RAJIV GANDHI UNIVERSITY OF THE HEALTH SCIENCES,

KARNATAKA, BANGALORE.

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE & ADDRESS

Miss .THUSHARA P R

I YEAR M.sc NURSING

RAJEEV COLLEGEOF NURSING,

KR PURAM, HASSAN.

2. NAME OF THE INSTITUTION RAJEEV COLLEGEOF NURSING,

KR PURAM, HASSAN.

3. COURSE OF THE STUDY & SUBJECT

DEGREE OF MASTER OF NURSING

OBSTETRICS AND GYNAECOLOGICAL NURSING.

4. DATE OF ADMISSION 11/07/ 2011.

5. TITILE OF THE TOPIC

EFFECTIVENESS OF VAT ON KNOWLEDGE REGARDING MANAGEMENT OF THIRD STAGE OF LABOUR.

6. STATEMENT OF THE PROBLEM

A STUDY TO EVALUATE THE EFFECTIVENESS OF VAT ON KNOWLEDGE REGARDING MANAGEMENT OF THIRD STAGE OF LABOUR AMONG ANM STUDENTS IN SELECTED ANM SCHOOLS AT HASSAN

[1]

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION

“God could not be everywhere, so he created mothers”

Jewish Proverb

Pregnancy is the sensational journey of a woman towards motherhood. The

word ‘Mother’ is associated with tenderness, care, affection, and love. Mother’s love

is boundless and her care is infinite. Women and children health is the strength of

society. Care during pregnancy and labour is very essential to ensure that we have a

healthy mother and a healthy baby at the end of the pregnancy. So it is very important

for the doctors, nurses and the midwives to have thorough knowledge about various

stages of pregnancy and labour1.

Labour purely in the physical sense may be described as the process by which

the foetus, placenta, membrane are expelled through the birth canal. The WHO, 1997

defines normal labour as low risk throughout spontaneous in onset with the foetus

presenting by the vertex, culminating in the mother and infants in good condition

following action2.

The process of giving birth is normally divided into stages. First stage is

mainly concerned with preparation of birth canal so as to facilitate expulsion of foetus

in the second stage. Second stage is that of expulsion of foetus. It begins when the

cervix is fully dilated in physiological labour the women usually feels the urge to

expel the foetus. It is complete when the baby is born. The third stage is defined as

the period from the birth of the baby to complete expulsion of the placenta and

membrane. During the third stage separation and expulsion of placenta and

membranes occur as a result of mechanical and haemostatic factor3.

The principles underlying the management of third stage are to ensure strict

vigilance aid to follow the management guidelines strictly in practice. Two methods

of management are currently in practice. They are expectant management and active

management. Expectant management is the placental separation and is descent to the

[2]

vagina is allowed to occur spontaneously. Minimal assistance may be given for the

placental expulsion if it is needed. In assistant expulsion, controlled cord traction

(modified Brandt- Andrews method) and fundal pressure method are used. Injection

of Oxytocin 5 to 10 units intra veinously or methargin 0.2mg is given intra

muscularly.

Active management of third stage is to excite powerful uterine contraction

following birth of the anterior shoulder by parenteral Oxitocin which facilitate not

only early separation of placenta but also produce effective uterine contraction

following its separation. Injection of Ergo metrine 0.25 mg or methargineis given with

intra veinously following the birth of anterior shoulder. This is followed by slow

delivery of baby taking at least two to three minutes. Placenta not delivered

instantaneously will be delivered by controlled cord traction method. If the first

attempt fails another attempt is made after two to three minutes failing which leads to

further attempts with same intervals.

According to a WHO study, the normal duration of the third stage of labour is

from 5 to 30 minutes with the mean delivery time of 8.3 minutes. The WHO

recommends that in the absence of haemorrhage, the woman should be observed for a

further 30 minutes following the initial 30 minutes before manual removal of the

placenta is attempted and the timing of manual removal as the definitive treatment is

left to the judgment of the clinician. If it fails placenta is removed manually and

examination of placenta, cord, vulva, vagina and perineum are done carefully4.

The main complications of third stage of labour are postpartum haemorrhage,

retained placenta, uterine inversion and placenta accerta. The studies have identified

the need to improve safe motherhood knowledge of ANM students to reduce the

maternal mortality.

6.2 NEED FOR THE STUDY

“Every minute around the world 380 women become pregnant,

190 women face unplanned or unwanted pregnancies,

[3]

110 women experience pregnancy related complications,

40 women have unsafe abortions, 1 woman dies.”

WHO

The World Health Organization states that every minute, at least one woman dies from

complications related to pregnancy or childbirth – which means 529 000 women a

year. Unavailable, inaccessible, unaffordable, or poor quality care is fundamentally

responsible5.

The pregnancy-related (direct) maternal mortality rate in the United States is

approximately 7-10 women per 100,000 live births. National statistics suggest that

approximately 8% of these deaths are caused by postpartum hemorrhage. In the

developing world, several countries have maternal mortality rates in excess of 1000

women per 100,000 live births, and World Health Organization (WHO) statistics

suggest that 25% of maternal deaths are due to postpartum haemorrhage, accounting

for more than 100,000 maternal deaths per year. The death of these mothers has

serious implications for the newborn and any other surviving children6.

Around 515 000 women die each year in childbirth, mostly in developing

countries. Severe bleeding in the postpartum period is the single most important cause

of maternal deaths worldwide. More than half of all maternal deaths occur within 24

hours of delivery, most commonly from excessive blood loss. It is estimated that

some 140 000 women die each year from postpartum haemorrhage (PPH) .postpartum

haemorrhage also causes serious morbidity in many women7

A case-control study was conducted between July 1, 2007 and June 30, 2008

at King Abdulaziz Medical City, Riyadh, Saudi Arabia. To identify health-related risk

factors for the development of post partum heamorrhage (PPH) in Saudi women. One

hundred and one patients with post partum haemorrhage and 209 control patients were

included. Bivariate associations between the different risk factors for the development

of post partum haemorrhage were studied. Multivariate logistic regression analysis to

identify significant risk factors for the occurrence of this obstetrics complication was

carried out. High parity was associated with a 17% increased risk of postpartum

[4]

haemorrhage. Risk factors in preeclampsia was associated with >6-fold increase.

History of ante partum haemorrhage (APH) increased the risk for post partum

haemorrhage by >8-fold. Other factors were: multiple pregnancy, vaginal delivery,and

prolonged third stage of labour8.

In India the single most common cause of maternal mortality is obstetric

haemorrhage, generally occurring postpartum and accounting for 25—33% of all

maternal deaths. The rate of death due to post partum haemorrhage (PPH) varies

widely in the developing world. Post Partum haemorrhage-related mortality rates

based on hospital studies are estimated to be 25—30% in India, and 43% in Indonesia.

However, women who come to a hospital for care do not represent the general

population of women. Because haemorrhage is more apt to occur and more difficult to

treat in the community, studies have suggested higher rates of post partum

haemorrhage-related mortality in these areas, but there is comparatively little data

available outside of a hospital setting9.In Karnataka Maternal Mortality Ratio is 213

which are lower than the National average10.

Postpartum haemorrhage is one of the leading causes of maternal death

worldwide; it occurs in about 10.5% of births and accounts for over 130 000 maternal

deaths annually. Active management of the third stage of labour is highly effective at

preventing postpartum haemorrhage among facility-based deliveries. In a systematic

review of randomized controlled trials, active management of the third stage of labour

was more effective than physiological management in preventing blood loss, severe

postpartum haemorrhage (> 500 ml) and prolonged third stage of labour. Further

research is needed to determine why certain providers or teams within a facility have

adopted active management of the third stage of labour, and why in-service training in

such management has little effect on practice. Important insights could be gained from

qualitative enquiry into provider practices where active management is common

practice, such as the Dublin maternity centre, where its use was documented at nearly

100% and in those health facilities in this sample where its use reached 60–80%.11

The prior studies in management of third stage of labour has revealed that

there is a major contribution to the maternal mortality from this stage. One reason

among many would be the lack of expertise in this area, thus I chose this study as my

research topic, through this study the knowledge of management of third stage of

[5]

labour can be improved. Since ANM students play a major role in the labour process.

This knowledge will be very useful for the professional growth as well as contribution

to the society. Using video assisted teaching programme more insight can be provided

for the ANM students at Hassan.

6.3 REVIEW OF LITERATURE:

Literature review is a standard requisition of scientific research. Review of literature

provides you with the current theoretical and scientific knowledge about a particular

problem, and resulting in a synthesis of what is known or not known. Review of

literature is presented under the following heading.

6.3.1 Review of Literature related to the prevalence of complication of third

stage of labour.

6.3.2 Review of Literature related to the management of third stage of labour.

6.3.3 Review of Literature related to the knowledge on management of third

stage of labour among ANM students.

6.3.1 Review of literature related to the prevalence of complication of third

stage of labour:

A study was conducted on ‘Risk factors of postpartum haemorrhage in Latin

American population’ in South American countries Argentina and Uruguay to reveal

the postpartum heamorrhage and other risk factors that are associated with third stage

of labour. The population was all the women who gave vaginal birth during a two

year period. The total population included 11,323 women. The Blood loss was

measured in all births using a calibrated receptacle. Moderate postpartum

heamorrhage and severe postpartum heamorrhage were defined as blood loss of at

least 500 ml and at least 1,000 ml, respectively. Moderate and severe postpartum

heamorrhage occurred in 10.8% and 1.9% of deliveries, respectively. There were

many factors which were contributing to the cause of postpartum heamorrhage and

the details are retained placenta (33.3%); multiple pregnancy (20.9%); macrosomia

(18.6%); and need for perineal suture. Active management of third stage of labour,

multiparity and a low birth weight baby, were found to be protective factors.12

[6]

A study was conducted at Ibidan, Nigeria to determine the frequency of

retained placenta at the University College Hospital Ibadan (UCH). This was a

descriptive study of five years which was carried out till 2007. During the study

period, 4980 deliveries took place at the University College Hospital, Ibadan and 106

cases of retained placenta were managed making, which made the incidence 2.13 per

cent of all birth. In this population Fifty-eight patients (64.8%) presented with

anaemia (packed cell volume less than 30 per cent) and 35 patients (38.8%) had blood

transfusion ranging between 1-4 pints. 1 patient required hysterectomy on account of

morbidly adherent placenta. Eleven patients (12.2%) had placenta retention in the

past, 28 patients (31%) had a previous dilatation and curettage, 14 patients (15.5%)

had previous caesarean sections and 47 patients (41.3%) had no known predisposing

factor. The study concluded that Retained placenta still remains a potentially life

threatening condition in the tropics due to the associated haemorrhage, and other

complications related to its removal.13

A five year study regarding the Prevalence, risk factors and severe obstetric

haemorrhage on third stage of labour was conducted in Norway in a population of All

women giving birth (307 415) in a period of five years. In this study, Cross-tabulation

was used to study prevalence, causes and acute maternal complications of severe

obstetric haemorrhage. Associations of severe obstetric haemorrhage with

demographic, medical and obstetric risk factors were estimated using multiple logistic

regression models. Severe obstetric haemorrhage was considered to be blood loss of >

1500 ml or blood transfusion. As a result of this study Severe obstetric haemorrhage

was identified in 3501 women (1.1%). Uterine atony, retained placenta and trauma

were identified causes in 30, 18 and 13.9% of women, respectively. The demographic

factors of a maternal age of ≥30 years and South-East Asian ethnicity were

significantly associated with an increased risk of haemorrhage. The risk was lower in

women of Middle Eastern ethnicity. The risks were substantially higher for multiple

pregnancies, von Willebrand’s disease and anaemia (haemoglobin<9 g/dl) during

pregnancy.14

[7]

6.3.2 Review of literature related to the management of third stage of labour:

A study Conducted among Zambian women found out that postpartum

haemorrhage is the major complication that is contributing to the maternal morbidity.

The ratio in Zambian women was found out to be 561 out of 100000 births given. In

this study Midwives employed in five public hospitals and eight health centers were

interviewed (N = 62), and 82 observations were conducted during the second through

fourth stages of labour. The observations proved that the births which followed

AMTSL (Active management of the third stage of labour). Data from facilities in

which oxytocin was available (62 births in 11 settings) indicated that a uterotonic was

used in 53 of the births (85.5%); however, AMTSL was conducted in strict accord

with the currently recommended protocol (a time-specific use of the uterotonic,

controlled cord traction, and fundal massage) in only 25 (40.4%) of births. The results

were concluding that the maternal morbidity was comparatively low when the Active

management of the third stage of labour methods was followed. 15

A small pilot trial (n = 200) was conducted in Assiut, Egypt, used 'sustained

uterine massage' started after delivery applied every 10 minutes and continued for 60

minutes. The findings are promising, since women receiving massage had less blood

loss > 500 ml and received less additional uterotonics than women not receiving

uterine massage. In the two surveys conducted by Prevention of Postpartum

Heamorrhage Initiative massage before placental delivery was practiced in about one

third of all deliveries. In the same surveys massage after placental delivery was used

in 80–90% of women although it was not possible to observe how long after delivery

the massage was continued .Williams Obstetrics states "massage is not employed but

the fundus is frequently palpated to make certain that the organ does not become

atonic and filled with blood from placental separation". In the United States and some

other countries, palpating the uterus and massaging if "soft" for the first few hours

after childbirth is considered standard of care. A systematic review to evaluate the

effects of sustained uterine massage from the time of birth of the baby currently

contains very little evidence to guide practice.16

In seven trials involving over 3000 women in hospital and/or developed

country settings, prophylactic oxytocin showed benefits (reduced blood loss (relative

risk (RR) for blood loss > 500 ml 0.50; 95% confidence interval (CI) and need for

therapeutic oxytocics.) compared to no uterotonics, although there was a non-

[8]

significant trend towards more manual removal of the placenta which was most

marked in the expectant management subgroup, and blood transfusions in the trials

with more manual removals of the placenta). In six trials involving over 2800 women,

there was little evidence of differential effects for oxytocin versus ergot alkaloids,

except ergot alkaloids are associated with more manual removals of the placenta, and

with the suggestion of more raised blood pressure than with oxytocin. In five trials

involving over 2800 women, there was little evidence of a synergistic effects of

adding oxytocin to ergometrine versus ergometrine alone. For all other outcomes in

the comparisons either there are no data or the number of adverse events is very small,

and so definite conclusions cannot be drawn.17

A study was conducted at Sweden regarding the Comparison of Active and

Expectant management of third stage of labour and also the relation of it towards the

after pain.  A single-blind, randomized, controlled trial was performed at two delivery

units in Sweden in a population of healthy women with normal, singleton

pregnancies, gestational age of 34 to 43 weeks, cephalic presentation, and expected

vaginal delivery. Women (n = 1,802) were randomly allocated to either active

management or expectant management of the third stage of labour. After pains were

assessed by Visual Analog Scale and the Pain-o-Meter. 2 hours after delivery of the

placenta and the day after childbirth. At 2 hours after childbirth, women in the

actively managed group had lower VAS pain scores than expectantly managed

women (p = 0.014). After pains were scored as more intense the day after, compared

with 2 hours after, childbirth in both groups. Multiparas scored more intense

afterpains, compared with primiparas, irrespective of management (p < 0.001). In this

study it was concluded that active management of the third stage of labour does not

provoke more intense after pains than expectant management.18

6.3.3 Review of literature related to the knowledge on management of third stage

of labour among ANM students:

The study was undertaken December, 2005, in four primary-health center

areas of Belgaum District, Karnataka State, India, covering 19 sub-centers serving 43

villages with a total population of 100 000. Within these villages, more than half the

deliveries are at homes or sub-centers. Most of these deliveries are undertaken by

ANMs who practice “expectant management “of the third stage oflabour without a

[9]

physician in attendance. The midwives participating in the study were responsible for

screening and recruiting study participants during the antepartum period, obtaining

informed consent, providing the intervention, measuring blood loss, following-up the

participants and their newborns for 6 weeks’ postpartum, and collecting study data.

The midwives were initially trained over 5 days in the conduct of research and

implementation of the study protocol. They were tested before and after training, and

certified. After 1 year, they were retrained for 2 days, and attended monthly meetings

for ongoing skill reinforcement. There were changes in auxiliary nurse midwife

personnel during the 3-year study, primarily in the first year, with six of the original

18 midwives having left and being replaced by seven new midwives. In total, 25

midwives participated over the course of the study.19

The maternal mortality ratio in Nepal is among the highest in South Asia, at

539 per100,000 live births. Neonatal deaths are also unacceptably high rated at

39Neonatal deaths per 1,000 live births. Global evidence shows that a large

proportion of these deaths can be averted through the implementation of skilled

attendance at the birth and access to emergency obstetric care for cases with

complications. In order to effectively address maternal and neonatal mortalities, the

Government of Nepal hasprioritized the National Safe Motherhood Programme within

the Nepal Health SectorProgramme. The main plan was to train Auxiliary Midwife

Nurses, Staff Nurses and Doctors labour management and complications on labour

process to make them Skilled Birth Attendants. Complementing this, the National

Policy on Skilled BirthAttendants (2006) aims to increase the percentage of births

assisted by a Skilled Birth Attendant to 60 percent by 2015. This required asubstantial

training effort in the next few years for the Auxiliary Midwife Nurses, Staff Nurses

and Doctors. 20

In Bugesera District, Rwanda, A quantitative study to determine the

knowledge, attitudes, and practices of obstetric care providers (OCPs), who are

crucial to the delivery of safe motherhood service, was done in the year 2010. The

study population was 168 OCPs. The study captured 87% of OCPs, that is 137 (82%)

were A2 level nurses. Most expressed a need to improve their knowledge (60.6%) and

skills confidence (72.2%) in safe motherhood. The mean percentage of correct

answers of 50 questions assessing overall knowledge was 46.4%; sections on

normal labour (39.3% correct) and obstetric complications (37.1% correct) were the

[10]

weakest. Fundal pressure during vaginal delivery was practiced by 60.8%, and only

15.9% of providers practiced active management of the third stage of labour for all

deliveries. Providers supported additional training, and 89.3% expressed willingness

to participate in a 2-day workshop even if it were their day off. The study has

concluded and identified the need to improve safe motherhood knowledge and

practices of OCPs21.

[11]

STATEMENT OF PROBLEM:

“A STUDY TO EVALUATE THE EFFECTIVENESS OF VAT ON KNOWLEDGE

REGARDING MANAGEMENT OF THIRD STAGE OF LABOUR AMONG ANM

STUDENTS IN SELECTED ANM SCHOOLS AT HASSAN”

6.4OBJECTIVES:

6.4.1 To assess the pre test knowledge regarding the management of third

stage of labour among the ANM students in both experimental and

control group.

6.4.2 To evaluate the effectiveness of VAT on the management third stage of

labour among ANM students in experimental group by comparing

pretest and post test knowledge scores.

6.4.3 To find the association between the post test score with their selected

socio demographic variables on the management of third stage of

labour among ANM students.

RESEARCH HYPOTHESES

H1: There will be a significant increase in knowledge on management of

third stage of labour among the ANM students those who receive Video

Assisted Teaching programme than the students who do not receive.

H2: There will be a significant association between post test knowledge on

management of third stage of labour among ANM students with the

selected demographic variables.

ASSUMPTIONS:

1. ANM students may have some knowledge regarding the management of

third stage of labour.

2. Video assisted teaching programme may improve the knowledge of the ANM students regarding the knowledge and management skills of third stage of labour.

[12]

3. ANM students knowledge regarding the management of the third stage of labour may vary with selected demographic variables.

4. Lack of management skills and knowledge regarding the third stage of

labour will increase the complications during the labour.

OPERATIONAL DEFINITIONS:

1. Evaluate: It refers to the estimation of outcome of Video Assisted

Teaching the level of knowledge on management of third stage of 3

2. Effectiveness: It refers to the outcome of video assisted teaching

program in increasing the knowledge of ANM students regarding the

management of third stage of labour.

3. Knowledge:Knowledge referred as awareness regarding management of

third stage of labour among ANM students

4. Video assisted teaching programme: It refers to multimedia teaching

on which organized and sequential representation on information

regarding management of third stage of labour.

5. Management of third stage of labour: Refers the effective

management and supervision in the third stage of labour. Includes

Expectant management and Active management. Expectant

management is the placental separation and its decent to the vagina are

allowed to occur spontaneously. Active management comprises three

components, administration of an uterotonic soon after delivery of a

baby, controlled cord traction, and uterine massage after delivery of

placenta.

6. ANM students: ANM students refer to the students who are studying for

ANM course in selected ANM schools at Hassan.

CONCEPTUAL FRAME WORK

Conceptual frame work used in this study is based on King’s Goal

Attainment Theory.

[13]

7 MATERIALS AND METHODS OF THE STUDY:

7.1 SOURCE OF DATA:

The data will be collected from the ANM students in the selected ANM

schools at Hassan.

7.2 METHODS OF DATA COLLECTION

7.2.1 RESEARCH APPROACH:

An evaluative approach

7.2.2 RESEARCH DESIGN:

Quasi-experimental (non –equivalent control group) design

Key

O1 –Assessing the existing knowledge of management of third stage of labour through structured questionnaire.

X - Administering video assisted teaching programme on management of third stage of labour.

O2 –Assessing the post test knowledge through structured questionnaire on management of third stage of labour on 8th day.

[14]

Group Pre test

Day 1

Intervention Post test

Day 8

Experimental

group(E)

30ANM

students

O1 X O2

Control

group(C)

30ANM

students

O1 -- O2

7.2.3 POPULATION:

The population consists of students who are studying in ANM

schools.

7.2.3 SAMPLE

ANM students who full fill the inclusion criteria.

7.2.4 SAMPLE SIZE:

Sample size of the study is 60.

7.2.5 SAMPLING TECHNIQUE:

Purposive sampling of non-probability sampling will be used in this

study.

7.2.6SELECTION OF TOOL

A structured knowledge questionnaire will be prepared for data

collection; it will consist of two sections

Section A: It consists of demographic profile of ANM students.

Section B: It consists of a structured questionnaire related to

management of third stage of labour.

7.2.7 CRITERIA FOR SELECTION OF SAMPLE:

I) INCLUSION CRITERIA:

i. Students who are studying in selected ANM schools.

ii. ANM students available at the time of data collection in the

Schools.

iii. ANM students who are willing to participate in the study.

iv. ANM students who can read & write Kannada.

[15]

2) EXCLUSION CRITERIA:

i. ANM students who are not willing to participate in the study.

ii. ANM students who are not present at the time of data

collection.

7.2.8DELIMITATIONS:

1. The sample size is limited to 30 experimental and 30 control

groups of ANM students.

2. Study is limited for a period of six weeks.

7.2.9 SIGNIFICANCE OF STUDY:

The study signifies the importance of video assisted teaching

programme on management of third stage of labour. It will enhance

the knowledge of ANM students regarding management of third stage

of labour and it also helps them to implement this knowledge in

future.

7.2.10 SETTING OF THE STUDY:

The study will be conducted selected ANM schools at Hassan.

7.2.11 PILOT STUDY

The pilot study is planned with 10% of the total size which will be

conducting in selected ANM schools and that will be excluded from

the main study.

7.2.13 DATA COLLECTION PROCEDURE

Formal permission will be obtained from concerned Schools. The

investigator introduces self and purpose of the study. Informed concern

was obtained from the sample.

[16]

Phase I: Pretest will be conducted to assess the pretest knowledge of

ANM students regarding the management of third stage of

labour.

Phase II: On the same day, video assisted teaching program will be

conducted to ANM students of experimental group

regarding the management of third stage of labour by using

instructional aids for 45 min to 1 hour duration.

Phase III: Post test will be conducted for the experimental group with

the same questionnaire after 8 days of structured video

assisted teaching programme.

7.2.14 VARIABLES OF THE STUDY:

i. Dependent variable : management of third stage of labour

ii. Independent variable: video assisted teaching programme on

management of third stage of labour.

iii. Attributing variable: demographic variables such as age,

Religion, education, marital status, type of family, members of

family, place of residence, education of family members,

occupation of parents.

7.2.15 METHOD OF DATA ANALYSIS AND PRESENTATION

DESCRIPTIVE ANALYSIS

1. Frequency and percentage analysis will be used to describe the

demographic variables of ANM students

2. Descriptive analysis such as mean and standard deviation will be

used to associate & compare the significance between pre and post

test scores of management of third stage of labour.

INFERENTIAL STATISTICS

1. The Chi –Square test will be used to determine the association

between management of third stage of labour and selected

demographic variables.

[17]

2. Paired t - Test will be carried out to assess the statistical

significance and compare the effectiveness of post intervention

score among ANM students.

7.3 DOES THE STUDY REQUIRE ANY INTERVENTIONS TO BE

CONDUCT ON PATIENTS OR OTHER HUMAN OR ANIMAL? IF

SO DESCRIBE BRIEFLY.

Yes, video assisted teaching programme will be administered as

intervention for the ANM students.

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION?

Yes, permission will be obtained from the research committee of Rajeev

College of Nursing and authorities of selected ANM schools at Hassan.

Informed consent will be obtained from ANM students who are selected

for the study.

[18]

8. LIST OF REFERENCES

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ON]2010 February 8th; Available from URL:

http://www.healthizen.com/blog/index.php/specials/pregnancy-journey-

motherhood/

2. Diane.Fraser.M, Margret.Cooper.A. “Myles Text Book For

Midwives”.14thedition. Churchill Livingstone; 2003.pg 436-437.

3. Diane Fraser M., Margret Cooper A. “Myles Text Book For

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4. Dutta D.C. “Text Book Of Obstetrics”.6thedition.Central Publication; 2004.pg

140-143.

5. “World Health Report”. 10th report. Geneva: WHO Office; 2005.

6. John Smith R. “Management of third stage of labour”. Medscape reference

[cited on]2010; September 10. Available from URL:

http://emedicine.medscape.com/article/275038-overview

7. Abalos E. “Active versus expectant management of the third stage of labour:

RHL commentary (last revised: 2 March 2009)”. The WHO Reproductive

Health Library; Geneva: World Health Organization. Available from URL:

http://apps.who.int/rhl/pregnancy_childbirth/childbirth/3rd_stage/

cd000007_abalose_com/en/index.html

8. Akkadri.H.M, Tariq.S,Tamim.H.M. “Risk Factors of PostpartumHaemorrhage

among Saudi Women”.Saudi Medical Journal.2009 October; 30(10):1305-10.

[19]

9. Geller E, Adams M.G, Kelly P.J, Kodkany B.S, Derman R.J. “Postpartum

hemorrhage in resource-poor settings”, International Journal of Gynecology

and Obstetrics. 2006; 92(3): 202-11.

10. “Studies by Ministry of Family Welfare, Karnataka”. Available from URL:

http://www.mohsw.nic.in/NRHM/state%20files/karnataka.htm

11. Cynthia Stanton , Deborah Armbruster , Rod Knight , IwanAriawan ,

SourouGbangbade , AshebirGetachew , et al. “Use of active management of

the third stage of labourin seven developing countries”.Bulletin of the World

Health Organization.2009march;87(3):207-15.

12. Sosa.C.G,Althabe.F,Belizan.M,Buekens.P. “Risk Factors For Postpartum

Heamorrhage In Vaginal Deliveries in a Latin-American Population”.J

Obstetrics and Gynaecology.2009june;113(6):1313-1319.

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