Student Dissertation

Agency : Postpartum Hemorrhage, Uterotonic Agent, Placenta, Skilled Birth Attendants, Supporti Supervision.

Objective : The objectives of the study were divided broadly into general and specific objectives; general objective is to assess the level of knowledge, attitude and practice regarding AMTSL amongst SN/FHW who have been trained in AMTSL. Specific objectives included to access the knowledge of SN/FHW about AMTSL practice along with their attitude and acceptability and to study the problems faced by them during AMTSL

Background : Postpartum hemorrhage is one of the world’s leading causes of maternal mortality. Active management of the third stage of labour (AMTSL) is a feasible and inexpensive intervention that can help save thousands of women’s lives. The World Health Organization (WHO) is making Pregnancy Safer Technical Update on Prevention of Postpartum Hemorrhage by AMTSL which recommends that “AMTSL should be practiced by all skilled attendants at every birth to prevent postpartum hemorrhage.” Currently, very little is known about the actual practice of AMTSL, therefore we did an assessment on AMTSL practices to identify major barriers to its use in GUJARAT.

Methodology : Study was descriptive cross sectional in nature. The study was conducted in six Districts of Gujarat. Twelve healthcare delivery services centre (two form each district) were selected based on the criteria of delivery load and SN/FHW trained in AMTSL. A standard checklist was used to evaluate the attitude and practice of AMTSL during delivery process. For the same at-least two deliveries occurring either under SN or FHW was observed/ recorded. Primary data was collected from the field through semi structured interview schedule. Furthermore at least two deliveries were observed per facility chosen against standard checklist

Findings : The results of the study show that oxytocin was used by staff nurses during the third stage of labour in 59 percent of cases. Use of AMTSL according to the ICM/FIGO definition was observed in 61 percent of responses, whereas using the Normal Delivery Care course definition (use of oxytocin within one minute of birth), correct AMTSL was observed in 69 percent of cases. If the definition of AMTSL is relaxed to allow for administration of the uterotonic drug within five minutes of delivery of the foetus, the proportion receiving AMTSL increases to 90 percent. Our data suggest that about two in five staff nurses and three in five were acquainted with the benefits and usage of correct AMTSL practices and contra indications of AMTSL respectively, but its use seems somewhat random with many staff nurses still preferring methergine to oxytocin. It was seen that refresh cascade training has not being conducted since long time ago and hence is required for improving service delivery. Also Guidelines were available at the health care facilities but were not being used as a tool for betterment of practices. Quality control measures are not being looked after especially in AMTSL. The distribution of years of obtaining expertise may be encouraging but it shows that the level and intensity of learning has reduced over the years. Incorporation of AMTSL in treatment protocol as well as supportive supervision and handholding is now required to improve the knowledge about AMTSL. Only 43% of respondents knew about the correct sequence of steps of AMTSL. The main suggestions given included a need of refresh cascade training for the SNs for AMTSL along with inclusion of practical aspects and live demonstrations, availability of medicine stock should be insured and there should be training on Inventory Management, facility wise guidelines can be made which can be formalized at state level and should be available in vernacular language and monthly performance review by nursing Mentor Group and on the site hand holding.