Effectiveness of Educational Program on Nurses/Midwives Performance Regarding Placenta Examination at Maternity Teaching Hospital in Sulaimani/Iraq

Effectiveness of Educational Program on Nurses/Midwives Performance Regarding Placenta Examination at Maternity Teaching Hospital in Sulaimani/Iraq

Dr. Atiya Kareem Mohammed ¹,Lana Abdul Hamed Muhamed Nury ² *

¹,² Department of maternal neonate nursing, College of Nursing, University of Sulaimani, City of Sulaimani, Iraq;

Corresponding author: Dr. Atiya Kareem Mohammed

Email:  atiya.mohammed@univsul.edu.iq

ORCID

ABSTRACT

Background: The placenta is feto-maternal organ. It arises from the trophoblastic layer of the fertilized egg. It works closely with the mother's circulatory system to perform functions that cannot be performed by itself while the foetation is in the womb. The placenta is a separate, distinct organ made up of both maternal and fetal components .

 Aim: To evaluate the effectiveness of educational programs of the placenta examination, on nurses'/midwives' level of performance. who were taking care of maternal during and after delivery

Research Design: Quasi-Experimental study was applied at a Maternity Teaching Hospital in Sulaimani City, from August 2021 to December 2021

Material and Method: A purposive convenience sample consists of (87) nurses/ midwives who were working in the delivery room, Postpartum ward, and theater room (emergency – cold cases) with different qualifications, and years of experience. A structured interviewing questionnaire; it includes three parts socio-demographic characteristics, professional background of the participants and an Observation checklist of  Nurses/Midwives’ performance regarding the placental examination.

Result: The findings shows that (90%) of study sample performed poorly on the pretest, but after implementing the education program the majority of them (94.3%) improved their performance and had good practice on the posttest. The result indicate that majority of N/M are above 40 years old, they have skills, but they apply their care in a traditional way, after receiving the program their practice improved.

Conclusion: The study concluded that the participants have poor practice regarding the examination of the placenta after delivery, as well as they, follow traditional performance, also the finding indicates that there was a significant association between Nurses/ Midwives `s age  with their overall practice.

Keywords: Nurse/Midwives , Performance, Placenta, Examination.

Received: 03 September 2021, Accepted: 15 December 2021, Available online: 20 January 2022

INTRODUCTION

The placenta is a feto-maternal organ. It arises from the trophoblastic layer of the fertilized egg. It works closely with the mother's circulatory system to perform functions that cannot be performed by itself while the foetation is in the womb (Bligh et al., 2016). The placenta is a separate, distinct organ made up of both maternal and fetal components(Favaro et al., 2015).

The placenta develops gradually throughout the first trimester of pregnancy and then increases corresponding with the uterus during the fourth month. When finished, it will resemble a sponge disk. It is a temporary organ with the same genetic traits as a developing fetus. The placenta interacts with its surroundings and vice versa (Burton & Jauniaux, 2018).

The fresh healthy placenta has a diameter of 15–20 cm and a thickness of 2.0–2.5 cm. It usually weighs between 500 and 600 grams (1/6 of the baby's birth weight). However, measures might vary greatly based on a variety of factors such as race, pathophysiology, and infant weight (Pozor, 2016).

The placenta's membranes are divided into two layers (the amnion and the chorion); the amniotic membrane release amniotic fluid, which is breathed in and out by the fetus and acts as a sort of protection and cushion against the uterine walls( Chappell. L. C. et al,2022). It also contributes to the maintenance of stable pressures and temperatures, allows for fetal development, and protects against infection. The amniotic membrane is responsible for the glossy look of this surface(Weinberg, 2021).

The maternal surface should be dark maroon and is made up of lobules, typically 15 to 20 of which are known as cotyledons. Sulci, or deep waterways, separate them. Each lobule is divided into smaller sections, each containing one lobule(Koren, G., & Ornoy, 2018). These same villi emerge from the chorion and contain fetal capillaries that bathe in the intervillous area. Maternal veins and arteries are embedded in the decidua and finish in the intervillous area; they are also in continuous circulation with the maternal circulation(Walejko et al., 2018).

The umbilical cord serves as a key link between the fetus and the placenta., the umbilical cord, which consists of the connecting stalk, vitelline duct, and umbilical veins encircling the amniotic membrane, has fully developed (Hegazy, 2016).

The umbilical cord is usually 55 to 60 cm long at term, with a diameter of 2.0 to 2.5 cm, and is spirally coiled to protect the vessels(Bligh et al., 2016). A typical cord consists of two arteries and one vein. The cord is usually situated in the center of the fetal skin, with blood vessels flowing outwards.

The umbilical arteries and veins are the lifeline that transports blood between the developing fetus and the placenta. The fetus would be unable to acquire oxygen and other nutrients or filter out carbon dioxide, urea, and other waste materials without this link to the placenta (Sibley et al., 2018).

The placenta is a fascinating and intricate organ (Kapila, V., & Chaudhry, 2020). For one reason, no organ can compete with the placenta in terms of function variety since it executes the acts of all main organ systems while they differentiate and grow in the baby. For example, there is an astounding range of morphological variation in placental types observed throughout mammals and even lower orders (Turco & Moffett, 2019). It functions as the fetus's lungs, intestines, kidneys, and liver. The placenta also has significant endocrine functions that influence maternal physiology and metabolism while simultaneously providing a safe and protected environment for the developing child Graham (Burton & Jauniaux, 2015).

Principal placental anomalies can have an impact on both the fetus's and the mother`s health. Accordingly, examining the placenta may reveal information about the impact of maternal diseases on the fetus or the cause of preterm birth, neurodevelopmental impairment, or fetal growth limitation. The advantages of placental testing include determining the cause of various unfavorable gestational outcomes, identifying infant risk factors for a long-term neurodevelopmental squeal, and improving risk assessment for upcoming gestations (Deneux-Tharaux et al., 2013).

A careful examination is required to verify that no part of the placenta or membranes has been retained since this might result in postpartum bleeding and/or infection. The placenta should be examined as soon as possible after birth. Every placenta, whether in the delivery room or the pathology unit, should theoretically be inspected. Any skilled staff, such as a nurse or assistant, can undertake the examination; it is not essential to be a pathologist or an obstetrician.

The initial inspection is easy and just takes a few minutes, but it is quite beneficial, particularly in situations when there are no substantial clinical signs and symptoms shortly after birth. According to (Schollenberg. E.et al., 2019), examining the placenta is crucial since it reflects the pathophysiology of both the mother and the baby. It can provide crucial diagnostic, prognostic, and therapeutic information, as well as possibly disclose information about future pregnancies. It may also give crucial information about any probable causes of newborn sickness or death.

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METHOD

Design Quasi-Experimental study has been chosen, this study aimed to assess the effectiveness of educational programs regarding the placenta and how to examine, Nurse‘/ Midwives‘ performance who were taking care of maternal during and after delivery in the Maternity Teaching Hospital in Sulaimani City.

Study sample: A purposive convenience sample consists of (112) nurses/ midwives who were working in the delivery room, Postpartum ward, and theater room (emergency – cold cases) with different qualifications, and years of experience at Maternity Teaching Hospital / Sulaimani City.

A researcher interviewed those who meet the inclusion criteria. The following figure shows the steps that were taken to get the final group of samples:

Flow chart shows the distribution of the study sample

Data collection: The researchers created the data collecting instruments after conducting a literature analysis on the examination of the placenta. The questionnaire addressed various variables, socio-demographic characteristics, professional background of the participants and an Observation checklist of  Nurses/Midwives’ performance regarding the placental examination.

 a structured interviewing questionnaire consisted of two parts:

• Part 1 consists of closed-end questions; it was constructed to collect nurses' age, educational level, and years of experience are among the demographic features of the participants.

* The level of education of nurses and midwives is divided into 4 levels like following: 

 Nursing School, graduated, Secondary Nursing School, graduated, Nursing and     Midwifery Institute graduated, College of nursing graduated.

• Part 2 Observation checklist of Nurses/Midwives’ performance regarding placental examination This part comprises (5) N/M performances during an examination of the placenta, which included; preparation performance (6 items), Observing usual things (2 items), Observing the Umbilical Cord (9 items), Examination of Membranes (5 items), and Examination of Placental Disk (18 items).

Statistical analysis: Reassessment scoring scales for scale dichotomous random variable, and scoring scales according to the following intervals: L (Low) 0.00 – 33.33;  M (Moderate) 33.33 – 66.66; H (High) 66.66 – 100, and evaluated by scoring scales (1, 2, and 3) for the practice measurements in relative to (do it in the correct way, do it in an incorrect way, didn’t do) respectively. In addition to that, for evaluating items of preceding measurements, three sequential intervals in light of preceding scoring scales: [(1.0 – 1.66), (1.67 – 2.33), (2.34 – 3)], are evaluated by (Low, Moderate, and High) respectively.

Data were analyzed by using descriptive and inferential statistics. Frequency, percentage, mean, standard deviation. Once the surveys and placental data were gathered, they were entered into an excel spreadsheet and were analyzed using the SPSS software, version 22. The “Chi-square test of association” was used to evaluate the nominal distribution of data. Fisher’s exact test was used in cases where the expected count >20% of the excel cells collective achieved a score of <5.

RESULTS

Table (1) demonstrate the socio-demographic characteristics of a participant, more than half percent of the study sample (51.7%) their age were ≥ 40 years, and 33.4% of them were between 20-29 years old while only a few of them (14.9%) their age between 30-39 years, with mean and standard deviation of (Mean± SD 36.2±10.5).

The results revealed that the highest proportion of the study sample (80.5%) was married, (17.2%) were single, and only (2.3%) of the participant were widowed. The findings show that the educational background of more than half (67.8 %) of Nurses and Midwives were Nursing and Midwifery Institute graduates, (25.3%) of them, had Secondary nursing school degrees, while the fewest of them graduated from Nursing school (2.3%) and College of Nursing (4.6%). The results point out that the highest percentage (65.5%) of the participant were governmentally employed, and (35.5%) of them had a contract.

Table 1: Nurses/ midwives socio-demographic data part one:

Table (2) demonstrate that the majority of the study sample (74.7%) didn`t have an extra job in the private sector, while (25.3%) of them gave care in private hospitals. More than half (66.7%) were working the night shift, and (33.3%) of them were the morning shift.  Tale 2 shows that more than half of Nurses and Midwives have done approximately 1-5 delivery in one shift, and (48.3%) of them they have done 6-10 delivery per shift. Regarding their experience in the health sector, more than half (57.5%) of the participants had >10 years of experience, and (36.8%) of them their experience 1-10 years, while a few  (5%) Nurses / Midwives had < 1- year of experience. Their workplace was divided into two areas (labor room and theater room), those who had >10 years of experience in the labor room represent (21.8%) percent of the study sample, and those who had 1-10 years were the lowest (3.4%) and (13.8%) of the participant had  < 1-year experience in the labor room, on the other hand, the finding of this table shows that the maximum percent (32.2%) of Nurse/Midwives their experience in theater room were 5-10 years, while (17.2%) had < 5 years of experience and those who had   >10years represent (11.5%) of the participant. The result of the present study indicates that the majority of Nurses/ Midwives (81.6%) didn’t participate in any training course regarding examination of the placenta only a few of them (18.4%) have participated. Regarding the number of Nurses/Midwives who were involved in giving care to a mother, (69%) of them said 3 Nurses/Midwives were involved, and (31%) of them said 2 Nurses/Midwives were involved. Table 2 indicated that only (18.4%) of Nurses/Midwives had information regarding the placenta and how to examine the placenta, about the main source of their information about the examination of the placenta (8.1%) of them they got from personal experience,(6.9%) from academic study,and few of them(1.1%) (2.3%) from the previous training course and through their coworkers.

Table 2: Nurses/Midwives` Professional Background:

Table (3) represents descriptive statistics (mean of scores) and differences in the pre-posttest of Nurses/ Midwives practice regarding placenta examination, This table explains there was a highly significant difference (P. 0.000) between the pretest & post-test of study samples' performance regarding Observe the “usual things” besides of the placenta with the mean score (5.21 ± 0.93) after receiving educational program.

Table 3: Nurse/ Midwives practice regarding placenta examination in pre&post education program

Table (4) This table demonstrates that statistically there was a highly significant association between pretest and posttest N/M practices, the highest proportion(90%) of the study sample had poor performance in the pretest, while in posttest the majority of them( 94.3%) improved their  performance and they had a good practice

able 4: Overall practice regarding placental examination in (pre&posttest) of education program.

Table (5) the result shows that there was a highly significant (p. 0.000) association between Nurses/Midwives' Overall practice with their level of education and a significant association with their age (p. 0.005), marital Status (p.0.003)and their employment (p. 0.045).

Table 5: Association between Nurses/Midwives Overall practice regarding placenta examination and their sociodemographic characteristics (pre& post-test).

Table ( 6) indicates that statistically there was a highly significant (p.0.000) association between N/M working in the private sector and their performance, and a significant association between Nurses/Midwives’ other professional backgrounds such as (Working shifts, Average number of delivery,  Years of experience as a nurse in health sector and  Years of experience in the theater room).

Table 6: Association between N/M Overall practice regarding placenta examination and their Professional Background (pre& posttest).

Discussion:

As nursing care is the main critical component of therapy in the labor unit, Nurses’ Knowledge deficit and poor manipulation of the third stage of labor surely will interfere with their ability to achieve positive pregnancy care outcomes. Therefore, this study aimed To evaluate the effectiveness of educational programs of the placenta examination, on nurses'/midwives' level of performance.

Eighty-seven Nurses/ Midwives were participate in this study. The Mean age of participants was (Mean± SD 36.2±10.5), the research outcomes specified the age distribution of the respondents while revealing that the highest age group is (≥ 40) years which made up (51.7%) of the secondary age category (20-29) years which constituted (33.4%). It also indicated that older nurse midwives made up the majority of the other groups. This distribution is approximately close to the results of A quasi-experimental study done by (El-Khawaga, D. et al, 2019)  in which the mean age of their participants was (33.72±9.894).

Our findings indicate that in more than half of Nurses/Midwives 51.7% who work in the delivery and theaters room, in middle age and above, the policy of the hospital supports them because according to their ages, actually, they have a good experience, regarding difficult labor.

 The findings show that the educational background of more than half (67.8 %) of Nurses and Midwives were Nursing and Midwifery Institute graduates, the same result as the previous study done by (Muzeya & Julie, 2020), most of the respondents (84.5%, n = 84) reported their primary level qualification into the midwifery year of study as an education degree, with a Diploma in Nursing, This result is inconsistent with a study done by Elnashar et al., (2019) in the Al Taif area of Saudi Arabia, which found that more than three-quarters of the sample (76.8%) had completed a college education.

In the descriptive study concluded that less than half  (47.3%) of the study sample have 6 – 10 years of experience, these results disagree with the finding of the current study, which illustrates that more than half (57.5%) of the participants had >10 years of experience, in the other hand A quasi-experimental study was done by (Abd-Allah, N.et al, 2017) among 30 nurses in all general hospitals in Port Said city, indicated that (56.6%) of nurses they had less than 10 years of experience in the health sector. Maternity Teaching Hospital has government and contracts Nurse/Midwife, 65.5% of the study sample were government employees, contracts they were newly graduated mostly from an institute, and they should be assistants to the old Nurses/Midwives in giving care to mothers.

It is obvious, from those Eighty-seven Nurses/ Midwives, a quarter of 25.3%  was working in the private sector, plus the public sector, also this is in the same line with the previous study done by (Ahmed et al., 2018) that 36.7% of the study sample work in a private hospital. Moreover, The existing study discovered a statistically there was highly significant (p.0.000) link between working in a private hospital and N/M overall practice. This result implies that if they have good knowledge and are improving their performance in the public sector, it will be reflected in the private sector because the same Nurses/Midwives are providing healthcare in both.

The current study indicates that only 23% of nurses and midwives participated in the training courses to improve their knowledge and practical performance; there was no significant association between the study sample’s participation in a training course with their overall practice. our finding is much better than the quasi-experimental study done by(Mohamed Abd Elhakm & Mostafa Elbana, 2018), which concluded that only 10.8% of the study sample participated in the training courses (n=55).

           The findings show that the participants have poor practice regarding how to examine the placenta after delivery in the pretest, due to a lack of continuing education programs. On the other hand, the Maternity Teaching Hospital is the only governmental hospital in the area and has a large number of patients who put a huge strain on the nurses and midwives, lowering the quality of healthcare. This result is not consistent with the descriptive cross-sectional study which concluded that the majority of study samples had moderate knowledge regarding assessing the placenta (K., 2018). Fortunately, the finding shows that there was a highly significant difference between the pretest & posttest of study samples' performance after

          receiving a comprehensive educational program regarding placenta from the researcher, it will indicate that enthusiastically they are looking for knowledge to improve their performance. 

          The current study demonstrates that there was a highly significant association between N/M age with overall practice, implying that the majority of them seem to have poor practice and follow traditional performance so even though they lack the authority to forward their education. The majority of N/M are above 40 years old, they have skills because they have more than 20 years of experience but they apply their care in a traditional way.

Because nurses are the largest group of healthcare workers and are accountable for the quality of care provided to patients, their perspectives on the success of their treatment are critical; they should have a diverse set of holistic skills, and evidence of nursing interventions is available. In order to determine the efficacy of therapy, they should also consult with other health professionals. They should also have the fundamental information and abilities to provide safe care, as well as be properly trained in practical and technical procedures to be able to use this knowledge. This study suggests that to carry out placenta examination skills effectively, regardless of the training program used, clinical nurses should undergo retraining every 6 months.

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CONCLUSIONS

The findings of the current study concluded that the participants have poor practice regarding the examination of the placenta after delivery, as well as they, follow traditional performance, also the finding indicates that there was a significant association between Nurses/Midwives' age with their overall practice.

ETHICAL CONSIDERATIONS

The scientific and ethics committees of the nursing and health sciences colleges at the University of Sulaimani authorized the study. Before collecting data, formal authorization was obtained from health and government authorities. Before collecting data, the study sample provided informed permission. The study received ethical approval from the Institutional Ethics Committee. 

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FUNDING
Therearenofundingsources. 

RECOMMENDATION 

Based on these findings, there should be an aforethought effort to upgrade nurses/midwives’ knowledge and performance, as well as developing a plan for continuing education programs every 6 months to improve their clinical skills.

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