An exploratory study on ‘Nurse Midwife Manpower’ requirement in labour room,Nehru Hospital,PGIMER,Chandigarh

http://doi.org/10.33698/NRF0103 Gagandeep Kaur, Baljit Kaur, Seema Chopra

Abstract : The aim of the study was to explore ‘Nurse Midwife manpower’ requirement for conduction of deliveries and for nursing care of mothers and new borns in labour room, Nehru hospital, PGIMER, Chandigarh. The research design adopted was exploratory for this study on the basis of observation of nurse midwives to identify time spent for conduction of deliveries and other midwifery and nursing care activities for mothers and new borns in labour room. Sample comprised of all midwifery and nursing care activities for the care of mothers and new borns along with the frequency of each midwifery care activity per day. Data was collected by observation of time taken by nurse midwives to complete various midwifery and nursing care procedures, with the help of midwifery and nursing care activity time record sheet and stop watch. The results of the study revealed that 35 full time nurse midwives were required to conduct deliveries and to provide care to mothers and babies for 24 hours in the month of August 08. After adding 30% leave reserve to the required number of nurse midwives per day, it was found that labour room required 45 full time nurse midwives to provide care to mothers and babies for 24 hours.

Key words :Midwifery and nursing care activities, Frequency of each midwifery care activity per day, Nurse Midwife manpower

Correspondence at : Gagandeep Kaur  National Institute of Nursing Education, PGIMER, Chandigarh

Introduction

The ‘Mid’ in the midwife originates from German word ‘mit’ meaning with. A Midwife means literally with the woman during birthing of her child. 1 Midwife means with woman or in France ‘wise woman’. Through out the ages women have been depending upon a skilled person, usually another woman to be with them during the child birth. 2 International confederation of Midwives and International Federation of Gynaecology and Obstetrics and World Health Organisation define Midwife and her sphere of practice as:’The Midwife is recognized as a responsible and accountable professional who work in partnership with woman to give necessary suppor t, advice during the pregnancy, labour and the postpartum period, to conduct bir ths is the Midwife’s own responsibility and to provide care for the new born and infant. This care includes preventive measures, promotion of normal bir th, detection of complications in mother and child, accessing of medical care or other appropriate assistance and carrying out of emergency measures.3 Midwives provide care to antenatal, postnatal mothers in variety of setting. In Indian settings family members are not allowed to enter in labour room. Without adequate support and advice of a Midwife, the woman in labour may simply adopt the sick role and take to bed. The support of midwife can provide the courage needed to mobilize and adopt varying position that may help-promote a normal delivery.4 Empowering women with sense of control in labour is an impor tant part of midwife’s role. It has been seen that, women who are well supported in labor5:

  • cope effectively with pain
  • experience higher satisfaction levels, in terms of birth and
  • require less pharmacological analgesia 5

All women should be able to receive one to one care in labour. Failure to provide this may result in increased rate of medical intervention and low morale among the staff as Midwives take on a role of more reminiscent of an obstetric nurse.4 A study was conducted to assess frequency with which fetal auscultation could be used as a primary mode of fetal assessment. It was found that auscultation with stringent evaluation and recording frequency is not feasible under normal labour and delivery room conditions unless 1:1 nursing care is available 6  A study was conducted to examine amount of support being provided by nurses during the childbirth and factors that influence provision of support it was found that nurses spent only 12.4% of their total time providing supportive care to labouring women. Barriers to providing support to patient identified by nurses include lack of time and insufficient staff.7 Determining the appropriate nurse staffing level has been and continues to be a complex task that depends upon many variables such as the patient, the nurse, the hospital environment, support staff availability, information technology, and the interaction of all these factors with one another within a rapidly changing healthcare system.8 A large body of literature explores this issue. Some of this research shows that certain patient outcomes which are sensitive to the quality of nursing care could be improved with better nurse-to-patient ratios.9 Furthermore, others have considered what alternative means there might be, aside from ratios, to improve patient outcomes and the satisfaction of nurses.10 Despite all the research, it is not yet clear what the ideal nurse-to-patient ratio would be, or even if one exists.Recently, action has been taken in Victoria (Australia) and California (USA) to set mandatory upwardly adjustable minimum nurse: patient ratios. In 2001 Victoria implemented mandatory minimum nurse: patient ratios in all public sector facilities. The minimum ratios vary to meet the needs of different units and shifts. Healthcare institutions are categorized into different levels according to acuity of care, size and location. For example: For ante/postnatal mothers at all hospital levels, 1: 5 + in charge and 1:6 + in charge nursing manpower is required in a.m. and p.m. shift respectively.11 California passed legislation in 1999 that established minimum nurse: patient ratios to be implemented in January 2004. For antenatal mothers at 1:4 nursing manpower is required.11 In order to establish appropriate staffing levels, healthcare facilities must take into account the number of patients and the number of RN hours. Both RN and patient characteristics are considered in the calculating RN staffing ratios. The RN staffing ratios achieved using these formulas should be published annually and then made available to the public.12 No standard criterion is used to calculate required midwife to newborns and mothers ratio in labour room of PGIMER, Chandigarh. Midwife to newborns and mothers ratio is not according to their needs. Review of literature also reflects that most of the studies for calculating nurse midwife manpower requirement are conducted in foreign countries and such studies are not conducted in India. Researcher in present research study had tried to explore the required midwife manpower in labour room for Indian setting.

Objectives

  • To determine nurse midwives required for conduction of deliveries in labour room, Nehru hospital,
  • To determine nurse midwives required for providing nursing care to mothers and new born babies in labour room, Nehru hospital, PGIMER,

Materials and Methods

The study was conducted in labor room, Nehru Hospital, PGIMER, Chandigarh. It is a major referral hospital in north India. The specialized quality of services of the Institute is renowned not only at national Level, but also internationally. It has a capacity of 1600 beds.Obstetric and Gynaecology department provides diagnostic, therapeutic and curative services. Labor room consists of various units and the bed capacity of units are; Observation room (7beds), Eclampsia room (2 beds), Post natal room (6 beds), Delivery room( 2 delivery tables beds), Nursery with capacity of five cradles, one resuscitaire and one transport incubator. Target population of study was all  midwifery and nursing care activities for the care of mothers and new borns in labor room during the period of data collection in the month of August 2008 along with the frequency of each midwifery and nursing care activity per day. Tools used for data collection were; Midwifery and nursing care activity sheet, which contained list of all midwifery and nursing care procedures required for care of mothers and new borns along with the frequency of each activity per day, Midwifery and nursing care activity time record sheet, which contained five columns to record time observation of each nursing and midwifery care procedure performed by nurse midwives to meet health needs of mothers and babies, Daily mother and baby census form and stop watch. Validity of tools was checked by seeking opinion of nursing experts and gynaecologists.Data was collected in month of August 2008. Verbal consent was taken from study subjects and they were made clear that study is not an evaluation of individual performance. Each nursing and midwifery care activity performed by nurse midwife was observed and recorded for 5 times in midwifery and nursing care activity time record sheet and then average time spent on each midwifery and nursing care procedure was calculated. Then this average time was multiplied with frequency of each nursing and midwifery care procedure per day to obtain the total time spent on each midwifery and nursing care procedure per day. This total time spent on each midwifery and nursing care procedure per day was multiplied with average census of labouring mothers, deliveries, babies and post natal mothers to calculate midwifery and nursing care hours for the care of labouring mothers, deliveries, babies and post natal mothers per day in month of August 08. Formula used for calculating number of Nurse Midwives required for providing nursing and midwifery care:

Nurses Midwives required=Total time required for providing care for 24 hours + 8.33%13

8 hours per shift An allowance of 8.33% was added to the account for personal fatigue, communication and other activities which were not captured by the time standards. 30% leave reserve was added to required number of nurse midwives for providing nursing and midwifery care for 24 hours.13

Results:A total of 407 labouring mothers were admitted in labour room in the month of August 2008. Out of these 407 labouring mothers, 343 had labour without any complication of pregnancy and labour which means an average of 11.06 mothers per day had uncomplicated labor whereas other 33 mothers in labour per month of August 08 had eclampsia which means average of 1.06 mother in labour per day had eclampsia. Labouring mothers admitted with gestational diabetes mellitus (GDM) were 25 per month of August 08 so average of 0.80 mother in labour had gestational diabetes mellitus (GDM) per day while only 6 mothers were on ventilator per month of August 08. (Table-1)

Table 1: Number of labouring mothers per month and average number of labouring mothers per day in the month of August 2008

 

  Per Month Average Per day
Labouring Mothers having    
– Uncomplicated Labour 343 11.06
– Eclampasia 33 1.06
– Gestational Diabetese Mellitus 25 0.80
– On Ventilator 6 0.19

Labouring Mothers                                                           No. of Mothers

It was analyzed that 1.06 labouring mothers with eclampsia required 11.41 nursing care hours per day whereas 0.80 labouring mother with GDM required 6.76 hours nursing care hours per day. Nursing care hours per day spent for providing care to 11.06 mothers with uncomplicated labour, were 89.03 hours on other hand 0.19 mother on ventilator required 1.86 nursing care hours per day. Time spent for performing other direct care activities was 2.23 hours while time spent for performing indirect care activities was 3.17 hours. A total of 115.09 nursing hours per day were consumed per day for performing nursing and midwifery care activities for mothers in labour. (Table 2)

Table 2 : Time consumed (nursing hours) per day for the care of labouring mothers

 

Activity Average time/ labouring mother / day (hours) Average census of labouring mother / day Average time/ day (hours)
Care of labouring mother      
(Observation room)      
1. Direct care activity      
1.1    Care of mother with 8.05 11.06 89.03
uncomplicated labour      
1.2    Care of mother with eclampsia 10.77 1.06 11.41
1.3    Care mother with GDM 8.46 0.80 6.76
1.4    Care of mother on ventilator 9.83 0.19 1.86
1.5    Preparation of mother for C-section 0.21 3.00 0.63
2. Other direct care activities 2.23 _ 2.23
3. Indirect care activities 3.17 _ 3.17
Total time consumed per day _ _ 115.09

A total of 314 vaginal deliveries were conducted in the month of August 2008. Out of these 314 vaginal deliveries, 171 were normal vaginal deliveries with episiotomy, 71 were normal deliveries without episiotomy. Numbers of Forceps deliveries conducted were 39 whereas no ventouse delivery was conducted in the month of August 08, only 2 ventouse deliveries followed by forceps were conducted. Numbers of breech deliveries conducted were 20 while 9 twin and 2 triplet deliveries were also conducted in the month of August 08. (Table-3)

Table 3 : Distribution of vaginal deliveries in the month of August 2008

N = 314

NVD with episiotomy                                                           171 (54.5)Type of delivers                                                                         n (%)

NVD without episiotomy                                                       71 (22.6)

Forcepsdelivery                                                                39 (12.4)

Breech delivery                                                                 20 (06.4)

Twin delivery                                                                  09 (02.9)

Triplet delivery                                                               02 (00.6)

Ventouse delivery followed by forceps                                      02 (00.6)

It was observed that average of 2.12 hours were spent for conduction of 2.29 Normal Vaginal Delivery (NVD) without episiotomy where as conduction of 5.52 NVD with episiotomy required 6.23 hours. On the other hand time spent for assisting in conduction of 1.25 forceps delivery was, 1.50 hours while 0.07 hours were spent for assisting in conduction of 0.06 ventouse delivery followed by forceps. On an average time spent for assisting in conduction of 0.64 breech delivery was 0.78 hours whereas time spent for assisting in conduction of 0.29 twin and 0.06 triplet delivery was 0.36 and 0.07 hours respectively. Average time spent for performing other direct care activities and indirect care activities per day in delivery room was 7.76 and 7.72 hours respectively. In total 26.61 hours per day were spent for conduction of 10.12 deliveries and performing other activities of delivery room. (Table 4)

Table 4 : Time consumed per day for the conduction of delivery and other activities of delivery room

 

Activity Average time/ labouring mother (hours) Average census of labouring mother / day Average time/ day (hours)
Conduction of delivery

1.      Direct care activity

1.1        Conduction of NVD without episiotomy

1.2        Conduction of NVD with episiotomy

1.3        Assisting in conduction of forceps delivery

1.4        Assisting in conduction of ventouse delivery

1.5        Assisting in conduction of breech delivery

1.6        Assisting in conduction of twin delivery

1.7        Assisting in conduction of triplet delivery

2.      Other direct care activity

3.      Indirect care activity

  

 

0.93

  

 

2.29

  

 

2.12
1.13 5.52 6.23
1.20 1.25 1.50
1.29 0.06 0.07
1.22 0.64 0.78
1.25 0.29 0.36
1.30 0.06 0.07
7.76 _ 7.76
7.72 _ 7.72
Total time consumed per day _ _ 26.61

A total of 326 new borns were delivered by vaginal delivery. Among these 326 new born babies, 302 were single born babies whereas there were 9 twins and 2 triplet babies. Out of these 326 new borns about 277 did not require any intensive new born resuscitation while 25 required intensive new born resuscitation in labour room nursery. Another 24 babies were born dead (Still birth) due to various reasons. A total numbers of 118 babies were delivered through caesarean section in the month of August 08. Out of these 118 babies, 93 were born to mothers admitted in labour room whereas

Table 5 : Time consumed per day for the care activities for new borns

 

Activity Average time/ activity

in minutes

 Average census / day Average time/ day in minutes
Care activities for new born      
I     Direct care activity      
1.      Preparation of articles 2.26 10.51 23.75
2.      Preparation of transport incubator for C-section 3.00 3.80 11.40
3.      Receiving baby for Caesarean section 40.18 3.80 152.68
4.      Immediate care of new born 9.24 8.93 82.51
5.      New born Resuscitation 15.36 0.80 12.28
6.     Performing legal formalities 6.36 13.54 86.11
7.      Administration of Injection Vitamin K 4.40 13.54 59.57
8.      Documenting the delivery 1.00 14.34 14.34
9.      Putting clothes to new born 6.41 13.54 86.79
10.    Conducting head to foot examination 7.35 13.54 99.51
11.    Inserting OG tube 4.47 2.00 8.94
12.    New born feeding      
12.1 Spoon feeding 180.00 2.00 360.00
12.2 Tube feeding 77.04 2.00 154.08
13.    Inserting I/V cannula 8.11 3.00 24.33
14.    Administering intravenous fluids 25.2 3.00 75.60
15.    Administering intravenous injections 26.26 2.00 52.52
16.    Assisting in collection of sample 9.60 5.00 48.00
17.    Care of baby under phototherapy 12.07 1.00 12.07
18.    Checking vital signs 76.50 5.00 382.50
19.    Maintaining hygiene 17.21 5.00 86.05
20.    Changing diaper 97.12 5.00 485.00
21.    Care of Still born 20.00 0.77 15.40
22.    Care of dead baby( died after birth) 22.00 0.51 11.22
II    Other direct care activities 293.33 – 293.33
III Indirect care activities 206.00 – 206.00
Total time consumed (in hours) per day – – 47.40 hours

25 were born to mothers admitted in antenatal ward. New borns delivered by caesarean section were provided immediate care after birth in labour room in operation theater by nurse midwife working in labour room nursery.On an average 10.51 new borns per day were delivered by vaginal delivery in labour room. Out of these10.51 new borns,8.93 did not require any intensive new born resuscitation whereas 0.80 required intensive new born resuscitation in labour room nursery and 0.77 baby was born dead (Still bir th). Average number of new borns delivered per day by caesarean section were 3.80.All stable babies shortly after their birth were shifted from labour room nursery to their mothers in postnatal care unit. On an average, 5 babies per day stayed in labour room nursery for close observation including medical and nursing care. Out of these 5 babies, average of 1 baby per day received phototherapy care, average of 2 babies per day received spoon feed, average of 2 babies per day received tube feed, average of 3 babies per day received I/V fluids, average of 2 babies per day received I/V injections.So in total 47.40 hours per day were spent for performing the direct and indirect nursing care activities for the care of new borns in labour room nursery. (Table 5) A total of 407 postnatal mothers were admitted in the month of August 2008 in labour room. Among these 407 mothers, 314 had vaginal delivery and 93 were operated for caesarean section. So it was calculated that average of 13.12 postnatal mothers per day stayed in labour room in the month of August 2008. Out of these 13.12 postnatal mothers,10.12 had vaginal delivery while 3 postnatal mothers had caesarean section. (Figure 1)

Figure 1 : Comparison of census of postnatal mothers with vaginal delivery and caesarean section in the month of August 2008

Average census of postnatal mothers per day for the month of August 2008 was 13.12. Out of these 13.12 postnatal mothers,10.12 had vaginal whereas 3 had caesarean section. It was observed that 10.12 postnatal mothers with vaginal delivery required 38.75 nursing care hours per day where as 3 postnatal mothers with caesarean section required 14.07 nursing care hours per day. Time spent per day for care of 8 babies in postnatal room mother was 8 hours. Direct care required 65.87 hours per day while 1.91 hours were spent for providing indirect care. In total 67.78 nursing hours per day were consumed for nursing care of 13.12 post natal mothers and 8 babies in post natal room. (Table 6)

Table 6 : Time consumed per day for the nursing care activities for post natal mothers

 

Activity Average time/ Average Average
  activity/ Case census / day time/ day
  in hours   hours

Care activities for post natal mothers and new borns in Postnatal room

  1. Direct care activity for

 

1.1 Post natal Mother with vaginal delivery 3.83 10.12 38.75
1.2 Post natal Mother with C-section 4.69 3 14.07
1.3 Babies in Postnatal room 1 8 08.00
2. Other direct care activities 5.05 – 5.05
3. Indirect care activities 1.91 – 1.91
Total time consumed per day _ _ 67.78

Formula to calculate number of Nurse Midwives required for providing nursing and midwifery care:

Nurses Midwives required=Total time required for providing care for 24 hours + 8.33%13

8 hours per shift

An allowance of 8.33% was added to the account for personal fatigue, communication and other activities which were not captured by the time standards. 30% leave reserve was added to required number of nurse midwives for providing nursing and midwifery care for 24 hours. 14 It was analyzed that 20 full time nurse midwives were required to provide care to 13.12 labouring mothers per day whereas 5 full time nurse midwives were required to conduct 10.12 deliveries and perform other activities of delivery room per day. Care activities for new born in nursery required 8 full time nurse midwives for 24 hours while 12 full time nurse midwives were required per day for providing nursing and midwifery care to 10.12   post natal mothers with vaginal delivery, 3 post natal mothers with caesarean section and 8 new born babies in postnatal room. In total labour room required 35 full time nurse midwives to conduct deliveries and to provide care to mothers and babies for 24 hours in month of August 2008. After adding 30% leave reserve14 to required number of nurse midwives, it was found that labour room required 45 full time nurse midwives for conduction of deliveries and for providing nursing and midwifery care to mothers and babies for 24 hours in month of August 2008.It was analyzed that 45 nurse midwives were required for conducting deliveries and providing care to mothers and newborns in labour room whereas in actual 15 nurse midwives were available in labour room in the month of August 08. (Figure 2)Figure 2 : Comparison between actual nurse midwife manpower in the month of August 08 and calculated nurse midwives required for labour room

Discussion:In the present study, methodology used for calculating nurse midwife manpower was based on calculating nursing hours spent for providing care to antenatal, intranatal, postnatal mothers and new born babies per day. While in similar study, methodology used for calculating nurse midwife manpower was based on bed occupancy rate and as per physical dependency of patient14. In present study it was analyzed that 16 nurse midwives were required for providing care to 13.12 laboring mothers for 24 hours. After adding 30% leave reserve, 20 nurse midwives were required for providing care to 13 laboring mothers for 24 hours. Calculated Nurse Midwives ratio in each shift is 1:2. California passed legislation in 1999 that established minimum nurse: patient ratios to be implemented in January 2004. Labour and delivery ratio given by California nurse’s association is 1:2 which is in agreement with the present study.15 It was analyzed that 4 nurse midwives required for conduction of 10.12 deliveries  for 24 hours. After adding 30% leave reserve,5 nurse midwives were required for conduction of 10.12 deliveries for 24 hours. Calculated nurse midwives ratio in each shift is 1:2 which is in agreement with the recommended 1:2 labour and delivery ratio given by California nurse’s association.15 In present study it was analyzed that 9 nurse midwives were required for providing care to 13.12 postnatal mothers for 24 hours.After adding 30% leave reserve, 12 nurse midwives were required for providing care to 13.12 postnatal mothers and 8 babies for 24 hours. Calculated nurse midwives ratio in each shift is 1:5.25 which is in agreement with recommended ratio of 1:5 in a.m. shift and 1:6 in p.m. shift for postnatal mothers: nurse midwives given by International council of nurses11 In the present study, methodology used for calculating nurse midwife manpower was based on calculating nursing hours spent for providing care to antenatal, intranatal, postnatal mothers and new born babies per day. Each midwifery and nursing care procedures, mentioned in midwifery and nursing care time record sheet was observed for 5 times to calculate the average time spent on each midwifery and nursing care procedure was calculated. Then this average time spent on each midwifery and nursing care activity was multiplied with the frequency of each midwifery and nursing care activity per day to find out time spent per day on each midwifery and nursing care procedure. Time spent per day on each midwifery and nursing care procedure was multiplied with daily census of labouring mother, deliveries, new borns and post natal mother to get the total time required for conducting deliveries and meeting the health needs of mothers and new born babies.Hence it was concluded that labour room required 35 full time nurse midwives to conduct deliveries and to provide care to mothers and babies for 24 hours. After adding 30% leave reserve to the required number of nurse midwives per day, it was found that labour room required 45 full time nurse midwives to provide care to mothers and babies for 24 hours. There is wide scope of improvement in calculating Nurse Midwife manpower requirement of labour room if nursing administrators develop the standardized procedural steps of various nursing and midwifery care procedures required in labour room and conduct further study to find out the standardized time required for various nursing and midwifery care procedures required in labour room.

References

  1. Varney H, Kriebs J M, Gegor C Textbook of midwifery. 4thed. All India publishers and distributors. New Delhi 2005: 3- 4.
  2. Fraser Diane M, Cooper Margaret A. Myles Textbook for 14th ed. Church hill, living stone. Edinburgh, London 2003: 3-5.
  3. The role of midwives: time for Midwives (the official journal of royal college of midwives) 2007; 10(9):320.
  4. One to one care in labour: a luxury? Midwives (the official journal of royal college of midwives) 2007; 10(9):427.
  5. Simkin p, Bolding Update on non pharmacological approaches to relieve labour pain and prevent suffering. Journal of midwifery and women’s health 2004; 49(6):489-502.
  6. orrison C john. Intra partum fetal heart rate assessment, monitoring by auscultation or electronic American journal of obstetric and gyneacology 1993; 168(1):63-66.
  7. Gale Jill, Fothergill et Measuring nursing support during childbirth. American journal of maternal child nursing 2001; 26(5): 264-271.
  8. Buerhaus What is the harm in imposing mandatory hospital nurse staffing regulations? Nursing Economics 1997; 15(2): 66 – 72.
  9. Cho S, Ketefian S, Barkauskas V, Smith The effects of nurse staffing on adverse events, morbidity, mortality and medical costs. Nursing Research 2003; 52(2): 71 – 79.
  10. Budreau G, Balakrishnan R, Titler M, Hafner Caregiver-patient ratio: Capturing census and staffing variability. Nursing Economics 1999; 17(6): 31-324.
  11. No Nurse: Patient Ratios. Available at www.icn.ch/matters_ rnptratio.htm: 15.8.2003.
  12. Hurst K. Relationship between patient dependency, nursing work load and International Journal of Nursing Studies 2005; 42:75-84.
  13. Carrie A, Sandra R, Kathleen G. A flexible staffing model for patient service associates. JONA 1997; 27(1):48-54.
  14. Jabeen Work study to find Nurses as per bed occupancy and per physical dependency of patients. Nursing journal of India 2001; LXXXXII (5):115-116.
  15. No RN-to-Patient Ratios. Available at www.calnurse.org/finalrat/ ratiobox.html: 15.8.2003.