Miss. GAYATRI.S.MUGALI 1ST YEAR M.Sc.

NURSING OBSTETRICS AND GYNAECOLOGICAL NURSING 2011-13 SHREE SIDDAGANGA INSTITUTE OF NURSING SCIENCES AND RESEARCH CENTRE, B. H.ROAD, TUMKUR- 572102.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA, BANGALORE.

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

MS.GAYATRI.S.MUGALI NAME OF THE CANDIDATE AND ADDRESS I YEAR M.SC.NURSING SHREE SIDDAGANGA INSTITUTE OF NURSING SCIENCES AND RESEARCH CENTRE,

1.

B.H.ROAD, TUMKUR-572 102. SHREE SIDDAGANGA INSTITUTE OF NURSING SCIENCES AND RESEARCH CENTRE,

NAME OF THE 2. INSTITUTION

B.H.ROAD, TUMKUR.-572 102.

COURSE OF STUDY 3. AND SUBJECT

MASTER OF SCIENCE IN NURSING OBSTETRICS AND GYNAECOLOGICAL NURSING

DATE OF ADMISSION 4. TO THE COURSE

11.07.2011

A STUDY TO EVALUATE THE EFFECTIVENESS OF STATEMENT OF THE PROBLEM VIDEO ASSISTED TEACHING EFFECT ON OF

KNOWLEDGE

REGARDING

5.

ANTENATAL EXERCISES ON NATURE OF DELIVERY MOTHERS TUMKUR. AMONG IN PRIMI ANTENATAL AT

SELECTED

HOSPITALS

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION To keep the body in good health is a duty...otherwise we shall not be able to keep our mind strong and clear. - Budda.

Health is a fundamental human right. It is central to the concept of quality of life. Health and its maintenance is a major social investment and is World-wide social goal. Health is multidimensional. This health may be assessed by such indicators as death rate, infant mortality rate and expectation of life. Ideally, each piece of information should be individually useful and when combined should permit a more complete health profile of individuals and communities.1

Reproductive health is a universal concern, but is of special importance for women arise during the reproductive years, in old age general health continues to reflect Earlier reproductive life events.

During the childbearing year, from conception through postpartum recovery, a woman's undergoes extensive changes which frequently necessitate many adaptations. and hormonal changes occur gradually throughout the 9 months of pregnancy, and these are reversed in a matter of weeks during postpartum recovery. Skeletal tissue, muscle and connective tissue, blood volume, cardiac output, body weight, and posture are affected.

The antenatal period is a time of physical preparation of birth and parenthood. Becoming a parent is a time of intense learning both for parents and for those close to them. The prenatal period provides a unique opportunity for nurses and other members of the health care team to influence family health. During this period, essentially healthy 3

woman seek regular care and guidance. The primary aim of antenatal care is to achieve healthy mother and a healthy baby at the end of a pregnancy 2.

Most women benefit greatly from exercising throughout their pregnancies and these exercises are called as antenatal exercises for example transversus exercises, pelvic tilting or rocking, pelvic floor exercise, foot and leg exercises, breathing exercise, walking and aerobics etc. During pregnancy mother will need to discuss exercise plans with doctor or other health care provider early on and make a few adjustments to normal exercise routine. The level of exercise recommended will depend, in part, on level of prepregnancy fitness. Maintaining a regular exercise routine throughout the pregnancy can help to stay healthy and feel best. Regular exercise during pregnancy can improve the posture and decrease some common discomforts such as backaches and fatigue. There is evidence that physical activity may prevent gestational diabetes, relieve stress, and build more stamina needed for labor and delivery.

The more active and fit mothers are during pregnancy, it will be the easier for mother to adapt to hers changing shape and weight gain. It will also help mother to cope with labour and get back into shape after the birth. Keep up normal daily physical activity or exercise for as long as mother feel comfortable.

Childbirth is a difficult process and exercise during pregnancy will help to increase the flexibility, endurance, and muscle control which are necessary for labor and delivery, thereby helpful in easier labor. Strengthening of the pelvic muscles will permit the Vagina to widen more easily during childbirth and also prevent urinary problems after delivery.

In addition to that More than 65% of the exercising women delivered in less than four hours, Significant reduction in the incidence of umbilical cord entanglement, Much lower incidence of fetus passing meconium from distress. Umbilical cord blood samples indicated that babies of exercising mothers remained relatively stress-free with plenty of

oxygen. They seemed to tolerate the stresses of delivery. Placentas of exercising mothers are larger, more efficient, and healthier-looking. If mother never exercised regularly before, mother can safely begin an exercise program during pregnancy after consulting with mother`s health care provider, but should not try a new, strenuous activity. Walking is considered safe to initiate when pregnant. The American College of Obstetrics and Gynecology recommends 30 minutes or more of moderate exercise per day on most if not all days of the week, unless you have a medical or pregnancy complication3. In video assisted teaching busy people can learn more in less time. And there is a higher retention rate, so that they remember and use the skills in their daily life. They understand the impact of a dramatic and memorable photo. Video is even more compelling. Participants will more readily participate if the environment is more entertaining. Video assisted teaching contains much of the content. The greatest advantage of video assisted teaching is that it allows us to integrate qualitative and quantitative methods of analysis4.

6.1 NEED FOR THE STUDY Pregnancy is a time when women need to be prepared physically to meet the challenges of childbirth and the transitions to parenthood. However, this needs to be within the realms of safe practice. The main aims of the study were to investigate the effects of undertaking a regular exercise programme during and following pregnancy on physical well-being, pregnancy and birth outcomes. Current medical practice recommends that pregnant women should most assuredly engage in some sort of exercise regimen while pregnant. Exercising during pregnancy is good for the mother. Pregnant women who exercise tend to have reduced risk of obesity, gestational diabetes, hypertension, and preeclampsia5.

A study was conducted to find out the effects of exercise during pregnancy on preterm births. The study consisting of 87,232 pregnant women. The study concludes that any sort of exercise during pregnancy leads to a reduced risk of preterm birth, Interestingly, it seems any kind of exercise no matter how light is better than no exercise at all in terms of preventing preterm birth. They did find that exercising late in pregnancy leads to a reduced risk of preterm birth, while early exercise showed no differences. While it is uncertain if exercise provides an actual protective effect against preterm birth, the study hints at an association and no negative effects were reported. Some adverse effects from rigorous exercise have been reported, so it is better to exercise lightly or moderately6. A study was conducted on water aerobics and pregnancy outcome by one randomized and controlled method, concluded similar findings that there were no adverse outcomes to the mother or fetus from physical activity. The study found further benefits in the group that participated in water aerobics had 58% less need for analgesics during labor7. The American Congress of Obstetricians and Gynecologists conduct study on exercises in pregnancy benefits babies and recommends 30 minutes a day for pregnant women, for as long as they are physically able. It's an even more important message for overweight and obese mothers-to-be, who tend to deliver heavier babies, who are then at higher risk of diabetes and obesity later in life. Those heavier children are then more likely to become overweight adults and in turn give birth to bigger babies. The goal of this study is to break the cycle of ever bigger generations of babie8.

Women who continue exercising regularly through the end of their pregnancies, three times a week for at least 20 minutes demonstrated the following reduced risks during the birth process. 35% decrease in the need for pain relief, 75% decrease in the incidence of maternal exhaustion, 50% decrease in the need to artificially rupture membranes, 50% decrease in the need to induce or augment labor with pitocin, 50% decrease in the need to intervene because of abnormalities in the fetal heart rate, 55% decrease in the need for episiotomy, 75% decrease in the need for operative intervention9.

Exercise during pregnancy such as transversus exercises, pelvic tilting or rocking, pelvic floor exercise, foot and leg exercises, breathing exercise, walking and aerobics etc. helps to alleviate many of the common problems of pregnancy. It improves circulation which helps to prevent constipation, hemorrhoids, varicose veins, leg cramps, and swelling of the ankles. It also prevents back pain by strengthening the muscles that support the back10.

Approximately 20-25% of the mothers undergo caesarian section every year which would have been reduce through early identification of problems. Researchers have reported that exercise plays an important role in promoting health and well being of the women in pre and postnatal period. A survey was conducted regarding womens beliefs about exercises during pregnancy in the Pacific. The result showed that most of the women were believed that there were several benefits of exercises while pregnant. All agreed that exercises might make women feel more energetic; 95.6% believed that physical activity can improve labour and delivery. 89.1% believed that physical activity during pregnancy can improve the baby health. The study concluded that pregnancy is not a prescription to stop exercising rather an important time to maintain fitness11.

A study to check the effectiveness of video technologies was conducted. The objective was to present a review of the current research literature regarding the use of dynamic video media in instruction. Research on the effect of antenatal exercises on nature of delivery was reviewed general of the effectiveness, acceptance and costs of several forms of educational television, teaching techniques used effectively with video media; combining visual and verbal information; the effect of motion, animation and interactivity, the relationship between media perceptions and learning the effect of various video production techniques on learning and critical perspective on learning from media. This review can be used as background material for future research or instructional development efforts concerned with learning from video based media12.

A very little information is received regarding effect of antenatal exercises on nature of delivery. Thus the researcher felt the need to contribute towards the effect of antenatal exercises on nature of delivery in order to educate the antenatal mothers with the help of a video assisted teaching and to evaluate the effectiveness of teaching programme and also to develop healthy life style among antenatal mothers.

6.2 REVIEW OF LITERATURE An experimental study was conducted to assess the effect of a antenatal exercise on low back pain during pregnancy, in primi and second gravidae. The study consisting of twenty-six low risk pregnancies with no previous or present history of back pain were identified at 20 weeks gestation and were randomly assigned into experimental and control group for 20 weeks. The experimental group received specific exercises and ergonomics. The control group received only ergonomic advice. Intensity of backpain was assessed with Visual Analog Scale. Mann-Whitey test was used to assess the differences between both the groups. The study reveals that antenatal exercise begun early during pregnancy, and before the onset of backpain, can significantly reduce the intensity of pain experienced during the course of pregnancy and postpartum. The study concludes that the specific exercise group, after intervention showed statistically and clinically significant lower pain intensity when compared to the group that received only ergonomic advice13.

The study was conducted to determine the effect of pelvic floor muscle training compared to usual antenatal and postnatal care on incontinence. There is some evidence shows that about a third of women have urinary incontinence and up to a tenth have faecal incontinence after childbirth. Pelvic floor muscle training in women having their first baby can prevent urinary incontinence in late pregnancy and postpartum. It is possible that the effects of Pelvic floor muscle training might be greater with targeted

rather than population-based approaches and in certain groups of women for example women who had bladder neck hypermobility in early pregnancy, a large baby. The result 8

shows that pelvic floor muscle training is commonly recommended during pregnancy and after birth both for prevention and treatment of incontinence14.

The study was conducted on critical evaluation of the scientific literature for the effects of exercise on pregnancy outcome. Maternal outcomes analyzed in this review were gestational diabetes mellitus, preeclampsia, and weight gain, fetal outcomes evaluated were birth weight, time of delivery, and mode of delivery. Despite methodological pitfalls in the studies published, the evidence suggests a benefit of exercise in pregnancy. Conclusion of this study is exercise in pregnancy could prevent and limit adverse maternal and fetal morbidities and provide a long-term benefit through reduction of maternal weight gain during pregnancy, and improvement in cardiovascular fitness. Pregnancy emerges as a unique time15.

A descriptive study was conducted in which 161 women of 18 to 45 years of age were interviewed in the third trimester of pregnancy. These women were receiving prenatal care at National Health Service primary healthcare units and had no pathologies for which physical exercise would constitute a risk. A previously elaborated knowledge, attitude and practice (KAP) questionnaire was used to collect data, which were then stored in an Epinfo database. Statistical analysis was conducted using Pearson's chisquare test and Fisher's exact test to evaluate the association between the study variables (p < 0.05). These results suggest that women's knowledge concerning the practice of physical exercise during pregnancy is reasonable and their attitude is favorable; however, relatively few actually exercise during pregnancy16.

A study was conducted to examine the relation between physical exercise during pregnancy and the risk of preterm birth. According to many national recommendations, women should be physically active during pregnancy, Self-reported data on physical exercise during pregnancy were collected prospectively for 87,232 singleton pregnancies. Hazard ratios for preterm birth according to hours of exercise per

week, type of exercise, and metabolic equivalent-hours per week, respectively, were calculated using Cox regression analysis. Results showed a reduced risk of preterm birth among the almost 40% of women who engaged in some kind of exercise during pregnancy in comparison with nonexercisers. The association was not affected by the type of exercise, and the results were not altered when the degree of preterm birth was taken into account. These findings do not indicate any adverse effects of exercise on the risk of preterm birth.

A Mother and Child Cohort Study was conducted by the Norwegian Institute of Public Health to estimate whether women doing pelvic floor muscle training before and during pregnancy have increased risk of perineal lacerations, episiotomy, vacuum/forceps delivery, or acute cesarean delivery. Participants were 18,865 primiparous women and data were collected by self-completed questionnaires. Data about obstetric outcomes were obtained from the Medical Birth Registry of Norway. Pelvic floor muscle training was categorized as less than once per week, one to two times per week, and at least three times per week both before and during pregnancy. The results of women who performed pelvic floor muscle training less than once per week, 7.2% sustained a third-degree or fourth-degree laceration compared with 6.3% of women who performed pelvic floor muscle training at least three times per week. A similar pattern was present for rates of episiotomy (29.1% compared with 24.9%), vacuum/forceps delivery (15.9% compared with 15.0%), and acute cesarean delivery (9.5% compared with 7.5%).conclusion of this study is Pelvic floor muscle training before and during pregnancy does not affect labor and birth outcomes or complication rates17.

An observational study was conducted regarding the effects of recommended levels of physical activity on pregnancy outcomes in America. A sample of 44 healthy antenatal mothers was taken as active and inactive mothers. Active mothers who engaged >30 minutes of moderate physical activity per day had significantly better fitness and lower sleeping heart rate compared to the inactive. The result showed duration of second stage of labour was 88 and 146 minutes in the active v/s inactive mothers (p=0.05). Crude

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odds ratio of operative delivery in the inactive v/s active was 3.7 (95% CI, 0.87-16.08). Birth weight, maternal weight gain and parity adjusted odds ratio was 7.6 (95% CI, 1.2345.8). The study concluded that active mothers had better outcome while compared to inactive mothers18.

A quasi experimental study was conducted to evaluate the effectiveness of antenatal exercises on nature of delivery between control and experimental group. Two hundred primi gravidae women who had normal pregnancy were selected by purposive sampling technique. Out of which 100 mothers were selected for each experimental and control group. The data was collected by using observational check list to find out the nature of delivery such as normal, normal with episiotomy, instrumental and surgical. The result of the study was primi mothers in control and experimental group according to their nature of delivery revealed that majority of the mothers both in control and experimental group had normal delivery with episiotomy 80% and 78% respectively. Where as the mothers who had normal delivery with out episiotomy 2% and 10% respectively and the mothers who had LSCS was 18% and12% respectively19.

The study was conducted to evaluative research approach with quasiexperimental Pretest and Posttest control group design adopted. The study includes 60 staff nurses who were selected as sample by non probability purposive sampling technique in selected hospitals of Hassan. Demographic data, structured knowledge, attitude questionnaire and video assisted teaching (VAT) were implemented for data collection procedure. It was observed that the over all post-test mean percentage of knowledge and attitude was higher (88% and 83.2%) in experimental group than in control group (37.86% and 54.6%) respectively, where t value were knowledge (t=26.67 at p<0.001) and attitude (t=16.32 at p<0.001). The finding signifies that the video assisted teaching was effective to enhance the knowledge and to mould attitude of staff nurses. This indicates that VAT was significantly effective in increasing the knowledge and attitude level of staff nurses20.

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6.3 STATEMENT OF THE PROBLEM A study to evaluate the effectiveness of video assisted teaching on knowledge regarding effect of antenatal exercises on nature of delivery among primi antenatal mothers in selected hospitals at Tumkur.

6.4 OBJECTIVES OF THE STUDY 1. To assess the knowledge regarding effect of antenatal exercises on nature of delivery among primi antenatal mothers. 2. To evaluate the effectiveness of video assisted teaching regarding effect of antenatal exercises on nature of delivery among primi antenatal mothers. 3. To find out an association between the pre test level of knowledge with their selected socio demographic variables.

6.5. OPERATIONAL DEFINITIONS 1. Knowledge-It refers to the correct response of the primi antenatal mothers regarding effect of antenatal exercises on nature of delivery as elicited by self administered knowledge questionnaire 2. Effectiveness- In this study it refers to improvement in the knowledge of primi antenatal mothers after video assisted teaching regarding effect of antenatal exercises on nature of delivery as measured by significant difference between pre test and post test knowledge score.

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3. Video assisted teaching- It refers to systematically organized teaching to provide information to primi antenatal mothers regarding effect of antenatal exercises on nature of delivery by using video clips. 4. Antenatal exercises- In this study it refers to the exercises which are needed during the pregnancy such as transversus exercises, pelvic tilting or rocking, pelvic floor exercise, foot and leg exercises and breathing exercise. 5. Primi antenatal mothers- In this study it refers to the mothers who are between the age group of 20-35 years conceived for the first time.

6.6.ASSUMPTION * Primi antenatal mothers may have limited knowledge regarding effect of antenatal exercises on nature of delivery. *Video assisted teaching is one of the best teaching strategies in imparting knowledge regarding effect of antenatal exercises on nature of delivery.

6.7. HYPOTHESIS H1: There will be a significant difference between pre test and post test knowledge scores regarding effect of antenatal exercises on nature of delivery. H2: There will be a significant association between the pre test level of knowledge with their selected socio demographic variables.

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6.8 VARIABLES Independent variable- Video assisted teaching. Dependent variable- Knowledge score.

7. MATERIALS AND METHODS 7.1 SOURCE OF DATA Information will be collected by means of self administered knowledge questionnaires regarding effect of antenatal exercises on nature of delivery.

7.2 METHODS OF DATA COLLECTION: 7.2.1 Research design Pre-experimental one group pre- test, post- test design. 7.2.2. Setting of the study Selected hospitals at Tumkur. 7.2.3 Population Primi antenatal mothers. 7.2.4 Sample Primi antenatal mothers in selected hospitals at Tumkur.

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7.2.5 Sampling technique Non probability convenient sampling technique. 7.2.6 Sample size 60 primi antenatal mothers. 7.2.7 Sampling Criteria Inclusive criteria: 1. Primi antenatal mothers who are attending OPD in selected hospitals. 2. Primi antenatal mothers with I and II trimester. 3. Primi antenatal mothers who can read and write Kannada Exclusive criteria: 1.Primi antenatal mothers who are not willing to participate. 2.Primi antenatal mothers with antenatal complication.

7.2.8 Tool for data collection The tool for the present study is self administered knowledge questionnaire. It consist of: Section A - Socio- demographic variables. Section B- Self administered knowledge questionnaire regarding effect of antenatal exercises on nature of delivery.

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7.2.9. METHOD OF DATA COLLECTION. The data will be collected from primi antenatal mothers by using self administered knowledge questionnaire, after obtaining permission from concerned authorities to conduct main study. On the day one, pre test will be conducted, on the same day video assisted teaching will be given to primi antenatal mothers. On the day eigh,t post test will be conducted to the same primi antenatal mothers to evaluate the effectiveness of video assisted teaching.

7.3 DATA ANALYSIS & INTERPRETATION Descriptive statistics Descriptive statistical techniques such as Frequency, Percentage, Mean, Median, Standard deviation. Inferential statistics Paired t test, Chi-square test

7.4. Does the study require any investigation or interventions to be conducted on mothers? YES.

7.5. Has ethical clearance been obtained from your institution?

YES.

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8. BIBLIOGRAPHIC REFERENCE: 1.Suneel Garg, Anita Nath. Current status of national rural health mission. Indian journal of community medicine. 2007;38(2):1895.available from: http://www.journaldatabase.org/journal/issn0970-0218. cited on:22.11.2011.

2. Basavanthappa BT. Essentials of midwifery & obstetrical nursing. 1st ed. Bangalore: Jaypee brothers medical publishers(p) Ltd ;2011. p.130.

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labor

Health 2008 5: 10. Available from:

http://www.infantrisk.com/content/exercise-and-pregnancy.

7. Hopkins SA. Baldi JC. Exercise training in pregnancy reduces offspring size without changes in maternal insulin sensitivity. J Clin Endocrinol Metab. 2010; 2080-

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8. Buscando la luz T. The positive impact of prenatal exercises. Indian Journal of physiotherapy. 2006;14(5):371-7. cited on: 21.11.2011.available from: http://birthfaith.org/exercise/the-positive-impact-of-prenatal-exercise.

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http://www.indianjournals.com/volume=3&issue=2&article=008.

11.Krans EE, Gearhart JG, Dubbert PM, Klar PM, Miller AL, Replogle WH. Pregnant Womens beliefs regarding exercise during pregnancy BMC Public Health 2005 Mar;46(3):67-73. 12.Wetzel et al. Review of the effectiveness of video media in instruction. Navy personal research and development centre. Sanliego.1993;04:39-42.

13.Hay smith J, Herbison GP. pelvic floor muscle training for prevention & treatment of urinary & faecal incontinence in antenatal & post natal women. Cochrane database of systematic reviews. 2008;182(12):1895. Available from: http://apps.who.int/rhl/pregnancy_childbirth/antenatal_care/general/CD007471/en/index. html.

14.Gavard JA, Artal R. Effects on pregnancy outcome, Department of obstetrics, gynaecology, women health. St. Louis university school of medicine. USA. available from: http://www.ncbi.nlm.nih.gov/pubmed/18463475

15. Carmen P, Ribeiro, and Helaine Milanez. Department of Obstetrics and Gynecology. School of Medical Sciences Reproductive Health. 2011; 8:3:1180-6.

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16.Mette Juhl. National Institute of Public Health Obstetrics & Gynecology. Copenhagen,\ Denmark. June 2009; Volume 113: 1279-84. available from: http://www.ajog.org/article/S0002-9378(09)00820-5/abstract 17.Sternfeld B. Physical exercise during pregnancy. Journal Article 1997 Jan;23(1):3347. 18.Melzer K, Schutz.Y, Soehnchen N, et al. Physical activity on pregnancy outcomes. American Journal of Obstetrics and Gynaecology 2002 Jan 6;202(3):266-70. 19.Selvanayaki. Effect of antenatal exercises on nature of delivery. Indian journal of Nightingale Nursing Times.2011;7:27-8.

20.Kumar Mahendra. International journal of nursing Education.2010; 2(2):25-7.

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