and relaxation, music and

audio analgesia were taken.8

A study to assess the effectiveness of non-pharmacological aspects in relieving labor

pain was conducted in a public maternity centre in Brazil. Clinical trials were taken

26

before and after therapeutic interventions like hydrotherapy, massages, hot and cold

applications, accupressure, trans-cutaneous electric nerve stimulation, aromatherapy etc.

It was conducted among parturients (n=100). A significant difference was observed in

pain relief showing reduced pain with the help of visual analogue scale.11

Alternative modalities have fewer or no side effects and require very few safety

precautions. They can be combined or used sequentially to enhance their total effect.

Surveys suggest that women prefer alternative modalities for pain relief during labor.9

Women tend to rate alternative modalities of pain relief highly in terms of satisfaction

and desire to repeat them in future labor, even though their pain relieving capability is

short lived. It can be practiced in any setting as it is easy and affordable.

Alternative modalities focus on preventing suffering rather than completely

eliminating pain. It helps the mother in building up self confidence, improving her coping

abilities and perceptions of child birth8. In fact the element that best predicts a woman’s

experience of labor pain is her level of confidence and the ability to cope with the pain.

Satisfaction, fulfillment and a sense of accomplishment are often high when woman

copes well, even when the pain she is experiencing is great.8A single modality can’t meet

the needs of every woman.

A study on knowledge and competence of nurses in pain management was

conducted across United States of America. A 74 item questionnaire was developed by

the investigators. The result was that on an average only 56% of items were answered

correctly. This demonstrated stronger knowledge in pain assessment and less knowledge

in pain management.12

27

In rural India, alternative modalities were used in some or other forms by the

dais who conducted deliveries in villages. Measures like aromatherapy, massages, hot

and cold applications are used in traditional settings.13 All these should be revived to

bring out a change in maternity services. The main requirement for this is the training of

nurses regarding these modalities which can bring out a change in viewing labor and its

pain in the society.

A midwife is the ideal person to help the women understand and select these

modalities. Suffering which is different from pain is not an outcome to be measured after

childbirth. Suffering is unlikely if indicators of satisfaction were positive during child

birth.8 Alternative modalities boost this positive satisfaction. It is the duty of the midwife

to bring about this positive satisfaction.

Although effectiveness of alternative modalities is proved by various studies it is

not practiced in many of our hospitals and maternity centers. There is a need to increase

awareness among midwives about women’s preferences for alternative modalities to

relieve pain during labor. The midwives should consider alternative modalities a valid

form of pain relief and coping. However possible women should be provided with

alternative modalities through a skilled person. The midwives should be stressed the need

for practicing these modalities as women are highly satisfied with these alternative

modalities of pain relief.

As of the investigator’s previous clinical experience alternative modalities are not

used to relieve pain during labor in many of our hospitals due to limited resources

available and various other factors. With the effectiveness of various alternative

28

modalities proved by different studies the need to stress the importance of these

modalities among nurses working in maternity department was felt. Hence a structured

teaching programme on alternative and contemporary modalities regarding pain relief

during first stage of labor can be effective in improving the standards of maternal

services.

29

2- OBJECTIVES

Statement of the problem

“A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED

TEACHING PROGRAMME ON KNOWLEDGE OF STAFF NURSES REGARDING

SELECTED ALTERNATIVE AND CONTEMPORARY MODALITIES OF PAIN

RELIEF DURING FIRST STAGE OF LABOR IN SELECTED MATERNITY

HOSPITALS, BANGALORE.”

Objectives of the study

1. To assess the knowledge of staff nurses regarding alternative and contemporary

modalities of pain relief during first stage of labor by conducting pre-test.

2. To assess the effectiveness of structured teaching programme regarding alternative

and contemporary modalities of pain relief during first stage of labor by using

post-test scores.

3. To find out the association between pre-test knowledge scores and selected

demographic variable.

Operational definitions:

Effectiveness It refers to the significant improvement in knowledge regarding alternative

and contemporary modalities among staff nurses after the implementation of structured

teaching programme.

30

Structured teaching programme

It refers to systematically developed instruction designed for a group of staff

nurses to provide information regarding alternative and contemporary modalities of pain

relief during first stage of labor.

Knowledge

It refers to specific information regarding alternative and contemporary

modalities of pain relief among staff nurses.

Alternative and contemporary modalities

It refers to safe, simple, effective, inexpensive therapies other than the

conventional methods that help in reducing pain during first stage of labor. In the present

study it refers to selected five modalities namely hydrotherapy, intra-dermal water

blocks, aromatherapy, breathing exercises, touch & massage.

First stage of labour

It refers to the period from the onset of true uterine contractions till the complete

dilatation of the cervix.

Pain relief It refers to a feeling of relaxation and reassurance along with the alleviation of

pain and its symptoms by the use of alternative modalities during the first stage of labor.

31

Staff nurse

In this study staff nurses refers to those who have completed basic training in

nursing and registered in respective nursing council available for the study and working

in the maternity department.

Hypothesis

H0 - There is no significant difference between mean pre-test and post-test knowledge

scores regarding alternative and contemporary modalities of pain relief.

H1 - The mean post test knowledge scores of staff nurses exposed to structured

teaching programme regarding alternative and contemporary modalities of pain

relief will be higher than the mean pre-test knowledge scores as measured by

knowledge questionnaire at 0.05 level of significance

H0.1 - There is no significant association between pre-test knowledge scores and

selected demographical variables

H1.1 - There is a significant association between pre-test knowledge scores and selected

demographical variables

Conceptual framework

A theoretical framework serves as a guide or map to systematically identify

a logical precisely defined relationship between variables. (Wood and Hamber, 1994)34

Theoretical framework provides ways and methods to conduct the study and

guiding the interpretation, evaluation and integration of significant findings. (Kothari,

2000)35

32

Theoretical framework selected for this study was based on general systems

theory as postulated by Von Bertalanffy (1998). This is regarded as a universal grand

theory because of its unique relevancy and applicability (Johnson and Webber, 2005). It

is one type of exchange theory. In general systems theory, systems are composed of both

structural and functional components that interact within the boundary that filters the type

and rate of exchange with the environment. Here all the living systems are open systems

because there is an ongoing exchange of matter, energy and information.

The following elements are common to the system:

The system is a unit that is greater than the sum of its parts and it has got various

subsystems which has boundaries. Communication and feedback mechanism is essential

for system to function in a system goal or end can be reached in various ways and any

change in one part causes change in the whole system.

According to Von Bertalanffy “INPUT” which is matter, energy and

information is received from the environment and in this study input is considered as the

various socio-demographic variables which have influenced the respondents.

According to Von Ludwig Bertalanffy, “THROUGHPUT” refers to matter,

energy and information that is modified or transformed within the system. The process by

which the system processes the input and releases an output. In this study throughput

includes 3 stages, first is the pre-assessment of knowledge by pre-test, second is the

administration of structured teaching programme on alternative modalities and third is the

post-assessment through post-test. This will process the information about alternative and

contemporary modalities of pain relief during first stage of labour.

33

According to systems theory, “OUTPUT” refers to energy, matter and

information that leave a system into the environment. In the present study it is the change

in knowledge that is obtained by structured teaching programme on alternative and

contemporary modalities. This can be assessed by means of post-test knowledge scores

which can be adequate, moderately adequate and inadequate which proves the

effectiveness of structured teaching programme.

According to the theory, “FEEDBACK” refers to the information regarding

responses used by the system (may be positive, negative or neutral). In the present study

it is the backflow of information regarding the adequate, moderately adequate and

inadequate changes in the level of knowledge in staff nurses which is measured through a

structured questionnaire in the post-test.

34

1

INPUT

TARGET GROUPSTAFF NURSES

DEMOGRAPHIC VARIABLES;

AGE, QUALIFICATION

EXPERIENCE RELIGION

THROUGHPUT

ASSESSMENT OF PRE-TEST KNOWLEDGE OF STAFF NURSES

DEVELOPMENT AND ADMINISTRATION OF STP ON ALTERNATIVE MODALITIES

ASSESSMENT OF POST-TEST KNOWLEDGE OF STAFF NURSES

OUTPUT

ADEQUATE KNOWLEDGE

MODERATELY ADEQUATE KNOWLEDGE

INADEQUATE KNOWLEDGE

STP EFFECTIVE

RE-ASSESSMENT

STP NOT EFFECTIVE

FIG 1: CONCEPTUAL FRAMEWORK BASED ON BERTALANFFY’S GENERAL SYSTEM’S MODEL

FEEDBACK

3. REVIEW OF LITERATURE

A review of literature refers to activities involved in identifying and

searching for information on atopic and also developing and understanding the state

of knowledge on the topic. A review of literature was undertaken to gain in depth

knowledge of the various aspects of the problem under study.14

The investigator carried out an extensive review of literature on the research

topic in order to gain an insight into the selected problem under study as well as to

collect maximum relevant information for building up the study. It helped to develop

the instruments and select the demographic variables in the study.

Review of literature for the present study has been organized under the

following headings.

1. Studies related to review of alternative and contemporary modalities

2. Studies related to effectiveness of aromatherapy in relieving pain during first

stage of labor

3. Studies related to effectiveness of massages in relieving pain during first

stage of labor

4. Studies related to effectiveness of breathing exercises in relieving pain during

first stage of labor

5. Studies related to effectiveness of intra-dermal water blocks in relieving pain

during first stage of labor

6. Studies related to effectiveness of hydrotherapy in relieving pain during first

stage of labor

7. Studies related to knowledge of staff nurses regarding alternative and

contemporary modalities of pain relief during first stage of labor

41

8. Studies related to effectiveness of structured teaching programme.

Studies related to review of alternative and contemporary modalities

A study was conducted in North America to assess the effectiveness of non-

pharmacological approaches to relieve labor pain and prevent suffering. 13 methods

were updated. Randomized controlled trials included 60 women, 30 of whom received

the alternative modalities and other 30 women in the control group with usual care.

Experimental group had statistically significant lower pain intensity scores (0.73 vs.

1.30). The results of these studies indicate that with appropriate skill and attention

alternative modalities are effective in reducing pain during labor. A systematic review

of 9 trials (n=2259) was conducted to compare outcomes of continuous labor support

versus usual care. Hence the effectiveness of alternative modalities in relieving pain

during labor was proved by this study.8

A study was conducted in Children's Hospital, Australia on the effectiveness of

alternative modalities in labor pain relief. Meta-analysis was performed using relative

risks for dichotomous outcomes and weighed mean differences for continuous

outcomes. Seven trials involving 366 women and using different modalities of pain

management were included in this review. The trials included one involving

acupuncture (n = 100), one involving audio-analgesia (n = 25), one involving

aromatherapy (n = 22), three trials of hypnosis (n = 189) and one trial of music (n =

30). These trials decreased the need for pain relief (relative risk (RR) 0.56, 95%

confidence interval (CI) 0.39 to 0.81). Women receiving alternative modalities were

more satisfied with their pain management in labor compared with controls (RR 2.33,

42

95% CI 1.55 to 4.71). Hence alternative modalities are effective in reducing labor

pain.15

Studies related to effectiveness of aromatherapy in relieving pain during first

stage of labor

A study was conducted at Oxford Brookes university to explore the effects

that essential oils can have on helping a mother mentally cope with labor. During the

eight-year study involving 8,000 mothers, they found that aromatherapy was effective

in managing labour pains. They found that using essential oils lessened maternal

anxiety and fear while inducing a sense of well-being. Fear and anxiety are two things

which can slow labour and make the mother to be unable to cope with the pain of

labour. The study showed a drop in the use of opiate pain relief by those mothers who

used aromatherapy during labour. The normal uptake of opiate pain relief would have

been expected to be 30% in the Oxford study this dropped to 0.4%.16

One large, uncontrolled prospective study reported on the use and

effectiveness of aromatherapy in a large referral maternity unit in the United

Kingdom. During this time, 8058 women received aromatherapy during labor under

the supervision of midwives trained in aromatherapy. Sixty-one percent of the women

received aromatherapy (lavender, rose, or frankincense) to relieve anxiety and fear.

Rose oil was rated helpful by most (71%), followed by lavender (50%). Lavender and

frankincense were used for pain by 537 women, of whom 54% found lavender helpful

and 64% found frankincense helpful. In conclusion, aromatherapy is inexpensive and

popular with laboring women and midwives.17

43

Studies related to effectiveness of massages in relieving pain during first stage of

labour

A retrospective descriptive survey design study was conducted on “10 Non

Pharmacological pain relief techniques” for 46 women who were at least 18 years old

in North California. Of the 10 Non Pharmacological strategies rated by the sample,

breathing techniques relaxation, acupressure and massage found to be most effective.

Results found that a greater use of techniques were safe and effective and enhance

patient satisfaction during birth experience.18

An experimental study was conducted in a public maternity centre of Brazil.

A randomized trial consisting of 60 women were selected to receive massage or usual

care was selected to explore the effectiveness of massages in relieving pain during

labor. Massage was performed three times, once during each phase of the first stage of

labor and lasted for 30 minutes in each phase. Pain and anxiety was measured using

present behavioral intensity (PBI) scale and visual analog scale for anxiety (VASA).

Although pain intensity increased steadily through progressing phases of labor, the

massage group had significantly lower pain intensity scores at each phase of labor

(0.73 versus 1.30 in latent, 1.73 versus 2.17 in active, and 2.17 versus 2.87 in

transition phases). 87 % of the women in the massage group reported that the massage

was helpful in providing pain relief.19

A study was conducted to assess the effect of massage therapy on severity of

pain and outcome of labour at selected hospitals of Tehran. The results demonstrated

that the mean of pain severity at the first stage of labour was significantly different

among the experiment group and the control group. Massage therapy could be

44

introduced as a new useful method during delivery; regarding its supportive role to

reduce the labour pain.20

Studies related to effectiveness of breathing and relaxation in relieving pain

during first stage of labor

A study conducted by Oregon Health Sciences University School of Nursing,

Nigeria in 1998 involving 4,171 women who used different methods for managing

first stage of labour has showed that the majority that is 84% of women used non-

drug methods, while about half 49% used drugs for relieving pain. Among 84% of

women who used non-pharmacologic methods, 55.2% of women found that paced

breathing is effective.21

A study conducted in a maternity centre in Coobee, USA has listed pain

relief options during childbirth and labour. Among those options breathing exercises

is one, and has shown that slow and regular breathing can promote relaxation,

reducing pain and increasing comfort. Research has shown that none of these

techniques adversely affect the baby in any way or produce after-effects in the

mother.22

Studies related to effectiveness of intra-dermal water blocks in relieving pain

during first stage of labor

An experimental study was conducted in the University of Mexico. A

randomized trial compared the effect of intra-dermal water blocks to a "placebo"

blank (using saline). It was found that intra-dermal water blocks significantly

decreased severe low back pain in laboring women. Pain relief lasted 45 to 120

45

minutes and most women stated they would want to use intra-dermal water blocks

again during a subsequent birth.23

One of the trials compared the efficacy of three different treatments to decrease

low back pain: intradermal water blocks, TENS, and usual care (massage, water

immersion, movement as needed. Even though the water blocks were effective in

decreasing low back pain, women in the usual care group had the lowest requests for

pain medication.24

Studies related to effectiveness of hydrotherapy in relieving pain during first

stage of labor

An experimental study was conducted in Columbia to determine the

effectiveness of hydrotherapy on labour. Using a randomized, pre-test –post test

control group design with repeated measures, 18 term parturient’s were assigned to a

control and an experimental group. Experimental subjects were placed in a tub of 37 0

C water for 1 hour during early labour. At 15 minutes bathers’ pain scores were

decreased compared to non bathers. After 15 minutes of immersion, bathers had a

significantly greater increase in plasma volume than non bathers. The findings offer

preliminary support for therapeutic effects of bathing in labour for acute, short term

anxiety and pain reduction. Findings from the study support the therapeutic effects of

water immersion as an alternative or supplemental intervention for clients who need

fast short acting anxiety and pain relief.25

A recent systematic review analyzed findings of 2 prospective cohort studies

and 7 RCTs of bathing published between 1987 and 2001. A total of 3496 women

participated in these trials. Sample sizes in the individual trials ranged from 18

to1237. The trials varied widely in study designs and quality, timing of entry into the

46

water, water temperature, and in baseline rates of epidural analgesia and other

interventions, as reflected by the rates in the control ("usual care") groups. Of the 3

best designed RCTs, 2 found a reduction in pain indicators in the bath groups1 one

did not. Maternal satisfaction was high in the bath group, with 89% stating they would

like to use the bath in a future labor.26

Studies related to knowledge of staff nurses regarding alternative modalities of

pain relief during first stage of labor.

A study was conducted on “Midwife’s utilization of non-pharmacological pain

management methods during the first of stage labor”. The data was obtained by means

of a structured questionnaire which was given to midwives working in the Maternity

wards of the Christian Hospital Association of Lesotho. 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 labor 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 labor.27

A descriptive survey was conducted in a large Canadian hospital on 97

registered staff nurses regarding nurse’s attitude towards providing continuous labor

support. Scores measuring nurses' attitudes, subjective norms, and intentions

regarding continuous labor support for women with epidural analgesia were

significantly lower than those for women without epidural analgesia (p<.0001).Top

perceived organizational barriers to continuous labor support included unit acuity and

method of patient assignment. Nurses view organizational barriers as important

factors influencing their ability to provide continuous labor support.28

47

A study was conducted across United States on nursing students and faculty

member’s knowledge of experience with and attitudes towards complementary or

alternative therapies. The study was designed to describe and compare the knowledge,

experience and attitude of nursing faculty and student’s .The results revealed that 85%

of the participants desired more education about complementary and alternative

medicine. Faculty and nursing students expressed positive attitude towards generating

complementary therapy into undergraduate nursing curriculum and nursing practice.29

Studies related to effectiveness of structured teaching programme.

A quasi experimental study was carried out at rural health centre at South

Pitchavaram in Tamil Nadu on effectiveness of structured teaching programme on

knowledge, Attitude and practices regarding tobacco consumption in rural

health setting. Sixty subjects who were attending the rural health centre were

selected by systematic random sampling technique. The data was collected by

questionnaire. Out of 19 smokers about 6 (31.6%) had the highest level of readiness to

quit smoking. Out of 28 tobacco chewers 15 (53.6%) had highest level of readiness to

quit their behavior of chewing tobacco. A structured teaching programme was found

to be effective in changing these behaviours.30

A study was conducted to assess the effectiveness of

structured teaching programme on knowledge and practice of

breast feeding among primi-postnatal mothers of maternity wards in

C.M.C Vellore hospital, research design employed descriptive survey

method, simple random sampling used, sample size were 100 primi-

postnatal mothers, tools used were observation checklist and

interview guide. The study’s results shows that mother who had

48

teaching programme showed highly significant knowledge gain and

good practice of breast feeding(P<0.01).31

A study was conducted to assess the effectiveness of

structured teaching programme on knowledge and practice of

breast feeding and its problems among lactating mothers in Vani

Villas Hospital, Bangalore. The descriptive evaluation study was

conducted on 20 lactating mothers of hospitalized children, data

collection done using a structured interview schedule and

observational checklist, analysis of data revealed that 50% of

mothers had satisfactory level of knowledge about the advantages

of colostrums. The desirable mothers and child relationship before

was 15% and after instruction was 50%, significant at P<0.01

level.32

An evaluative study was conducted on the effectiveness of

structured teaching programme on breast feeding among ante natal

mothers at Mangalore among 30 mothers selected by purposive

sampling technique. Data was collected using a structured closed

ended questionnaire, following which a planned teaching

programme was administered. The study findings revealed that the

mean post-test knowledge score was significantly higher than the

mean pre-test knowledge score (t=52.65, P < 0.001), showing

effectiveness of the structured teaching programme in improving

the knowledge on breast feeding benefits and practices.33

49

4. METHODOLOGY

The research methodology indicates the general pattern to gather valid and

reliable data for the problem under investigation.34

Research methodology is a way to systematically solve the research problem. It

involves systematic procedure by which the researcher starts from initial identification

of research problem to its final conclusion.14

This chapter deals with description of various steps adopted to collect and

organize data for the study. It includes the research approach, research design, setting

of the study variables under study, population, sample and sample size, sampling

technique, development of the tool, development of structured teaching programme,

method of data collection and plan for data analysis.

Research approach

Research approach indicates the basic procedure for conducting the research

study. Research approach helps the researcher to determine what data to be collected

and how to analyze it. It also suggests possible conclusions to be drawn from the data.

The selection of approach depends upon the purpose of the study.35

50

In view of the nature of the problem selected for the study, an evaluative

approach was found appropriate.

Evaluation research is an applied form of research that involves finding out

how well a programme, procedure or policy is working. Its goal is to assess or

evaluate the success of a programme.34

Research design

The research design is the plan, structure and strategy of investigation for

answering the research question. It is the overall plan or blue print, the researcher

select to carry out their study.35

The term research design refers to the plan or organization of a scientific

investigation. Research design helps the researcher in selection of subjects,

manipulation of experimental variables, control of extraneous variables, procedure of

data collection and the type of statistical analysis to be used to interpret the data.14

Quasi-experimental one group pre-test post-test design without control group

was selected as the research design for the present study. The primary objective of

study was to find the effectiveness of structured teaching programme.

The design chosen for the study is presented in the table-1 as follows

Group Pre-Test(Day 1)

Intervention(Day 2)

Post-Test(Day 7)

Experimental 01 X 07

51

Key:

01: Assessment of knowledge by pre-test.

X: Structured teaching programme on Alternative and contemporary modalities

of pain relief during first stage of labour.

02: Assessment of knowledge by post-test.

A structured questionnaire was administered to staff nurses working in

maternity department in Fortis hospitals on day 1, following that a structured teaching

programme on alternative and contemporary modalities was delivered. Post-test was

conducted on day 7 to assess the effectiveness of structured teaching programme.

52

53

RESEARCH DESIGNQUASI-EXPERIMENTAL ONE GROUP

PRE-TEST POST-TEST DESIGN WITHOUT CONTROL GROUP

POPULATIONSTAFF NURSES WORKING IN MATERNITY DEPARTMENTS

SAMPLE60 STAFF NURSES OF MATERNITY DEPARTMENT, FORTIS HOSPITAL

PRE-TEST

STRUCTURED QUESTIONNAIRE REGARDING ALTERNATIVE AND CONTEMPORARY MODALITIES

STRUCTURED TEACHING PROGRAMME REGARDING ALTERNATIVE AND CONTEMPORARY MODALITIES

POST TEST

STRUCTURED QUESTIONNAIRE REGARDING ALTERNATIVE AND CONTEMPORARY MODALITIES

ANALYSIS

DESCRIPTIVE & INFERENTIAL STATISTICS

DAY 7

DAY 1

SAMPLING TECHNIQUE

NON-PROBABILITY PURPOSIVE SAMPLING

Setting

The setting is the physical location and conditions in which data collection

takes place. This study was conducted in Fortis hospital, Bannerghatta road,

Bangalore. Fortis hospital was selected for the study on the basis of feasibility of

conducting study and the availability of the sample.

Variables under investigation

A variable is a phenomena or characteristic or attribute under a study.

Variables are the measurable characteristics of a concept and consist of a logical

group of attributes.35

Three types of attributes were identified in the study. They are independent

variable, dependent and extraneous variable.

Independent variable:

According to Treece and Treece (1988) the independent variable is the one

variable that stands alone and not dependent on any other. It is the cause of the

action.34

In present study it refers to the structured teaching programme regarding

alternative and contemporary modalities of pain relief.

Dependent variable:

54

Dependent variables are the effect of the independent variable and cannot exist

by itself (Treece and Treece 1988).34

In the present study it refers to the knowledge of staff nurses regarding

alternative and contemporary modalities.

Demographic variables:

An uncontrolled variable that greatly influences the results of the study is called

as the demographic variables (Treece and Treece 1988).

Demographic variables selected for this study are age in years, qualification,

experience and religion.

Population

Population refers to the complete set of observations or measurements about

which the investigator would like to draw conclusions. Population is a group whose

members possess specific attributes that the researcher is interested in studying. In the

present study the population consists of all staff nurses working in maternity

departments of various hospitals.35

Sample and sampling technique

Sample:

A sample is a subset or portion of the population that has been selected to

represent the population of interest.14

The present study was conducted among 60 staff nurses working in maternity

department of Fortis hospital, Bannerghatta road, Bangalore.

55

Sampling Technique:

Sampling is a process of selecting a group of people, events or position of the

population to represent the entire population.34

Non-probability purposive sampling technique was used to select 60 staff

nurses working in maternity department of Fortis hospital as the sample for the

present study.

Criteria for selecting the sample

Inclusion Criteria:

1. Staff nurses who are willing to participate in this study.

2. Staff nurses who are available during the period of data collection.

Exclusion Criteria:

1. Staff nurses working in departments other than the maternity department.

Selection and development of tool

Tools are the procedures or instruments used by the researcher to collect the

data. It acts as a best instrument to assess and collect the data from the samples of the

study.35

The instruments selected in a research must be the best vehicle for drawing

conclusion for the study. It is a device used to measure the concept of interest in a

research project.14

The present study was aimed to evaluate the effectiveness of structured

teaching programme on knowledge of staff nurses regarding alternative and

contemporary modalities of pain relief during first stage of labour. Structured teaching

programme followed by administration of structured knowledge questionnaire was

56

used as an appropriate and effective method to evaluate the knowledge of the staff

nurses.

The main strengths behind development of the tool were:

Review of research and non-research materials in the areas relevant to

alternative and contemporary modalities of pain relief

Experts’ opinion and suggestions were taken from the field of nursing and

medicine in determining the important areas to be included.

Discussion with colleagues and personal experience in clinical settings.

Books.

Preparation of the blueprint

A blueprint on knowledge questionnaire regarding alternative and

contemporary modalities was prepared consisting of Eight sub-areas that include,

general information about labour, general information about labour pain, alternative

and contemporary modalities, aromatherapy, massages, breathing exercises, intra-

dermal water block, hydrotherapy. It depicted the distribution of items according to

the content areas based on three domains: knowledge, comprehension and application.

Development of criteria checklist for the tool

Criteria checklist was developed to validate the tool regarding accuracy,

relevance and appropriateness of the content.

Description of tool

Data collection tool contain items on the following aspects;

Part I: includes items related to demographic variables - Age (in years), qualification,

experience, religion

57

Part II: Includes 40 knowledge questions of which Nine items were related to

General information about labour, Three items regarding labour pain, Two items

regarding alternative modalities, Six items regarding aromatherapy, Five items

regarding massages, Five items regarding breathing exercises, Five items regarding

intra-dermal water blocks, Five items regarding hydrotherapy.

The knowledge regarding alternative and contemporary modalities was

measured in terms of knowledge score. Each correct answer was given a score of one

mark and wrong answer or unanswered was given a score of zero. The maximum

score was 40. To interpret level of knowledge the scores were distributed as follows;

Inadequate knowledge ≤ 50 %

Moderately adequate knowledge 51 – 75 %

Adequate knowledge > 75 %

Content validity of the tool

Content validity represents the universe of content which provides the

framework and basis for formulating the items that will adequately represent the

content.

The constructed tool along with objectives, blue print and criterion checklist

was submitted to seven experts in the field of obstetric nursing and medicine for

content validity. The selection of experts was done based on their experience and

clinical expertise. The experts were requested to give their opinions regarding

relevancy, accuracy and appropriateness of the items for further modifications.

Pre-testing of tool

58

Pre-testing of the structured questionnaire was done to check the clarity of

items, their feasibility and practicability. The prepared questionnaire was

administered to ten staff nurses. The sample chosen were similar in characteristics to

those of the population under study.

The investigator found that the language of tool was simple and practicable; the

average time taken to complete the questionnaire for each sample was 30 –

45minutes. The tool consisted of 40 items. Based on the pre-testing suggestions given

by the experts, modification and rearrangement of few items were done.

Reliability

Reliability of research instrument is defined as the extent to which the

instrument yields the same results on repeated measures. The reliability of a

measuring tool can be assessed in the aspects of stability, internal consistency, and

equivalence depending on the nature of the instrument and aspects of the reliability

concept.14

The method adopted for the present study was split-half method to measure the

homogeneity of the tool. The questionnaire was first divided into two equivalent

halves and correlation for the half test was found using Karl Pearson’s correlation

coefficient formula. The tool was found to be statistically reliable for the main study.

Ethical consideration

The researcher had taken permission from the parent institution to conduct the

research study. Permission was obtained from the nursing superintendent of Fortis

hospital, Bangalore. Consent was taken from the subjects before data collection. The

subjects were informed that the confidentiality of data will be maintained.

59

Development of structured teaching programme

Teaching plan is a guide for the teacher because it helps to cover the topic

comprehensively with proper sequence of points and without missing anything.

The steps to prepare teaching plan were:

Review of literature

Framing the outline of the content.

Preparation and organization of content.

Deciding the method of instruction and AV aids.

Preparation of the final draft.

Editing the teaching plan evaluating the teaching plan.

1. Review of literature:

An extensive literature review was undertaken from research and non research

materials, internet sources, journals etc., regarding alternative and contemporary

modalities.

2. Framing the outline of the content:

The outline of the teaching plan was framed which included setting of the

general and specific objectives regarding alternative and contemporary modalities,

specifying the date, time, place and size of the group, number of sessions and duration

of sessions.

3. Preparation and organization of the content:

Content of the structured teaching programme on alternative and contemporary

modalities was prepared and organized under various headings according to the

60

specific objectives. Structured teaching programme was organized under various

headings such as, general

information about labour and labour pain, alternative and contemporary modalities,

aromatherapy, massages, breathing exercises, intra-dermal water block, hydrotherapy.

4. Deciding the method of instruction and AV aids:

The method of instruction adopted was lecture method with power point

presentation.

5. Preparation of the final draft of structured teaching programme:

General and specific objectives of the teaching plan were given in the

beginning of the structured teaching programme. Final draft of structured teaching

programme was organized under various headings such as general information about

labour and labour pain, alternative and contemporary modalities, aromatherapy,

massages, breathing exercises, intra-dermal water block and hydrotherapy.

6. Editing the teaching plan.

The prepared structured teaching programme was edited by professional

editors.

Description of structured teaching programme

Structured teaching programme was prepared to enhance the knowledge of staff

nurses regarding alternative and contemporary modalities which consist of the

following content.

Introduction

General information about labour and labour pain

Alternative and contemporary modalities

Aromatherapy

61

Massages

Breathing exercises

Intra-dermal water blocks

Hydrotherapy

Content validity of the structured teaching programme:

Content validation of the structured teaching programme was ascertained in

consultation with the experts in the field of nursing such as obstetrics and

gynaecological nursing. Suggestions and recommendations of the experts were

considered to modify the content of structured teaching programme.

Pre-testing of the structured teaching programme:

Pre-testing of the validated structured teaching programme was done at Fortis

Hospital, Bangalore to determine the feasibility, clarity and ambiguity, and time taken

to complete the teaching. The time taken by the researcher to complete the teaching

programme was 30-40 minutes. The researcher did not face any problems during the

administration of the structured teaching programme. Structured teaching programme

found to be feasible with regard to time, simplicity and clarity.

Pilot study

Pilot study is a small scale version of the proposed study conducted to

refine the methodology. It is conducted similar to the proposed study, using similar

subjects, the similar setting, the same treatment, the same data collection and the same

analysis technique.

The Purpose of the Pilot Study:

To find out the feasibility of conducting the final study

To evaluate the tool constructed.

To finalize the plan for analysis.

62

The pilot study was conducted in Fortis Hospital, Bangalore from 1.3.2012 to

10.3.2012 to find the feasibility of the study. Ten staff nurses were selected using

purposive random sampling technique. The subjects for the pilot study possessed the

same characteristics as that of the sample for the final study, but were not included in

the main study. Prior to the study permission was obtained from the concerned

authority. The selected subjects were informed of the purpose of the study and

consent was obtained. Assessment of knowledge was done by using structured

questionnaire. Post-test was conducted using the same structured questionnaire on the

seventh day of pre-test and after the administration of structured teaching programme.

The time taken to complete one questionnaire was 30-40 minutes. The collected data

were analyzed using descriptive and inferential statistics.

After conducting the pilot study, it was found that the study was feasible.

The concerned authority and the sample were found to be cooperative, the

questionnaire and structured teaching programme were relevant and the time and cost

of the study was within the limit.

Problems faced during pilot study:

Some of the subjects have to be reminded personally to come for the post-test.

Number of subjects showed great reluctance to participate in study as they

complained of tiredness due to their tiring duty shifts.

Procedure for data collection of main study

Before collecting the data, permission was obtained from the concerned

authority. Keeping in mind the ethical aspect of research, the data was collected after

obtaining the informed consent of the sample. The samples were assured anonymity

and confidentiality of information provided by them. The researcher collected the data

63

from the subjects. Pre-test was conducted from 15th March 2012 to 15th April 2012

followed by administration of structured teaching programme using A V aids. The

duration of the session was 30 minutes. Post-test was conducted from 21st March

2012 to 21st April 2012 to evaluate the effectiveness of structured teaching

programme.

Plan for data analysis

The data obtained will be analyzed on the basis of the objectives of the study

using descriptive and inferential statistics. Inferential statistics which are based on

laws of probability provide a means of drawing conclusion about the population from

which data was obtained for the study. Plan for data analysis includes:

The data was entered in a master sheet.

Data was analyzed using descriptive and inferential statistics.

Description of the subjects with respect to demographic variables was presented

in terms of frequency and percentage.

Mean, Standard Deviation, and Mean Percentage was used to evaluate the

knowledge level of staff nurses on alternative and contemporary modalities.

Statistical significance of the effectiveness of structured teaching programme

was analyzed using Paired ‘t’ test.

Chi-square test was used to find out the relationship between demographic

variables and knowledge level of staff nurses on alternative and

contemporary modalities.

Results would be represented in tables and graphs.

Summary

64

A quasi-experimental design with evaluative approach was adopted in order

to evaluate the effectiveness of structured teaching programme regarding alternative

and contemporary modalities of pain relief during first stage of labour among staff

nurses working in maternity department in Fortis hospital, Bangalore. Pilot study was

conducted to find out the feasibility of the study. Validity and reliability of the

questionnaire and structured teaching programme was tested. Closed ended questions

were used to assess the knowledge regarding alternative and contemporary modalities.

Data was collected from the sample after obtaining permission from the concerned

authority. Collected data was analysed using descriptive and inferential statistics and

was presented in the form of tables, graphs and diagrams.

65

5. RESULTS The chapter deals with the analysis and interpretation of data collected

from staff nurses regarding alternative and contemporary modalities. The analysis and

interpretation was based on the data collected by using structured questionnaire. The

data collected were organized, tabulated, analyzed and interpreted by using

descriptive and inferential statistics. Statistical analysis is a method of rendering

quantitative information and elicits meaningful form of research data. It is the process

of organizing and synthesizing data so as to answer research questions and to test the

hypothesis.

Objectives of the study

1. To assess the pre-test knowledge scores of staff nurses regarding alternative and

contemporary modalities of pain relief during first stage of labor.

2. To assess the effectiveness of structured teaching programme regarding

alternative and contemporary modalities of pain relief during first stage of

labor by using post-test scores.

3. To find out the association between pre-test knowledge scores and selected

demographic variable.

66

Hypothesis

H0-There is no significant difference between mean pre-test and post-test knowledge

scores regarding alternative and contemporary modalities of pain relief.

H1-The mean post test knowledge scores of staff nurses exposed to structured

teaching programme regarding alternative and contemporary modalities of

pain relief will be higher than the mean pre-test knowledge scores as

measured by knowledge questionnaire at 0.05 level of significance

H0.1-There is no significant association between pre-test knowledge scores and

selected demographical variables

H1.1-There is a significant association between pre-test knowledge scores and

selected demographical variables

Organisation of findings

The collected data were edited, tabulated, analyzed, interpreted and

findings obtained were presented in the form of tables and diagrams which were

represented under the following sections.

Section 1:

Demographic profile of staff nurses.

Section 2:

Knowledge of staff nurses regarding alternative and contemporary

modalities of pain relief during first stage of labour in pre-test and post-test

Section 3:

Findings related to effectiveness of the structured teaching programme by

comparing the mean pre-test & mean post-test knowledge scores

67

Section 4:

Association of pre-test knowledge scores of staff nurses with the selected

demographic variables

Section – 1

Demographic profile of staff nurses

Table – 2: Distribution of respondents according to their age

n=60Age

(in years) Frequency Percentage

20-25 26 43.3

26-30 30 50.0

31-35 2 3.3

36-40 2 3.3

Total 60 100

Table - 2 shows the distribution of respondents according to their age. It can

be seen from the table that majority of the respondents i.e. 30 (50%) are in the age

group of 26-30 yrs and 26 (43.3%) are in the age group of 20-25 yrs. Only 4 (6.6%)

are in the age group of 31-40 yrs. The above data is represented in cylindrical diagram

in the Fig 3

68

69

20-25 years 26-30 years 31-35 years 36-40 years0.0%5.0%

10.0%15.0%20.0%25.0%30.0%35.0%40.0%45.0%50.0%

Fig - 3: Cylindrical diagram showing percentage dis-tribution of respondents by age

Age in years

Fre

quen

cy in

per

cent

age

70

Table – 3: Distribution of respondents according to Qualification

n=60

Qualification Frequency Percentage

GNM 47 78.3

B.Sc. Nursing 13 21.7

Total 60 100

In Table 3 the distribution of respondents according to their qualification is

shown. It is evident that majority of them 47(78.3%) have GNM qualification and 13

(21.7%) of them have completed B.Sc. nursing. The above distribution is given in pie

diagram in Fig 4

71

78.30%

21.70%

Fig- 4: Pie diagram showing percentage distribution of respondents by their qualification

GNM

B.Sc. Nursing

72

Table – 4: Distribution of respondents according to years of experience

n=60

Experience Frequency Percentage

Below one year 3 5.0

1-3 years 25 41.7

4-6 years 27 45.0

7 years and above 5 8.3

Total 60 100

In Table - 4 the distribution of respondents according to experience is given. It

was observed that out of 60 staff nurses majority of them 27(45%) have 4-6 years of

experience and 25(41.7%) of them have1-3 years of experience. 5 (8.3%) of them

have experience of 7 years and above and only 3(5%) of them have less than one year

experience. The above distribution is given in pyramid diagram in the Fig 5

73

Below one year1-3 years

4-6 years7 years and above

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

Fig - 5: Pyramid diagram showing frequency distribution of re-spondents according to their experience

Experience in yearsFreq

uenc

y in

per

cent

age

74

Table – 5: Distribution of respondents according to religion.

n=60

Religion Frequency Percentage

Hindu 23 38.3

Christian 37 61.7

Total 60 100

In Table 5 the distribution of respondents according to religion is given. It was

found that out of 60 staff nurses majority of them 37(61.7%) were Christians and

23(38.3%) were Hindus. This distribution is shown in pie diagram in fig 6

75

38.3%

61.7%

Fig - 6: Pie diagram showing percentage distribution of respondents by religion

HinduChristian

76

SECTION II

KNOWLEDGE OF STAFF NURSES REGARDING ALTERNATIVE AND

CONTEMPORARY MODALITIES OF PAIN RELIEF DURING FIRST

STAGE OF LABOUR IN PRE TEST

TABLE – 6: Distribution of respondents according to pre-test and post-test

knowledge scores.

n=60

Knowledge levelPre test Post test

Frequency Percent Frequency Percent

Inadequate knowledge52 86.7 0 0.0

Moderately adequate knowledge 8 13.3 9 15.0

Adequate knowledge0 0.0 51 85.0

Total 60 100 60 100

In the Table 6 distribution of respondents according to pre-test and post-test

knowledge scores is given. The pre-test was conducted by administering a structured

questionnaire to the staff nurses. In which majority of nurses 52(86.7%) of them have

inadequate knowledge, 8(13.3%) of them have moderate knowledge and none of the

staff nurses (0%) have adequate knowledge. The above data clearly indicates the need

for a planned teaching programme on imparting the knowledge to the staff nurses.

The post-test was administered after the structured teaching programme. The post-test

knowledge scores show a significant difference ie, none (0%) them are having

inadequate knowledge, 9(15%) are having moderate knowledge and majority of them

51(85%) have acquired adequate knowledge from the structured teaching programme

77

on alternative and contemporary modalities of pain relief during first stage of labour.

This distribution is given in the diagram below in Fig 7

78

Inadequate knowledge Moderate knowledge Adequate knowledge0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Fig - 7: Pre-test and post-test knowledge level of respondents

Pre testPost test

Knowledge level

Freq

uenc

y in

per

cent

age

79

TABLE – 7: Mean, Mean percentage and standard deviation for the pre test knowledge of staff nurses

n=60Sl.

No.

Knowledge

aspects

No. of

Items

Max

ScoreMean

Mean

%Median SD

1 General

information about

labour

9 9 5.53 61.44 6 1.478

2 General

information

regarding labour

pain

3 3 1.57 52.33 2 0.927

3 Alternative and

contemporary

modalities

2 2 0.38 19 0 0.666

4 Aromatherapy 6 6 1.97 32.83 2 0.901

5 Massages 5 5 1.13 22.6 1 1.033

6 Breathing

exercises5 5 1.85 37 2 0.954

7 Intra-dermal

water blocks5 5 2.05 41 2 1.080

8 Hydrotherapy 5 5 2.48 49.6 2.5 1.142

Overall 40 40 16.97 40.42 18 3.773

The above table 6 shows the mean, mean percentage and standard deviation of pre test

knowledge scores in various aspects. The mean, mean percentage and SD in the area

of general information about labour is 5.53, 61.44% and 1.478 respectively. The

scores in the area of general information regarding labour pain are 1.57, 52.33 and

0.927, in the areas of alternative and contemporary modalities are 0.38, 19 and 0.666,

80

in the area of aromatherapy are 1.97, 32.83 and 0.901, in the area of massages the

scores are 1.13,22.6 and 1.033, in the area of breathing exercises the score are 1.85,37

and 0.954, in the area of intra-dermal water blocks 2.05, 41 and 1.080 and the scores

of hydrotherapy are 2.48, 49.6 and 1.142. The overall pre test mean, mean percentage

and SD are 16.97, 40.42 and 3.773 respectively.

81

Genera

l infor

mation about la

bour

Labour pain

Altern

ative m

odalities

Aromathera

py

Massa

ges

Breathing ex

ercise

s

Intra

-dermal w

ater block

s

Hydrothera

py

Over all

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

Fig - 8: Mean percentage of pre-test knowledge scores of the re-spondents

Knowledge aspects

Mea

n pe

rcen

tage

82

TABLE – 8: Mean, Mean percentage and standard deviation for the post test knowledge of staff nurses

n=60Sl.

No.

Knowledge

aspects

No. of

Items

Max

ScoreMean

Mean

%Median SD

1 General

information

about labour9 9 8.12 90.22 8 0.922

2 General

information

regarding

labour pain

3 3 2.52 84 3 0.624

3 Alternative and

contemporary

modalities

2 2 1.13 56.5 1 0.596

4 Aromatherapy 6 6 4.27 71.16 4 1.148

5 Massages 5 5 3.40 68 3.5 1.265

6 Breathing

exercises5 5 3.93 78.6 4 0.918

7 Intra-dermal

water blocks5 5 4.32 86.4 4 0.701

8 Hydrotherapy 5 5 4.52 90.4 5 0.770

Overall 40 40 32.20 80.5 32.5 2.773

The above table 7 shows the mean, mean percentage and standard deviation of post

test knowledge scores in various aspects. The mean, mean percentage and SD in the

area of general information about labour is 8.12, 90.22% and 0.922 respectively. The

scores in the area of general information regarding labour pain are 2.52, 84 and 0.624,

in the areas of alternative and contemporary modalities are 1.13, 56.5and 0.596, in the

area of aromatherapy are 4.27, 71.16and 1.148, in the area of massages the scores are

3.40, 68and 1.265, in the area of breathing exercises the score are 3.93, 78.6and

83

0.918, in the area of intra-dermal water blocks 4.32, 86.4 and 0.701and the scores of

hydrotherapy are 4.52, 90.4and 0.770.

84

Gener

al inform

ation abou

t labour

Gener

al inform

ation re

garding la

bour pain

Altern

ative a

nd contem

porary

modaliti

es

Aromather

apy

Massa

ges

Breathing ex

ercis

es

Intra

-dermal w

ater b

locks

Hydrother

apy

Overall

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%

100.00%

Fig - 9: Mean percentage distribution of post-test knowledge scores of respondents

Knowledge aspects

Mea

n pe

rcen

tage

Fig 9: Mean percentage distribution of post test knowledge scores of staff nurses.

85

SECTION III

FINDINGS RELATED TO EFFECTIVENESS OF STRUCTURED

TEACHING PROGRAMME

TABLE 9: Comparison of pretest and post test knowledge scores

n= 60

The above table shows the comparison between the pretest and post test

knowledge score of staff nurses regarding alternative and contemporary modalities of

pain relief during first stage of labor in various aspects. The ‘t’ test values shows

significance (at the level of α=0.05) in all the areas.

86

Sl. No.

Knowledge aspects

Pre test Post testMean

differencet Value Df

Inference

Mean S D Mean S D

1General information about labour

5.53 1.478 8.12 0.922 2.58 12.205 49 S

2

General information regarding labour pain

1.57 0.927 2.52 0.624 0.95 6.913 49 S

3Alternative and contemporary modalities

0.38 0.666 1.13 0.596 0.75 7.123 49 S

4 Aromatherapy 1.97 0.901 4.27 1.148 2.30 15.057 49 S

5 Massages 1.13 1.033 3.40 1.265 2.26 12.124 49 S

6 Breathing exercises 1.85 0.954 3.93 0.918 2.08 13.17 49 S

7Intra-dermal water blocks

2.05 1.080 4.32 0.701 2.26 14.738 49 S

8 Hydrotherapy 2.48 1.142 4.52 0.770 2.03 10.613 49 S

Overall 16.97 3.773 32.20 2.773 15.23 31.91 49 S

It is evident that compared to pre-test knowledge scores there is significant

increase in the post-rest knowledge scores in all the areas. Hence the null hypothesis

(H0) related to no difference between pre-test and post-test overall mean scores is

rejected and research hypothesis (H1) is accepted. Therefore it can be interpreted that

the structured teaching programme was effective in improving the knowledge of staff

nurses regarding alternative and contemporary modalities.

6. DISCUSSION

87

This chapter presents the discussion of findings based on

sample characteristics, knowledge of staff nurses working in

maternity department on alternative modalities of pain relief during

first stage of labour, effectiveness of structured teaching

programme and association between pre-test knowledge score of

staff nurses and selected demographic variables.

The aim of this study was to develop and implement

structured teaching programme to improve the knowledge of staff

nurse on alternative modalities of pain relief during first stage of

labour. The effectiveness of structured teaching programme was

evaluated by assessing the knowledge of staff nurses on alternative

modalities.

Objectives of the study

The objectives of the study are:

1. To assess the knowledge of staff nurses regarding alternative and contemporary

modalities of pain relief during first stage of labour by conducting pre-test.

2. To assess the effectiveness of structured teaching programme regarding

alternative and contemporary modalities of pain relief during first stage of

labour by using post-test scores.

3. To find out the association between pre-test knowledge scores and selected

demographic variables

Hypothesis

The hypothesis will be tested at 0.05 level of significance

88

H0-There is no significant difference between mean pre-test and post-test knowledge

scores regarding alternative and contemporary modalities of pain relief.

H1-The mean post test knowledge scores of staff nurses exposed to structured

teaching programme regarding alternative and contemporary modalities of pain

relief will be higher than the mean pre-test knowledge scores as measured by

knowledge questionnaire at 0.05 level of significance

H0.1-There is no significant association between pre-test knowledge scores and

selected demographical variables

H1.1-There is a significant association between pre-test knowledge scores and

selected demographic variables

Major findings of the study

Majority of the respondents i.e. 30 (50%) are in the age group of 26-30 yrs

It was found that based on qualification majority of the respondents 47(78.3%)

have GNM qualification and 13 (21.7%) of them have completed B.Sc.

nursing.

It was observed that out of 60 staff nurses majority of them 27(45%) have 4-6

years of experience

Out of 60 staff nurses majority of them 37(61.7%) were Christians and

23(38.3%) were Hindus.

Section 2: Pre-interventional knowledge score

In the present study the pre-interventional score shows that majority of the

samples 52 (86.7%) had inadequate knowledge regarding alternative modalities of

pain relief before the administration of structured teaching programme. 8 (13.3%) of

them had moderately adequate knowledge and none of them had adequate knowledge.

89

The findings of this study are consistent with an evaluative

study done to assess the knowledge of staff nurses in selected

hospitals, Bangalore on alternative and contemporary modalities of

pain relief during first stage of labour. The samples were selected by

random sampling and the data were collected using structured

questionnaire. The result showed that the mean post-test

knowledge scores (36.18%) was found to be significantly higher

than their mean pre-test knowledge score (23.14%) as evident from

‘t’ value.

Section 3: Evaluation of effectiveness of STP

The analysis result of the present study shows that the mean post-test

knowledge score obtained by the staff nurses is improved to 80.5% from a mean pre-

test knowledge score of 40.42%. With the structured teaching, 15% of staff nurses

were found to have moderately adequate knowledge and remaining 85% were found

to have adequate knowledge and none among the staff nurses had inadequate

knowledge regarding alternative and contemporary modalities of pain relief during

first stage of labour. This gives an inference that the structured teaching programme

was effective in improving the knowledge level of staff nurses regarding alternative

modalities.

The findings of the study was consistent with an evaluative study done to assess

the knowledge of adolescent girls (16-18yrs) in a selected college, Bangalore

regarding reproductive health and sexual issues before and after administration of

structured teaching programme. A sample of 60 adolescent girls was selected by

purposive sampling technique. A pre-test was conducted and STP was administered to

90

the subjects. The post-test was conducted after seven days. The findings revealed

higher post-test mean score. Thus the study showed that the STP was effective in

improving the knowledge level of adolescent girls.

Section 3: Association between the pre-test level of knowledge and selected

demographic variables.

The study findings revealed that there is no association between the

demographic variables such as age, qualification, experience and religion among the

pre-test level of knowledge among staff nurses working in maternity department.

Summary

The findings of the study and other studies have shown that knowledge

regarding alternative and contemporary modalities of pain relief during first stage of

labour was very less among staff nurses. It considerably increased after the

administration of a structured teaching programme.

91

7. CONCLUSION

The main aim of the study was to assess the effectiveness of structured

teaching programme on knowledge regarding alternative and contemporary modalities

among staff nurses. Information was given to the staff nurses through a structured

teaching programme which includes various aspects like, general information about

labour and labour pain, aromatherapy, massages, breathing exercises, intra-dermal

water blocks and hydrotherapy.

The following conclusions were drawn on the basis of findings of the study:

The pre-test findings showed that knowledge of staff nurses regarding alternative

and contemporary modalities was inadequate.

The administration of structured teaching programme helped the nurses to

understand more about alternative and contemporary modalities.

Most of the nurses were having adequate level of knowledge after the teaching

programme.

The structured teaching programme is proved to be very effective method of

transforming information.

Nursing implications

The findings of the study have implications on the field of nursing education,

nursing practice, nursing administration and nursing research.

Nursing education

92

Education is the key component to update and improve the knowledge of an

individual. In the present scenario, knowledge on alternative and contemporary

modalities of pain relief in first stage of labour is much deficient among the nursing

students as well as the nursing staffs as this body of knowledge is not fully developed

and is still on the path of expansion and discoveries. Hence, there is a dire need to

include these components into present curriculum prescribed by INC. It is the duty of

maternity nurses to educate their clients. Hence, to excel in this strategy nurses need

to be well equipped with enormous amount of knowledge that will convince clients

approaching them. In-service education regarding this topic should be conducted to

improve the knowledge of the staff nurses who are working in the obstetric

departments.

Nursing administration

Nurse administrators are the key persons to plan, organize and conduct in-

service education programmes. Nurse administrator’s support should be necessary to

conduct and evaluate health education programmes. They can help to improve the

knowledge of the staff nurses working in maternity departments by providing various

teaching programmes with the help of various AV aids. They are in a key position to

organize, implement and evaluate educative programmes which will in turn helps to

improve the knowledge as well as to meet the future needs and accelerate the

standards of maternity services.

Nursing practice

Nursing is an art and a science. As a science, nursing is based upon a body of

knowledge that is always changing with new discoveries and innovations. When

nurses integrate the science and art of nursing into their practice, the quality of care

provided to clients is at a level of excellence that benefits clients in numerous ways.

93

They are the key persons of the health team, who plays a vital role in the promotion

and maintenance of health. They can provide adequate teaching to both parents and

family members so that they will come to know about the advantages of the vast

developing field of pain relief during labour through alternative modalities. Hence the

nurses should have adequate knowledge about these modalities to improve the

standards of maternity care.

The major role and responsibilities can be summarized as:

Identifying the problems of the woman in labour

Providing appropriate information regarding the topic alternative modalities of

pain relief during labour

Helps the women to ventilate all their doubts by interpersonal interactions.

Helps the women in labour to select the appropriate modality for effective pain

relief.

Effective application of alternative modalities of pain relief during first stage

of labour and thereby managing labour pain effectively.

Nursing research

The main goal of the nursing research is to improve the knowledge of staff

nurses through the implementation of evidence based practice. The study provides a

baseline data for conducting other research studies. The study will be a motivation for

the budding researchers to conduct similar studies in large scale. The study will be a

reference for the research scholars. Further research works can be conducted with

every medical condition to identify most effective knowledge imparting strategies.

Limitations

The following points were beyond the control of the investigator:

Study is limited only those who are willing to participate in the study

94

Study samples were small

There were limitations due to the duty schedule of the nurses

The study was limited to the experience of the researcher

The relevant study was scanty as very few nursing studies were conducted on

alternative and contemporary modalities of pain relief during first stage of labour.

The study was confirmed to only on selected hospital, which obviously imposed

limits to larger generalizations.

Recommendations

On the basis of the findings of the study, the following recommendations have been

made:

a. A similar study can be replicated on a large scale to generalize the findings.

b. A similar study can be conducted to find the differences in the knowledge level of

the staff nurses on the basis of various institutional settings such as government

and private institutions.

c. A similar study can be conducted to find differences the knowledge level of the

nursing students as well as the nursing staffs.

95

8. SUMMARY

Statement of the problem

“A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED

TEACHING PROGRAMME ON KNOWLEDGE OF STAFF NURSES

REGARDING SELECTED ALTERNATIVE AND CONTEMPORARY

MODALITIES OF PAIN RELIEF DURING FIRST STAGE OF LABOR IN

SELECTED MATERNITY HOSPITALS, BANGALORE.”

Objectives of the study

1. To assess the knowledge of staff nurses regarding alternative and contemporary

modalities of pain relief during first stage of labor by conducting pre-test.

2. To assess the effectiveness of structured teaching programme regarding alternative

and contemporary modalities of pain relief during first stage of labor by using

post-test scores.

3. To find out the association between pre-test knowledge scores and selected

demographic variables

Hypothesis

H0-There is no significant difference between mean pre-test and post-test knowledge

scores regarding alternative and contemporary modalities of pain relief.

H1-The mean post test knowledge scores of staff nurses exposed to structured

teaching programme regarding alternative and contemporary modalities of

96

pain relief will be higher than the mean pre-test knowledge scores as measured

by knowledge questionnaire at 0.05 level of significance

H0.1-There is no significant association between pre-test knowledge scores and

selected demographical variables

H1.1-There is a significant association between pre-test knowledge scores and

selected demographical variables

Conceptual frame work and methodology

The conceptual framework of the present study was based on Von Ludwig

Bertalanffy’s General Systems Theory.

This study adopted quasi-experimental one group pre-test post-test research

design. In the present study, a total of 60 staff nurses working in maternity

department were selected from Fortis Hospital, Bangalore. Samples were

selected by using non probability purposive sampling technique.

The tool used for data collection consisted of Performa for socio-demographic

data and structured questionnaire.

Three types of variables were identified in the present study. Independent refers

to the structured teaching programme regarding alternative and contemporary

modalities of pain relief during first stage of labour and dependent variables

refer to the knowledge of staff nurses regarding alternative and contemporary

modalities. Demographic variables selected for this study were age (yrs),

qualification, experience and religion.

The instrument used for data collection was self administered knowledge

questionnaire on alternative and contemporary modalities. Data collection tool

contain items on the following aspects;

97

Part I: It includes items of demographic variables – age (yrs), qualification,

experience and religion.

Part II: Includes 40 knowledge questions regarding alternative and contemporary

modalities. A structured teaching programme was developed on alternative and

contemporary modalities of pain relief during first stage of labour.

The pilot study was conducted in Fortis Hospital, Bangalore from 1.3.2012 to

10.3.2012to find the feasibility of the study. Ten staff nurses working in

maternity department were selected using purposive random sampling

technique.

The main study was conducted from 15-3- 2012 to 21-4-2012 in Fortis

Hospital, Bangalore. Samples were selected by non probability purposive

sampling technique. Pre-test was administered before structured teaching

programme and post-test was administered after six days.

Data gathered were analyzed using descriptive and inferential statistics and was

presented in tables and graphs.

Major findings of the study

Findings related to demographic variables

It was observed that majority of the respondents i.e. 30 (50%) are in the age

group of 26-30 yrs and 26 (43.3%) are in the age group of 20-25 yrs. Only 4

(6.6%) are in the age group of 31-40 yrs.

It was noted that with regard to the qualification of the staff nurses majority of

them 47(78.3%) have GNM qualification and 13 (21.7%) of them have

completed B.Sc. nursing

It was observed that out of 60 staff nurses majority of them 27(45%) have 4-6

years of experience and 25(41.7%) of them have1-3 years of experience. 5

98

(8.3%) of them have experience of 7 years and above and only 3(5%) of them

have less than one year experience.

Among the 60 staff nurses, 37(61.7%) were Christians and 23(38.3%) were

Hindus.

Findings related to pre-test and post-test scores

In pre-test knowledge score, highest mean percentage of 61.44% was obtained in

the area of General information about normal labour and the lowest mean

percentage of 19% was in the area of alternative and contemporary modalities.

In post-test knowledge scores, the maximum mean percentage of 90.4% was in

the area of hydrotherapy and the lowest mean percentage of 56.5% was in the

area of alternative modalities.

Findings related to effectiveness of structured teaching programme

Overall mean percentage in post-test knowledge was found to be 80.5% and in

pre-test knowledge was (40.42%), revealing a significant difference in the knowledge

level with their P-value in all areas were 0.001 which was greater than the table value

at 0.05 level of significance. Therefore the null hypothesis (H0) was rejected and

research hypothesis (H1) was accepted, which depicts the effectiveness of structured

teaching programme.

Findings related to association of knowledge scores with selected demographic

variables

In the present study, it is apparent that the pre-test knowledge scores of staff

nurses are found to be statistically not significant with the demographic variables i.e.

age (yrs), qualification, experience and religion. Hence it is proved that there is no

99

significant association between knowledge scores with selected demographic

variables.

As expected in the hypothesis of the study, the investigator found that there

is a significant improvement in the knowledge of staff nurses regarding alternative

and contemporary modalities of pain relief during first stage of labour after the

structured teaching programme. Hence it is concluded that the structured teaching

programme was very effective on alternative and contemporary modalities of pain

relief during first stage of labour staff nurses working in maternity department.

100

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24. Martensson L, Willin G. Labour pain treated with cutaneous injections of

sterile water: a randomized controlled trial. British journal of obstetrics and

gynaecology 1999; 106:633.

25. Benfield RD, Herman J, Kate VL, Wilson SP, Davis JM. Hydrotherapy in

labour. Research in nursing and health 2001; 24: 57-67.

26. Penny Simkin, Michael CK. Non-pharmacological approaches to management

of labour pain 2007. Available at URL:www.uptodate.com.

27. Roets L, Moru MM, Nel M. Lesotho’s midwife’s utilization of non

pharmacological pain management methods during first stage of labour.

Cochrane database library PMID 1624548.

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28. Payant L, Davis B, Graham ID, Peterson WE, Clinch J. Nurse’s intentions to

provide continous labour support to women. Journal of obstetrics and neonatal

nursing. July 2008; 37(4):405-414.

29. Kim SS, Exlen JA, Kim KB. Nursing students and faculty member’s

knowledge of experience with an attitude toward complementary and

alternative therapies. Journal of nursing education 2006 September; 45(a):375-

378.

30. Gowri N. Effectiveness of STP on knowledge and practices regarding tobacco

consumption in rural health setting. The nursing journal of India. Feb 2010;

vol(2).

31. Yanichin. Study to assess the effectiveness of organized instruction on

knowledge , skill and attitude of practice of breast feeding in CMC, Vellore

2002.

32. Sarojamma. Study on the knowledge and practice of breast feeding in mothers

of hospitalized infants in Vanivilas hospital, Bangalore 2000

33. Shailaja KG. A study to assess the knowledge and confidence of the primi-

para mothers regarding exclusive breast feeding. Nightingale nursing times.

March 2008 Vol 3(12).

34. Denise F Polit, Cherry Tatano Beck. Nursing research: generating and

assessing evidence for nursing practice. Lippincott publications. 8th edition.

Pg: 105, 139, 337-341, 367, 712.

35. Basavanthappa BT. Nursing research. Jaypee publishers. First edition 2003.

Pg: 49, 66, 93, 215, 219.

104

ANNEXURE A

ETHICAL CLEARANCE CERTIFICATE

105

ANNEXURE B

LETTER SEEKING PERMISSION TO CONDUCT THE STUDY

106

ANNEXURE C

LETTER REQUESTING CONSENT TO VALIDATE THE TOOL

107

Date:

FROM,

MS. SHANTI SONU SAM 2nd year M.Sc NursingFortis Institute of NursingBangalore-560078To,

………………………………..........

……………………………...............

Forwarded through:

THE PRINCIPAL,Fortis Institute of Nursing,Bangalore.

Sub: - Requisition for expert opinion on content validity of the research tool.Respected Sir/Madam,

I, Ms. Shanti Sonu Sam, 2nd year M.Sc nursing student of Fortis

Institute of Nursing Bangalore, have selected the topic “a study to assess the

effectiveness of structured teaching programme on knowledge of staff

nurses regarding selected alternative and contemporary modalities of

pain relief during first stage of labour in selected maternity hospitals,

Bangalore” for dissertation to be submitted to Rajiv Gandhi University of

Health Sciences, Bangalore as a partial fulfillment of university requirement

of awarding M.Sc Nursing degree.

Here with I am enclosing a copy of

a) Acceptance form

b) Letter requesting opinions and suggestions from experts

c) Statement of problem, objectives and hypothesis

d) Tool

e) Answer keys

108

f) Blue print

g) Evaluation criteria check list

h) Lesson plan

i) Certificate of content validity

I kindly request you to examine the structured teaching programme and

tool and give your valuable opinion and suggestions for further improvements.

I would be highly obliged and remain thankful for your great help if

you could kindly return this structured teaching programme and tool, after

signing the “ContentValidity Certificate” attached here with, as early as

possible.

Thanking you

Yours sincerely,

Shanti Sonu Sam

Forwarded for expert validation

and approval through, Principal.

109

ANNEXURE D

ACCEPTANCE FORM FOR TOOL VALIDATION

Problem statement:

“A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED

TEACHING PROGRAMME ON KNOWLEDGE OF STAFF NURSES

REGARDING SELECTED ALTERNATIVE AND CONTEMPORARY

MODALITIES OF PAIN RELIEF DURING FIRST STAGE OF LABOUR IN

SELECTED MATERNITY HOSPITALS, BANGALORE.”

I……………………………………………….....would/ would not agree upon in

validating the tool.

Name:

Designation:

Address:

Signature:

Date…………….

Place……………

110

ANNEXURE E

CONTENT VALIDATION CERTIFICATE

I hereby certify that, I have validated the tool of Shanti Sonu Sam, IInd year

M.Sc.Nursing student, Fortis Institute of Nursing, Bangalore who is under taking this

study: “A study to assess the effectiveness of structured teaching programme on

knowledge of staff nurses regarding selected alternative and contemporary

modalities of pain relief during first stage of labour in selected maternity

hospitals, bangalore.”

Place:Signature of the Expert.

Date:

Designation and Address.

111

ANNEXURE F

LETTER TO THE PARTICIPANTS REQUESTING CONSENT TO PARTICIPATE IN THE STUDY

Dear participants,

I, Miss. Shanti Sonu Sam, IInd year M.Sc. nursing student of Fortis

institute of nursing, Bangalore, am planning to conduct a research project on “A

study to assess the effectiveness of structured teaching programme on knowledge

of staff nurses regarding selected alternative and contemporary modalities of

pain relief during first stage of labour in selected maternity hospitals,

Bangalore”. I request you to participate in the study.

The information provided will be kept confidential and anonymity will be

maintained throughout and after the study.

Thank you for participating in the study

Yours faithfully

Miss. Shanti Sonu Sam

Date:Place:

112

ANNEXURE G

LIST OF EXPERTS FOR TOOL VALIDATION

1. Mrs. P. Swarnalatha

Principal

BMS Hospital Nursing College

N.R. Colony, Bangalore-560019.

2. Mrs. Reddamma

Professor

Government College Of Nursing, Fort

Banglore-2

3. Mrs. saraswathi

Principal

VenkateshwaraCollege of nursing

Bangalore.

4. Mrs. Balalakshmamma,

Lecturer

The Oxford College of nursing

Bangalore.

113

5. Mrs. D. Kanitha

Lecturer

NIMHANS College of nursing

Bangalore.

6. Mrs. Kamala J

Associate Professor

Kempegowda College of nursing

Bangalore.

7.Dr. GayathriKamath

Dept. of Obstetrics and Gynaecology

Fortis Hospitals

Bangalore.

114

ANNEXURE H

BLUE PRINT FOR DISTRIBUTION OF ITEMS

The blue print of the structured questionnaire for assessing knowledge

regarding alternative and contemporary modalities is given below:

AREAS

KNOWLEDGE ASSESSMENT QUESTIONNAIRE

Knowledge Comprehension Application Total items

Percentage

Item no.

No. of items

Item no.

No. of items

Item no.

No. of items

Normal labour 1,2,4,7,8 5 3,5 2 7,9 2 9 22.5

Labour pain 10,11,12 3 - - - - 3 7.5

Alternative modalities 17,18 2 - - - - 2 5

Aromatherapy 15,16,17,19,20 5 18 1 - - 6 15

Massages 21,22,24,25 4 23 1 - - 5 12.5

Breathing exercises 26,29,30 3 27,28 2 - - 5 12.5

Intra-dermal water blocks

31,32,33,34 4 35 1 - - 5 12.5

Hydrotherapy 36,38,39 3 37,40 2 - - 5 12.5

Total no 29 9 2 40

Percentage 72.5% 22.5% 5% 100%

115

ANNEXURE I

TOOL FOR DATA COLLECTION

INSTRUCTIONS

Read the questions carefully

Answer all the questions to the best of your ability

Please tick for the appropriate answer.

Part 1-Details with demographic data.

Part2-Details with structured questionnaire to assess the knowledge

regardingalternative and contemporary modalities of pain relief.

Part 1: Demographic profile

Participant No: _________________________

Date: _________________________

1. Age:______________________

2. Qualification: _____________________

3. Working experience: _____________________

3. Religion: ____________________

116

Part II Structured Questionnaire

Section A: General information regarding labour

1) What is normal labour?

a. It is the expulsion of viable products of conception through

vagina.

b. It is the expulsion of viable products of conception through

womb.

c. It is the removal of viable products of conception through

abdomen.

d. It is the expulsion of products of conception before 28 wks.

2) What is the other name for normal labour?

a Dystocia

b Eutocia

c Delivery

d Caesarean

3) Who is a parturient?

a Postnatal mother

b Person supporting woman in labour

c Person conducting labour

d Woman in labour

4) How many stages are there in normal labour?

117

a One

b Two

c Three

d Four

5) The first stage of labour starts with the onset of:

a Cervical effacement

b True uterine contractions

c Rupture of membranes

d Show

6) What is the duration of first stage of labour in primi

mothers?

a 8-12 hours

b 4-8 hours

c 14-16 hours

d 6-8 hours

7) What is second stage of labour?

118

a It is the stage of full dilatation of cervix

b It is the stage of rupture of membrane

c It is the stage of foetal descend

d It is the stage of foetal expulsion

8) Which stage is characterized by the expulsion of placenta?

a First stage

b Third stage

c Fourth stage

d Second stage

9) Which is the most important aspect of management during

first stage of labour?

a Aseptic precautions

b Psychologicsupport

c Minimizing labour pain

d Maintaining body temperature.

Section B: General information on labour pain

10) Who brought out the concept of gate control theory?

a RonaldMelzack and P D Wall

119

b Penny Simkin and Ronald Melzack

c P D Wall and PennySimkin

d Penny Simkin and April Bolding

11) Where is the pain modulation gate situated?

a Cerebrum

b Cerebellum

c Spinal cord

d Medulla oblongata

12) What are the characteristics of true labour pain?

a Pain is from abdomen, back and then thigh.

b Pain is from back, abdomen and then thigh.

c Pain is felt over lower abdomen and then thigh.

d Pain is felt from lower back to thigh.

Section C: Alternative and contemporary modalities

13) What do you mean by alternative and contemporary

modalities?

a Modalities using medical interventions

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b Modalities used along with medical interventions

c Modalities other than medical interventions

d Modalities providing permanent relief

14) How do alternative modalities help in minimizing labour

pain?

a By blocking pain receptors

b By blocking pain modulation gate

c By blocking nerve impulses

d By using medical interventions.

Section D: Aromatherapy

15) What is aromatherapy?

a Use of essential oils

b Use of drugs

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c Use of perfumes

d Use of flowers

16) How does aromatherapy works?

a Stimulates chemo-receptors in oro-pharynx

b Stimulates chemo-receptors in naso-pharynx

c Stimulates pain receptors in naso-pharynx

d Stimulates receptors in naso-pharynx

17) How are essential oils extracted?

a Steam distillation

b Churning leaves

c Blending flowers

d Mixing oils

18) What is usually mixed with essential oils to dilute them?

a Water

b Rose water

c Vegetable oil

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d Perfumes

19) Which oil can be used in latent phase of first stage of

labour?

a Lavender, rosemary

b Rosemary, jasmine

c Jasmine, lavender

d Lavender, neroli

20) Which oils can be used in active phase?

a Lavender, jasmine, rosemary

b Lavender, neroli, rose

c Jasmine, lavender, sage

d Peppermint, lavender, neroli

Section E: Massage

21) Define massage

a Rubbing muscles

b Pressing the body muscles

c Rubbing and kneading muscles

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d Stroking body parts

22) How does massage help in minimizing labour pain

a By stimulating the release of endorphin

b By blocking the production of adrenaline

c By promoting uterine contractions

d By promoting muscle relaxation

23) Which massage can be used to warm up women in labour?

a Back massage

b Foot massage

c Shoulder massage

d Sacral massage

24) What is effleurage?

a Making small circles in palm

b Simple stroking of hand, abdomen and back

c Stroking feet and hands firmly

d Light, circular stroking of abdomen, lower back

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25) What are meissner’s corpuscles?

a Nerve endings

b Sensory receptors

c Nerve fibres

d Pain receptors

Section F: Breathing Exercises

26) How does breathing exercises help in minimizing labour

pain?

a Relieves anxiety and pain

b Relaxes the mother

c Redirects from the painful response

d Reduces pain

125

27) How are breathing exercises beneficial to the baby?

a Provides more oxygen

b Promotes well being

c Promotes health

d Promotes breathing

28) What is the ideal time for breathing exercises?

a During and at the end of contractions

b At the beginning and at the end of contractions

c At the beginning of each contractions

d In between contractions

29) What is slide breathing?

a Four, short, light puffing breaths

b Deep breaths and exhale slowly

c Deep abdominal breaths

d Inhale and exhale with relaxed lips

30) When is light accelerated breathing done?

126

a Latent phase

b Transitional phase

c Active phase

d Expulsive phase

Section G: Intra-dermal water blocks

31) What are intra-dermal water blocks?

a Injecting sterile water

b Sterile water injections intra-dermally

c Sterile injections

d Water injections

32) What is the site for intra-dermal water block?

127

a Posterior inferior iliac spine

b Anterior superior iliac spine

c Posterior superior iliac spine

d Anterior inferior iliac spine

33) How many points are used for intra-dermal water blocks?

a Two

b Three

c One

d Four

34) How does intra-dermal water block minimizing labour

pain?

a By blocking pain transmission

b By stimulating endorphin release

c By reducing anxiety and stress

d By blocking pain receptors

35) What is the precaution to be taken after water blocks?

128

a Avoid wiping

b Avoid massaging

c Avoid repeat injections

d None of the above

Section H: Hydrotherapy

36) What is hydrotherapy?

a Therapy that uses medicines

b Therapy that uses drugs

c Therapy that uses water

d Therapy using massages

37) What is the ideal time to start water immersions?

129

a Cervical dilatation greater than 5 cm

b Cervical dilatation greater than 3 cm

c Cervical dilatation less than 5 cm

d Cervical dilatation less than 3cm

38) What kind of water is used for water immersions?

a Lukewarm water

b Cold water

c Clean water

d Warm water

39) How long should mother stay in water tub during

immersion?

a 2 hours

b 3hours

c 20 min

d 4 hours

40) How does buoyancy help in minimizing labour pain?

a Relieves pressure on joints and muscles

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b Reduces pain on muscles

c Increases circulation

d Decreases fluid retention.

131

LESSON PLAN ON

ALTERNATIVE AND CONTEMPORARY MODALITIES OF PAIN RELIEF DURING FIRST

STAGE OF LABOUR

GUIDED BY, SUBMITTED BY,

MRS. GOWRI SAYEE MS. SHANTI SONU SAM

ASSOCIATE PROFESSOR 2ND YEAR M.Sc NURSING,

OBSTETRICS AND GYNAECOLOGICAL NURSING OBSTETRICS AND GYNAECOLOGICAL NURSING

FORTIS INSTITUTE OF NURSING FORTIS INSTITUTE OF NURSING

NAME OF THE INSTITUTION Fortis institute of nursing

132

COURSE M.Sc. nursing 2nd yearSUBJECT Obstetrics and Gynaecological NursingTOPIC Alternative and contemporary modalities

NAME OF THE RESEARCH GUIDE Mrs. Gowri Sayee Associate Professor

NAME OF THE CO-GUIDE Mrs. Sabitha Sibbala Associate Professor

NAME OF THE RESEARCHER Ms. Shanti Sonu SamPARTICIPANTS OF THE STUDY Staff nursesDURATION 1hourMETHOD OF TEACHING Lecture cum discussionMEDIA OF TEACHING Power point, Black board

133

GENERAL OBJECTIVES

At the end of the class the participants will be able to gain knowledge regarding alternative and contemporary

modalities of pain relief during first stage of labour and will be able to apply that knowledge in their practical life situation.

SPECIFIC OBJECTIVES

At the end of the class participants will be able to:

• Introduce the topic

• Define alternative and contemporary modalities

• Describe about aromatherapy

• Describe the process of massaging

• Explain the different types of massages

• Explain the different types of breathing exercises

• Explain about intra-dermal water blocks

• Describe about hydrotherapy

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1 2 min To

introduce

the topic

INTRODUCTION:

Birth is a normal, healthy part of a woman’s

life. This unexplainable happiness is usually

accompanied by severe pain due to contractions.

The amount of pain a woman experiences is

influenced by many individual, physical,

emotional and environmental factors. There are

several measures used for relieving pain during

labour. Alternative and contemporary modalities

are one among them; it refers to all those

therapies not provided by the conventional

methods. These modalities boosts up the

confidence of the women, hence these modalities

should be made available.

Introducing

the topic

Listening

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2 2 min To review

about

normal

labour.

PHYSIOLOGY OF NORMAL LABOUR

The precise mechanism of initiation of labour is

still obscure. Series of events that take place in the

genital organs to expel the viable products of

conception out of the womb through the vagina

into the outer world is called normal labour. It’s

otherwise called eutocia.

Stages of labour:

Normal labour is divided into 4 stages.

First stage of labour starts from the onset of

true labour pains and ends with full dilatation of

cervix. Its average duration is about 12 hrs in

primi-gravida and about 6 hrs in multi-gravida.

Reviews

about

normal

labour

Listens What is

normal

labour?

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Second stage starts from full dilatation of

cervix till expulsion of fetus. Full cervical

dilatation is upto 10 cm.

Third stage begins after the expulsion of fetus

and ends with the expulsion of placenta and

membranes.

Fourth stage is the stage of observation for at least

one hour after the expulsion of placenta and

membranes.

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3 2 min To explain

about

labour pain

PHYSIOLOGY OF LABOUR PAIN

The first symptom to appear in first stage of labour

is painful intermittent contractions. This pain is felt

anteriorly with simultaneous hardening of the

uterus. Initially the pain is not strong enough and

come at various intervals of 15-30 min with

duration of about 30 sec. The pain starts from the

abdomen, back and then radiates to thigh.

Probable causes of labour pain are:

• Myometrial hypoxia.

• Stretching of perineum over the fundus.

• Stretching of cervix during dilatation.

• Compression of nerve ganglion.

Explaining

about

labour pain

Listening What are the

causes of

labour pain?

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4 2 min To explain

about pain

relief

measures.

PAIN RELIEF MEASURES

Normal labour may be easy and trouble free

provided a rational approach is made with the

beginning of pregnancy. Pain can be relieved by

various measures:

Sedatives and analgesics.

Epidural analgesia.

Inhalation agents.

Alternative and contemporary modalities.

Due to various research evidences of their

effectiveness, popularity among patients, no side

effects, natural pain relief alternative and

contemporary modalities can be considered much

effective.

Explaining

about pain

relief

measures

Listening slide Name the

different

pain relief

measures?

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5 2 min To introduce

about various

modalities

ALTERNATIVE & CONTEMPORARY

MODALITIES

Alternative and contemporary modalities are

those therapies given other than the usual

medical interventions. Some of the benefits:

It considers human body as a whole.

There are no side effects.

They are easily affordable.

Simple to prescribe and practice.

It does not interfere with the progress of

labour.

Promotes a sense of accomplishment.

They have no effect on state of

consciousness.

Introducing

about

alternative

modalities

Listening Board What are the

advantages?

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GATE CONTROL THEORY

• It implies that a non-painful stimulus can

block transmission of a noxious stimulus.

• It is based on the premise that the gate

modulates the pain impulses.

• There are three types of nerve fibres: A-Delta

fibres(sharp pain), C fibres(dull pain), A-Beta

fibres(light touch).

• The substantia gelatinosa acts as the

modulating gate.

• A-Delta and C firbres open the gate and A-

Beta fibres close the gate.

• Alternative modalities activate the A-Beta

fibres and thus the gate is closed.

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6 10

min

To explain

about

aromatherapy

AROMATHERAPY

Aromatherapy is the science of using highly

concentrated essential oils or essences distilled

from plants in order to utilize their therapeutic

properties. The use of aromatic substances

stimulates the chemoreceptor sites in the naso-

pharynx and directly affects the hypothalamic-

pituitary,adrenal axis. Administration includes

putting drops in a pillow, in a bath, or in

awoman’s brow. Essential oils are as potent as

drugs and equally open to misuse or abuse.

Explaining

about

aromathera

py

Listening PPT Explain about

aromatherapy

144

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Important essential oils

(1) Lavender Oil

Lavender oil is extracted from the flower

of lavender primarily through steam distillation.

The benefits of lavender oil are:

It’s balancing and calming.

It relieves tension and stress.

It induces sleep and reduces pain.

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(2) Peppermint Oil:

Peppermint is a cross between the watermint

and spearmint and is native to Europe. Some of

the benefits are:

It’s cooling and refreshing.

It relieves nausea and headache.

It also reduces pain.

It improves immunity.

(3) Rosemary Oil:

Rosemary is very popular in the

Mediterranean region as an herb. Some of the

benefits are:

It relieves pain and strengthens the body.

It’s used for hair, mouth and skin care.

It boosts mental activity.

146

It can be used as room freshener too.SL

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147

(4) Neroli Oil:

Neroli oil has been widely used across the world

for centuries. Derived from the blossoms of

bitter orange tree. It is extracted by steam

distillation. Some of the benefits are:

It has a soothing and relaxing effect.

It relieves headache and nausea.

It prevents the scarring of skin.

It also improves digestion.

(5) Rose Oil:

Rose oil is extracted from fresh Damascus rose

by steam distillation. Some of the benefits are:

It is an uterine tonic and supports labour.

It is an anti-depressant.

It reduces nausea and fatigue

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148

(6) Jasmine Oil:

Jasmine oil is extracted from the flowers of

jasmine, the very famous flower. Some of the

benefits are:

It is uplifting and balancing.

It eases birth and reduces pain.

It also acts as a sedative.

It relieves anxiety.

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Aromatherapy can be used according to

different phases of first stage:

Latent Phase:

During the early phase of labour when

contractions begin, the mother should relax and

take a nap if possible. In a 10ml bottle pour

4drops of lavender, 2 drops of neroli and add

vegetable oil. Massage temples, forehead and

chest and advice to take deep breaths.

Active Phase:

During this phase, contractions become intense

and frequent. In 10ml bottle pour 6 drops

lavender, 1drop neroli, 1drop rose oil and add

vegetable oil. Massage and advice to breathe

and relax.

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7 5 min To explain

about various

massages.

TOUCH AND MASSAGES:

Touch and massages stimulates the body to

release endorphins which are natural pain killing

and mood lifting hormones. Some of the

massages are:

(1) Hand massages:

Simply stroke each hand in turn, first on the

back, then on the palm, sweeping firmly down

from wrists to fingertips. Make small circles all

over the palm.

Explaining

about

various

massaging

techniques

Listening PPT What are the

different

types of

massages?

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(2) Foot massages:

Simply stroke feet firmly from ankle to toes or

make circles with thumb all over the soles of

feet. Feet become cold during labour and a foot

massage can help to warm up.

(3) Effleurage:

Light circular stroking of abdomen and lower

back. It stimulates nerve endings called

meissner’s corpuscles which travel faster than

signals of a pain thereby blocking pain

transmission. Use a flat hand stroke on the arms,

legs and broad flat surface of the back.

Effleurage with only fingertips gliding is called

feathering.

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(4) Back massage:

Firm massage can be applied on lower back to

relieve contraction and discomfort from long

hours of labour.

(5) Shoulder massage:

This massage can be performed to facilitate

breathing and relaxation.

(6) Knee press:

Make the woman to sit on a firm chair with

feet touching the floor. Kneel on the floor and

extend hands out to her knee and cover her

knees. During a contraction lean on body weight

and apply pressure to her knees.

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(7) Sacral massage:

Use the palm of hand over the sacral area and

massage firmly. The hand not being used is

supporting the woman either on hip or shoulder.

(8) Circular hip massage:

Either the woman kneels on the floor or against

the head of a bed and supported by pillows.

Two hands are placed on either side of the spine

in the sacral region with the hands pointing in

an upward direction.

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TIME SPECIFIC

OBJECTIVE

CONTENT TEACHER’S

ACTIVITY

LEARNER’S

ACTIVITY

AV

AIDS

EVALUATION

8 5 min To explain

about

breathing

exercises.

BRETHING EXERCISES:

It simply means breathing at any number of

possible rates and depths. The theory behind

breathing patterns is that the thought process is

redirected from the painful response. Breathing

exercises should be done at the beginning and at

the end of each contraction. Some of the

breathing exercises are:

(1) Slow breathing:

Begin slow breathing when contractions

are intense enough.

Take an organizing breath.

Release all tension and breathe out.

Focus attention.

Explaining

about

breathing

exercises

Listening PPT What are

breathing

exercises?

155

SL

NO

TIME SPECIFIC

OBJECTIVE

CONTENT TEACHER’S

ACTIVITY

LEARNER’S

ACTIVITY

AV

AIDS

EVALUATION

(2) Light accelerated breathing:

Keep breathing shallow and light.

The inhalation should be quiet, but

exhalation clearly audible.

Take a deep breath, release all tension

and breathe out

Focus attention.

Exhale through mouth.

(3) Variable transition breathing:

Referred as pant-pant-blow breathing.

Take an organizing breath, release all

tension and breathe out.

Breathe out through mouth in light

shallow breaths.

156

SL

NO

TIME SPECIFIC

OBJECTIVE

CONTENT TEACHER’S

ACTIVITY

LEARNER’S

ACTIVITY

AV

AIDS

EVALUATION

After every second, third, fourth or fifth

breaths blow out a longer breath.

(4) Slow relaxed abdominal breathing:

Inhale slowly through nose, allowing

belly to expand first then chest.

Exhale slowly through mouth pursing

lips.

6-9 breaths to be taken.

(5) Slide Breathing:

Four, short, light puffing breaths.

157

SL

NO

TIME SPECIFIC

OBJECTIVE

CONTENT TEACHER’S

ACTIVITY

LEARNER’S

ACTIVITY

AV

AIDS

EVALUATION

9 5 min To explain

about intra-

dermal water

blocks.

INTRA-DERMAL WATER BLOCKS

It is a new technique for non-narcotic pain relief

originally developed to relieve pain from kidney

stones. With slight modifications it can be used

in labour, especially for posterior positions.

Procedure:

• Fill a small tuberculin syringe with sterile

water

• Identify the posterior superior iliac spine

and mark them

• Approx. 3 to 4 cm down and 1 to 2 cm in

identify other two points and mark them.

• During a contraction inject a small

amount of sterile water into the skin

raising a bleb.

Explaining

about intra-

dermal

water

blocks

Listening PPT What is intra-

dermal water

blocks?

158

SL

NO

TIME SPECIFIC

OBJECTIVE

CONTENT TEACHER’S

ACTIVITY

LEARNER’S

ACTIVITY

AV

AIDS

EVALUATION

• Repeat at the other three sites as quickly

as possible.

• During the injection the woman will feel

a sharp stinging pain.

• The stinging will fade in 10 to 15 sec.

• Avoid back massage after the water

block as it could shorten the duration of

action.

• The small blebs block the pain

transmission as explained by gate control

theory.

159

SL

NO

TIME SPECIFIC

OBJECTIVE

CONTENT TEACHER’S

ACTIVITY

LEARNER’S

ACTIVITY

AV

AIDS

EVALUATION

10 5 min To explain

about

hydrotherapy

HYDROTHERAPY

One of the safest and most effective forms of

pain relief in labour is the immersion in deep

water or a warm shower. Hydrotherapy has been

used for relaxation, healing and pain relief for

centuries. It relieves the stretching sensations of

ligaments and areas associated with posterior

presentation.

Mode of action

The hydrostatic pressure of water relieves

some of the discomforts of contractions.

Warm water soothes tired and aching

muscles.

Explaining

the use of

hydrothera

py

Listening PPT Explain the

use of

hydrotherapy

in labour.

160

SL

NO

TIME SPECIFIC

OBJECTIVE

CONTENT TEACHER’S

ACTIVITY

LEARNER’S

ACTIVITY

AV

AIDS

EVALUATION

There are three factors that contribute to

the benefit of hydrotherapy: heat,

buoyancy and massage.

Immersion in water results in increased

circulation.

It lowers the blood pressure and decrease

any fluid retention or swelling.

The buoyancy of water creates a

weightless feeling and promotes

relaxation.

The mother should get into bath tub at around

4 to 5cm cervical dilatation. Time in tub should

be limited to 2 hours. Warm water should be

used.

161

SL

NO

TIME SPECIFIC

OBJECTIVE

CONTENT TEACHER’S

ACTIVITY

LEARNER’S

ACTIVITY

AV

AIDS

EVALUATION

11 2 min To conclude

the topic

CONCLUSION

Alternative and contemporary modalities are the

techniques which imparts a sense of well being

in an individual with the desired effect. The

main advantage is that it can be discontinued at

any time without any side effects. Midwives

should possess adequate knowledge about these

modalities.

Concluding

the topic,

asking

questions.

Asking

doubts.

162

SL

NO

TIME SPECIFIC

OBJECTIVE

CONTENT TEACHER’S

ACTIVITY

LEARNER’S

ACTIVITY

AV

AIDS

EVALUATION

12 BIBLIOGRAPHY

1. Dutta D.C. Textbook of obstetrics. 1st edition,

2004. Central agency, New Delhi.

2. Annamma Jacob. A comprehensive textbook

of midwifery. Jaypee publications, New Delhi

2005.

3. Trolle B, Moller M, Kronberg H, Thomson S.

The effect of sterile water blocks on low back

pain. British journal of obstetrics and

gynaecology. 1991; 164; pg 1277-81.

4. www.wikipedia.org

5. www.expectantmothersguide.com

6. www.aromalchemy.com

7. www.womenshealth.com

163

164

165

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

61.44%

52.33%

19.00%

32.83%

22.60%

37.00%41.00%

49.60%

40.42%

90.22%84.00%

56.50%

71.16% 68.00%

78.60%86.40%

90.40%

80.50%

Fig -10: Comparison of pre and post test knowledge scores of the respondents

Pretest Scores

Post-test scores

166

167

SECTION IV: ASSOCIATION OF PRE TEST KNOWLEDGE SCORES WITH DEMOGRAPHIC VARIABLES

Table – 10: Association of pre test knowledge scores of staff nurses with selected demographic variables

n= 60

Variables Below Median

Median and above

Chi square Df P value

(0.05)Inferen

ce

Age in years

20-25 years 12 14

0.292 3 7.82 NS26-30 years 12 18

31-35 years 1 1

36-40 years 1 1

Qualification

GNM 18 292.240 1 3.84 NS

B.Sc. Nursing 8 5

Experience

Fresher 3 0 5.038 3 7.82 NS

1-3 years 10 15

4-6 years 10 17

16

7 years and above 3 2

Religion

Hindu 8 151.111 1 3.84 NS

Christian 18 19

The above table 9 shows that there is no significant association between age of staff nurses and total pre-test knowledge scores (chi square-

0.292, Df-3, P value -7.82). Similarly the other demographic variables viz; qualification (chi square – 2.240, Df – 1, P value – 3.84), experience

(chi square – 1.111, Df – 1, P value – 3.84) also have no association with the total knowledge scores of staff nurses as they are found to be non-

significant at 0.05 level of significance. Hence the null hypothesis (H0.1) is accepted and research hypothesis (H1.1) rejected.

17

18