Patient satisfaction with intrapartum and postpartum nursing care

MINISTRY OF HIGHER EDUCATION REPUBLIC OF CAMEROON

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THE UNIVERSITY OF BUEA PEACE-WORK-FATHERLAND

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FACULTY OF HEALTH SCIENCES
Department of Nursing

PATIENT SATISFACTION WITH INTRAPARTUM

AND POSTPARTUM NURSING CARE :

THE CASE OF BUEA REGIONAL HOSPITAL

ANNEX

A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE AWARD OF A BACHELOR OF NURSING
SCIENCE (BNS) DEGREE.

CHWINUI NGWINGMECHI MBEINKONG
UB 029154

Supervisor: Dr. NDE FON Peter

BUEA, July 2010.

CERTIFICATION.

This is to certify that the Research work «Patient Satisfaction with Intrapartum and Postpartum Nursing Care» carried out in the Buea Regional Hospital Annex was done by CHWINUI NGWINGMECHI MBEINKONG and meets the criteria for the award of a Bachelor Degree in Nursing Science.

Sign: Sign:

Dr. Nde Fon Peter Chief Ndeso Atanga

Supervisor Head of Department

Sign:

Pr. Peter Martins NDUMBE
Dean of Faculty

DEDICATION

This piece of work is dedicated to all Nurses who have the God-given

Assignment of caring for the Sick.

ACKNOWLEDGEMENTS

This research work would definitely not have been brought to light without the restless efforts of several personalities. I will like to appreciate all of you who built a step in one way or the other for me to climb to the top of this mountain: Special thanks to my Lord and Saviour Jesus Christ who gave me salvation and a reason to live.

A million thanks to my supervisor Dr. Nde Fon Peter for the sleepless nights in directing and correcting this piece of work.

Many thanks go to my lecturers Chief Ndeso Atanga, Dr. Mrs Mary Bih suh, Dr Palle John and Mr Sab Clement for all their guidance.

Innermost gratitude goes to my family: to my lovely parents

Mr and Mrs Ghogomu MBEINKONG for their unfailing love and tender care. To my caring sisters Yehyeh, Nuigo, Keinui and my dear brother Halle for their love.

Sincere thanks go to my lovely niece Pearl Ciana for the love she gave me through out my stay in Yaounde.

Heartfelt thanks to my special friend Edwin for all his assistance.

I must recognize the love and support of my friends Alvina, Calvin, Betrand, Kelvina and Lesley for their support and to all my classmates who made UB a place to be during my 4 years of study.

To the staff of the Buea Regional Hospital Annex Maternity, for all your collaboration, I say THANK YOU.

LIST OF ABBREVIATIONS

A/L Advanced Level

AAP American Academy of Paediatrics

ACOG American College of Obstetricians and Gynaecologists AIDS Acquired Immune Deficiency Syndrome

AMTSL Active Management of Third Stage of Labour

BRHA Buea Regional Hospital Annex.

C/S Caesarean Section

DIVC Disseminated Intravascular Coagulation

EFW Estimated Foetal Weight

FH Fundal Height

FSH Follicle Stimulating Hormone

FSLC First School Leaving Certificate

HIV Human Immunodeficiency Virus

O/L Ordinary Level

TB Tuberculosis

WHO World Health Organization

LIST OF TABLES

Table 1: The Bishop Scoring System 21

Table 2: Distribution according to Age 37

Table 3: Distribution according to Levels of Education 38

Table 4: Distribution according to Profession 39

Table 5: Distribution according to Marital Status 40

Table 6: Distribution according to Number of days spent at Maternity 40

Table 7: Distribution according to Parity 41

Table 8: Mode of Delivery 41

Table 9: Distribution according to Nurses' Attitude on Admission 42

Table 10: Distribution according to Nursing Comfort Measures 42

Table 11: Distribution according to Breathing Techniques Taught 43

Table 12: Distribution according to Environmental Hygiene 43

Table 13: Distribution according to Time spent with patients 43

Table 14: Distribution according to Interpretation of Patients' feelings 44

Table 15: Distribution according to Monitoring Vital signs 44

Table 16: Distribution according to Patient Education 45

Table 17: Distribution according to Examination of Baby 46

Table 18: Distribution according to Examination of Mother 46

Table 19: Rating during Intrapartum (using the Likert's Scale) 47

Table 20: Rating during Postpartum(using the Likert's Scale) 48

Table 21: Patients' Recommendation of the Maternity 49

Table 22: Patients' Opinion on how satisfaction can be improved. 50

LIST OF FIGURES

Figure 1: Spontaneous Symphysiotmy 18

Figure 2: Estimated Foetal Weight 20

Figure 3: Intramuscular administration of Oxytocin 24

Figure 4: Deliverance of the placenta 25

Figure 5: Examining the placenta 25

Figure 6: Sketch diagram of BRHA 32

Figure 7: Organigram of BRHA 33

Figure 8: Distribution according to Age 47

Figure 9: Distribution according to Levels of Education 48

Figure 10: Distribution according to Professional 49

Figure 11: Distribution according to Marital Status 50

Figure 12: Distribution according to Number of days spent at Maternity 51

Figure 13: Distribution according to Gravidity 52

Figure 14: Distribution according to Mode of Delivery 52

Figure 15: Distribution according to Patient Education 56

Figure 16: Rating during Intrapartum 58

Figure 17: Rating during Postpartum 59

Figure 18: Patients' Recommendation of the Maternity 60

Figure 19: Data Entry Form 64

TABLE OF CONTENTS

CERTIFICATION i

DEDICATION ii

ACKNOWLEDGEMENTS iii

LIST OF ABBREVIATIONS iv

LIST OF TABLES v

LIST OF FIGURES vi

TABLE OF CONTENTS vii

ABSTRACT ix

CHAPTER 1: INTRODUCTION AND OBJECTIVES

1.0. Introduction 2

1.1. Background 3

1.2. Problem statement 4

1.3. Objectives of the study 5

1.4. Research questions 5

1.5. Hypothesis 5

1.6. Purpose of study 5

1.7. Justification 6

1.8. Limitations of the study 6

1.9. Operational definition of terms 7

CHAPTER 2: LITERATURE REVIEW

2.0. AN OVERVIEW OF LABOUR, DELIVERY AND POSTPARTUM 9

A. Introduction 9

B. Normal Labour and Delivery (Intrapartum) 9

C. The Postpartum Period (Puerperium) 12

2.1. NURSING CARE AND RESPONSIBILITIES 19

A. Introduction 19

B. Nursing role during labour and delivery 19

C. Nursing role during the postpartum period 26

2.2. PATIENTS' PERCEPTION ON NURSING CARE 29

Patient Satisfaction with Intrapartum and Postpartum Nursing Care: Buea Regional Hospital Annex.

CHAPTER 3: METHODOLOGY

3.1. Study design 32

3.2. Study period: 32

3.3. Study site 32

3.4. Study population 34

3.5. Sampling method 34

3.6. Sample size 34

3.7. Data collection procedure 34

3.8. Ethical considerations 35

3.9. Budget 35

CHAPTER 4: PRESENTATION AND ANALYSIS OF RESULTS

4.1 Socio-Demographic Data 37

4.2. Intrapartum Nursing Care Assessment 42

4.3. Postpartum Nursing Care Assessment 44

4.4. Assessment of Patient Satisfaction 47

4.4.1. Rating during Intrapartum (using the Likert's Scale) 47

4.4.2. Rating during Postpartum(using the Likert's Scale) 47

4.5. Patients' Recommendation of the Maternity 49

4.6. Patients' Opinion on how satisfaction can be improved. 50

CHAPTER 5: DISCUSSION, CONCLUSION AND RECOMMENDATIONS

5.0. Introduction 52

5.1. Discussion of results 52

5.2. Conclusion 58

5.3. Recommendations 59

REFERENCES

APPENDIX

ABSTRACT

This research project «Patient Satisfaction with Intrapartum and Postpartum nursing care the case of Buea Regional Hospital Annex» was conceived due to the fact that nursing care is hardly evaluated and so rarely improved on. This research aims at evaluating nursing care by assessing patient satisfaction with nursing care offered.

It is a descriptive study targeting patients in the postpartum ward who either had a normal delivery or an emergency caesarian section in the BRHA maternity. Data was collected using a structured questionnaire which was self-administered to a convenient sample of 37 participants.

The study revealed that the nursing care offered during intrapartum was average but was poor during postpartum. Majority of the ratings for patients' satisfaction during intrapartum (42.3%) were good implying that the patients were fairly satisfied; while a majority of the ratings during postpartum (37.6%) were poor implying that they were unsatisfied with the care. A majority (52.8%) of the population somewhat agreed to recommend the maternity services based solely on the nursing care they received. This therefore means that the participants were fairly satisfied with the care offered in this maternity.

Nurses therefore must improve on the care offered during labour and delivery (intrapartum) and strive to provide adequate and standard care to the postpartum mothers.

INTRODUCTION AND OBJECTIVES

1.0. INTRODUCTION

Health is not the mere absence of disease and infirmity but a state of complete physical, social and mental wellbeing of an individual and should be a universal human right [1]. Better health care outcomes will therefore include social aspects of pregnancy and childbirth [2]. A good outcome should be that every woman should be satisfied with the care and support she received during pregnancy, delivery and postpartum periods and to feel that she and her baby have been the center of care [3].

For many a woman, labour and childbirth is a time of excitement and anticipation alongside uncertainty, anxiety, fear, and pain. The memories and experience of childbirth remain with the woman throughout her life. Clearly, the support and care they receive during this period is critical [4].

Nurses have an important, enabling role to help the woman during childbirth. There must be a high percentage of interpersonal skills in the care of the woman in addition to being technically competent [5].

Postpartum period is significant for two important things: It is a time for physiological adjustments for both the mother and her baby; and a period of important social and physiological adjustments [6]. An emphasis on individualized client-driven postpartum teaching including self-care and newborn care is essential. Nursing care here should be flexible and organized in collaboration with the woman to address her individual needs [3].

Evaluation is one of the most critical phases of the nursing process because it supports the basis of the usefulness and effectiveness of nursing practice. Nursing practice is patient-driven and patient-centered. Accordingly, patient satisfaction has been strongly advocated for by nursing professionals worldwide to be an important indicator of quality nursing care delivery [7].

The purpose of measuring satisfaction here is to understand the patients' experience of labour and childbirth and access postpartum care in order to obtain information about the quality of nursing care and identify problem areas.

1.1. BACKGROUND

In accordance with international professional standards and guidelines, contemporary maternity care providers strive to create a childbirth experience that is safe for the mother and her baby which is positive and satisfying for the childbearing woman [8]. Researchers have focused on identifying factors that promote a positive experience. Beneficial outcomes of a positive childbirth experience include self-esteem, efficient and enhanced maternal attachment and compliance [9].

Research has demonstrated that a positive childbirth experience helps a woman develop a positive attitude towards motherhood, which helps facilitate transition into the maternal role [10]. The positive experience can also establish rich and successful family relations, encourage self-esteem, improve self-confidence and ensure positive development of the woman [11].

We need to accept that labour is a time for unique sensitivity to environmental factors. Events and the interactions occurring during labour have powerful psychological effects, therefore for the benefit of both the parturient woman and her child, a positive childbirth experience is desirable [9]. Studies also confirmed that the intrapartal nurse would be the deciding factor on whether the woman has a positive or negative experience during childbirth [5]. Postpartum women experience physical discomfort and psychological changes following delivery of their infants [3].

Several scientific studies have been carried out on postpartum care and it was found that parents valued the postpartum information they were taught [7]; also, mothers' satisfaction with postpartum care is dependent on their perceptions of the nurse's ability to place them at ease [11]. Nursing care qualities that contributed to the satisfactory experience include information sharing, calmness, demonstration of confidence and the anticipation of unstated needs [4]. These findings illustrated qualitative inquiry for understanding patient satisfaction with care.

The 2009 birth rate estimate in Cameroon, stood out at 31.4/1000 persons [12]. Latest survey indicated that 62% of such childbirths were assisted by a skilled birth

attendant [13]. This indicates that health practitioners are receiving more than half of the total births and hence a need for improved quality of nursing care.

It is known that nursing and midwifery services are the backbone of the healthcare system in almost all countries in the world [14]. They represent between 60-70% of the health personnel [15]. It is thus important that we assess quality of nursing care we offer in order to improve on it. Patient satisfaction is an important indicator.

For many years, nurses have dictated what is «good» for their patients and how much of it is «good» because the patient is usually entitled to receiving care. To evaluate and improve the quality of care provided, it is of vital importance to investigate the quality of care in the context of healthcare. Patient satisfaction is a significant indicator of the quality of care [5].

1.2. PROBLEM STATEMENT

During the natural course of childbirth, a woman's functional ability is limited and she is unable to control her body's natural physiologic process. The intrapartum and postpartum patients thus rely on the clinical assistance of the nurses and the clinical staff [16].

It is generally said that the primary reason why patients are admitted to the health facility is to receive care that cannot be gotten elsewhere. The major role of the nurse is to care. In our society and in most hospitals, nurses focus on other tasks leaving out the great aspect of care. This is revealed in their attitude towards patients, co-workers and even in the performance of their tasks.

Although special care needs to be given to the woman during and after the delivery periods, with the available resources manpower and time, nurses rather tend to give patients the care they deem worth giving and not necessarily what is required of them to meet the patients' needs. Sub-standard care is bound to be offered. More often than not, the patients' needs are not fully met and this makes some patients not to perceive the care as positive.

1.3. OBJECTIVES OF THE STUDY 1.3.1. General Objectives

To evaluate the quality of nursing care offered during intrapartum and postpartum periods using patients' satisfaction as an indicator.

1.3.2. Specific Objectives

· Evaluate nursing care offered during intrapartum and postpartum periods.

· Assess patient satisfaction with care.

· Identify ways of improving satisfaction hence quality of care.

1.4. RESEARCH QUESTIONS

The following questions were drawn up to respond to the objectives of the study.

? What nursing care is being offered during intrapartum and postpartum periods? ? How satisfied are the patients with the care they receive?

? How can patient satisfaction with care be improved?

1.5. HYPOTHESIS

Patients receiving intrapartum and postpartum care in BRHA are not satisfied with the nursing care they receive.

1.6. PURPOSE OF STUDY

This study is important in measuring and improving the quality of nursing care offered in the maternity service of BRHA. It is anticipated that the findings in this study will aid in:

1. Identifying the quality of nursing care offered during intrapartum and postpartum periods in BRHA.

2. Assessing patient satisfaction with nursing care.

3. Making recommendations on how patient satisfaction can be improved.

1.7. JUSTIFICATION

Numerous study findings indicate that nursing care is the key determinant of patient satisfaction [7]. To improve on the quality of care provided, it is of vital importance to evaluate the care.

Intrapartum and postpartum periods are delicate periods in the life of every woman. It is thus important that optimum care be given to the woman during this period without which complications may arise [17].

Nurses will never know the quality of care they offer until it is being assessed. This study on patient satisfaction, therefore, will provide a means of evaluating the care and will provide a spring board for its improvement.

1.8. LIMITATIONS OF THE STUDY

A number of factors limited the scope of this research project:

A) FINANCIAL DIFFICULTIES.

The lack of financial resources was a great problem, thus making it difficult to get enough information and carry out the research with ease.

B) TIME CONSTRAIN.

Time was also a problem the research had to take place simultaneously with other academic work.

C) INABILITY TO PROVIDE ADEQUATE PRIVACY.

The researcher was unable to provide adequate privacy when the patients were responding to questions. This made it more difficult since some of the responses were influenced by the presence of other patients.

Nonetheless, this study is a necessary preliminary step toward a better patient satisfaction with nursing care not only for those in labour but for all will-be mothers.

1.9. OPERATIONAL DEFINITION OF TERMS

PATIENT: A person receiving medical care.

SATISFACTION: A pleasant feeling which you get when you receive something you wanted or when you have done something you wanted to do.

NURSING: The art and science of assisting an individual, sick or well, by performing

those activities contributing to his/her recovery (or even to a peaceful death), that he/she will perform unaided if he/she had the necessary strength, will or knowledge to do this, in such a way as to gain independence as soon as possible.

CARE: The process of protecting and looking after someone

INTRAPARTUM: The period during labour and delivery

POSTPARTUM: The period following the delivery of the baby to approximately 6 weeks after delivery.

LITERATURE REVIEW

2.0. AN OVERVIEW OF LABOUR, DELIVERY AND POSTPARTUM

A. Introduction

The physiological transition from being a pregnant woman to becoming a mother means an enormous change for each woman both physically and psychologically. It is time when every system in the body is affected and the experience, though unfortunately not joyous for all, represents a major occurrence in the woman's life [17].

According to the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG), labour is a sequence of uterine contractions that results in effacement and dilatation of the cervix and voluntary bearing-down efforts leading to the expulsion per vagina of the products of conception. Delivery is the mode of expulsion of the foetus and placenta [18].

The puerperium, or postpartum period, generally lasting 6-12 weeks is the period of adjustment after delivery when the anatomic and physiologic changes of pregnancy are reversed, and the body returns to the normal non-pregnant state [19].

B. Normal Labour and Delivery

B.1. Physiologic Preparation for Labour [20]

Prior to the onset of true labour, several preparatory physiologic changes commonly occur:

The settling of the foetal head into the brim of the pelvis, known as lightening, usually occurs 2 or more weeks before the onset of labour in first pregnancies.

Braxton Hicks contractions, which are irregular, painless uterine contractions occurring with slowly increasing frequency, during the last 4-8 weeks of pregnancy. They are distinguished from true labour contractions by lack of cervical change in response to such contractions.

Several weeks before the onset of true labor, the cervix begins to soften, efface, and dilate (1-2cm), the mucus plug within the cervical canal may be released as small amount of blood-tinged mucus from the vagina known as bloody show.

B.2. Characteristics of True Labour [21]

These signs are usually indicative that true labour has begun:

1. Regular painful uterine contractions occurring frequently about 3-6 times in every 10-20 minutes.

2. Dilatation of the cervical os.

B.3. Physiology of Normal Labour [22]

Normal labour is a continuous process that has been traditionally divided into three stages for purposes of study: the first, second and third stages.

· The first stage of labour, further subdivided into the latent, active and transitional phases, is the interval between the onset of labour and full cervical dilatation.

· The second stage is the interval between full cervical dilatation and delivery of the baby.

· The third stage of labour is the period between the delivery of the baby and the delivery of the placenta.

B.3.1. First Stage of Labour:

The duration of the first stage of labour in primiparous patients is noted to range from 6-18 hours, while in multiparous patients the range is reported to be 2-10 hours. The lower limit of the normal for the rate of cervical dilatation during the active phase is 1.2 cm per hour in first pregnancies and 1.5 cm per hour in subsequent pregnancies.

The latent phase is prior to the active phase and last 6-8 hours. The cervix dilates from 0 to 3-4cm. The length of the cervix shortens from 3cm to less than 0.5cm long.

The active phase begins when the cervix is about 4cm dilated and ends at full dilatation (10cm).

The Transitional phase is from 8cm dilation until expulsive contractions are felt by the woman.

B.3.2. Second Stage of Labour:

The second stage generally takes from 30 minutes to 3 hours in primigravid women and from 5-30 minutes in multigravid women. The median duration is 50 minutes in primipara and 20 minutes in multipara.

The transition period between the first and second stage is marked by more frequent contractions and often server pain. Symptoms are increased in bloody show and a feeling of pressure on the rectum accompanied by a desire to bear down with each contraction. The descent of the fetus also called the station, is evaluated to assess the progress of labour. It is done by measuring the relationship of the bony portion of the foetal head with respect to the maternal ischial spines. According to ACOG, when the bony portion of the foetal head is at the level of the ischial spines, the station is ¹¹0¹¹.

The mechanism of labour in the vertex position consists of engagement of the presenting part, flexion, descent, internal rotation, extension, external rotation, and expulsion of the baby in this chronological order.

B.3.3. Third Stage of Labour:

This is the stage of separation and expulsion of the placenta and its membranes. It usually last for 2 hours in primigravids and 1 hour for multigravids. Separation of the placenta generally occurs within 2-10 minutes by the end of the second stage, but it may take 30 minutes or more to spontaneously separate.

Signs of placental separation are:

v' A fresh gush of blood from the vagina.

v' The umbilical cord lengthens outside the vagina.

v' The fundus of the uterus rises up.

v' The uterus becomes firm and globular.

When these signs appear, it is safe to place traction on the cord. The gentle traction, with or without counter-pressure between the symphysis and fundus to prevent descent of the uterus, allows delivery of the placenta.

C. The Postpartum Period (Puerperium)[23]

The puerperium consists of the period following the delivery of the baby and placenta to approximately 6 weeks postpartum and further classified as:

- Immediate Postpartum 4 Birth to 24 hours

- Early Postpartum 4 24 hours to 1 week

- Late Postpartum 4 1 week to weeks

The immediate postpartum period is a critical time for both maternal and neonatal physiologic and emotional adjustment. It is during this time that most postpartum complications occur.

C.1. Different phases of postpartum [17]

The postpartum period has three phases:

· «Taking in» phase: During the taking in phase, which is within the first 24 hours after delivery, physical recovery occurs. The mother is passive and dependent needing to be mothered herself. She is fatigued after the hard work of labour and needs nourishment, rest and sleep. However, she also needs her baby so that the attachment phase can continue.

· Following the taking in phase, the woman goes through the «taking hold» and «letting go» phases. It has generally been accepted that these phases last 3 to 14 days each. In the «taking hold» phase, the woman gains control over her body and assume her independence and autonomy. In the letting go phase, the woman establishes new maternal role patterns.

C.2. Postpartal Systemmic Adaptations

A comprehensive nursing assessment is based on a sound understanding of the normal physiologic process of puerperium:

C.2.1. Uterine Changes

1. Uterine Involution.

The uterus increases markedly in size and weight during pregnancy (about 10 times the non-pregnant weight, reaching a crude weight of about 1000 g) but involutes rapidly after delivery to the non-pregnant weight of about 50 to 100 g at an average rate of 1cm/day.

Patient Satisfaction with Intrapartum and Postpartum Nursing Care: Buea Regional Hospital Annex.

Immediately following delivery, the uterus weighs about 1 kg, and its size approximates that of a 20-week pregnancy (at the level of the umbilicus). At the end of the first postpartum week, it normally will have decreased to the size of a 12-week gestation and is just palpable at the pubic symphysis. During involution, the size of the cells decrease markedly but there is no decrease in number. The outermost layer becomes necrotizing and is sloughed off in lochia. Proteolytic enzymes promote autolysis except at the placenta site [24]. Involution usually causes myometrial contractions or after pains and last three weeks. Breastfeeding increases such contractions due to further release of oxytocin. Mothers might need a first class analgesic.

2. Changes in fundal position.

Following expulsion of the placenta, the uterus contracts firmly to the size of a large grape fruit. Walls of the uterus are about 4 to 5 cm in diameter. After birth, the top of the fundus remains at the umbilicus for about half a day. On the first day following birth, the fundus is 1cm below the umbilicus. The top of the fundus descends 1cm or a finger breath per day until it descends into the pelvis about the tenth day [17].

3. Lochia .

One of the unique capabilities of the uterus is its ability to rid itself of the debris and remains after delivery. This discharge, termed lochia is classified according to its appearance and content:

v' Lochia rubra is dark red in color persisting for 2-3 days and contains erythrocytes,
epithelia cells, leukocytes, bacteria, lanugo and occasionally fetal meconium [10].

v' Lochia serosa is pinkish to brownish. It flows from about the 3^rd day to 10^th day composed of serous exudates shreds of decidual erythrocytes, leukocytes, cervical mucus and numerous micro-organisms.

v' Lochia Alba is composed of primary leukocytes, decidual cells, epithelia cells, fat cervical mucus, cholesterol crystals and bacteria [10].

Lochia has a stale musty odour which is not offensive.

4. Cervical changes.

Following birth, the cervix is spongy, flabby and formless. It appears bruised but the original form of the cervix is regained within a few hours. The cervical os admits two fingers for a few days following birth but only one finger by the end of the first week. Change of shape of the os is permanently changed by child bearing [24].

5. Uterine Vessels

Successful pregnancy requires a massive increase in uterine blood flow. To provide for this, arteries and veins within the uterus, and especially those of the placental site, enlarge remarkably, as they transport blood to and from the uterus. Within the uterus, growth of new vessels also provides for the marked increase in blood flow. After delivery, the caliber of extra uterine vessels decreases to equal, or at least closely approximates that of the pre pregnant state. Within the puerperal uterus, larger blood vessels are obliterated by hyaline changes which are gradually resorbed, and replaced by smaller ones.

C.2.2. Vaginal and Perineal Changes

Following birth, the vagina appears oedematous and may be bruised. Lacerations may be present and rugae obliterated. The site of vagina decreases and rugae returns to normal within 3 weeks. Soft tissue in and around the perineum may appear oedematous with some bruising.

C.2.3. Mammary glands

After birth, the inter play of maternal hormones leads to the establishment of milk production at the level of the mammary glands of the breasts. This occurs through a series of mammogenesis (cellular multiplication at the start of pregnancy) and lactogenesis (cellular differentiation by the end of pregnancy).

Rapidly increasing Progesterone levels causes secretion of prolactin, which in turn causes milk letdown to be effective within the first (24-48) hours after delivery. Such breasts are usually swollen, tender and febrile on touch.

Colostrum flows for about 5 days, which gradually becomes converted to full milk by the 4^th week.

C.2.4. Weight Loss

In addition to the loss of about 5 to 6 kg due to uterine evacuation and normal blood loss, there is usually a further decrease of 2 to 3 kg through diuresis. Most women approach

their self-reported pre-pregnancy weight 6 months after delivery but retain an average surplus of 1.4 kg

C.2.5. Urinary System

The postpartal woman has an increased bladder capacity, swelling and bruising of the tissue around the urethra, decreased sensitivity to fluid pressure hence at risk of over distention and incomplete emptying. Urinary output increases during early postpartum due to puerperal diuresis [25].

C.2.6. Gastro-Intestinal System

Hunger following birth is common and the mother may enjoy a light meal. Frequently, she is thirsty and will drink large amounts of fluid. Bowels tend to be sluggish after birth because of the lingering effects of progesterone and decrease abdominal muscle tone [17].

C.2.7. Changes in Vital signs

During the postpartum period, with the exception of the first 24 hours, the woman should be afebrile. Blood pressure should remain stable and within normal range following birth. Puerperal bradycardia with rates of 50 to 70 beats per minute commonly occurs during the first 6 to 10 days [26].

C.2.8. Others

Temporal amenorrhoea within 6-12 weeks in 100% of non-breastfeeding mothers, and about 36 weeks in 70% of mothers carrying out effective breastfeeding.

Ovulation occurs only after 40 days for non-breastfeeding mothers and may extend right up to 6 months for breastfeeding mothers due to the inhibitory effect of prolactin on FSH through a negative feedback mechanism.

Hypercoagulability due to triggering of the intrinsic pathway by thromboplastin, massively released in the course of placental detachment. This poses a high risk of thromboembolic complications within the first 3 weeks following delivery.

C.3. Postpartal Psychological Adaptations

C.3.1. Depression

It is common for a mother to exhibit some degree of depressed mood a few days after delivery. This situation, termed postpartum blues, describes a transient period of

depression that occurs in most women during the first week or two after birth. It is manifested by mood swing, anger, weepiness, anorexia, difficulty sleeping and a feeling of letting down. It is likely the consequence of a number of factors:

v' The emotional letdown that follows the excitement and fears that most women experience during pregnancy and delivery.

v' The discomforts of the early puerperium.

v' Fatigue from loss of sleep during labour and postpartum.

v' Anxiety over her capabilities for caring for her infant after leaving the hospital. v' Fears that she has become less attractive.

In the great majority of cases, effective treatment need be nothing more than anticipation, recognition, and reassurance. This mild disorder is self-limited and usually remits after 2 to 3 days, although it sometimes persists for up to 10 days. Should postpartum blues persist or worsen, a careful search should begin for symptoms of major depression, which can occur in almost 20 percent of puerperal women [24].

C.3.2. Maternal Role

During the first two days, the woman turns to be positive and somewhat dependent. Maternal role attainment therefore is a state whereby the woman learns about her behavior and becomes comfortable with her identity as a mother [17].

Although post partum period is a time of many physiological and psychological changes, the stressors, they are usually considered good and are not unhealthy [27].

C.3. Postpartum Complications

Several factors can hinder the normal physiological and psychological puerperal evolution. Such complications greatly account for the geometrically increasing maternal mortality in a developing country like Cameroon from:

v' 430 deaths/100.000 in 1990

v' 669 deaths /100.000 in 2000

1' 1000 deaths/100.000 in 2010 [EDS 2010 (national statistics and demographic data)] Maternal mortality according to WHO is the death of a woman when she is pregnant, in labour or within the 42 days following termination of the pregnancy due to obstetrical induced causes [28]. These values are relatively quite explosive, with a woman dying each minute due to pregnancy complications [29].

These postpartum complications are:

1. Postpartum Haemorrhage: This is the leading cause of maternal mortality (24.8%) and noticed in 5% of total pregnancies worldwide [30]. It is defined as excessive bleeding greater or equal to 500ml following a per vagina delivery. It is termed «severe» if values exceed 1000ml. Possible aetiologies include:

v' Persisting uterine atony (70-90)%.

v' Obstetrical genital lacerations (cervical, vaginal and perineal tears).

v' Retention of placental debris.

v' Others (retention of the entire placenta, haemorrhagic endometritis, uterine inversion, uterine rupture, coagulopathies such as DIVC).

2. Infection: Second leading cause of maternal mortality after bleeding

(14.9%) [30]. The most common infectious causes of puerperal fever include:

v' Endometritis usually due to premature rupture of membranes.

v' Urinary infections (pyelonephritis).

v' Breast pathologies (lymphangitis, galactophoritis).

3. Pre-eclampsia / Eclampsia: Third major cause of maternal mortality

worldwide (12.9)% and 25% of all eclampsia occurs during postpartum[30]. Pre-eclampsia is a diastolic blood pressure greater or equal to 90mmHg measured 4hours apart (or 110mmHg in a unique measurement) associated with a proteinuria of (0.3-5) g/l within 24 hours and occurring at a gestational age at 20 weeks and above. Eclampsia is simply pre-eclampsia associated with tonico-clonic convulsions [31].

4. Thrombo-embolic diseases: Usually are caused by hypercoagulability.

Favourable factors include age (above 40 years), multiparty, obesity,

dystocia or difficult labour, underlying cardiac pathologies and past history of thromboembolic diseases. The most common manifestations are pelvic phlebitis, superficial and deep venous thrombosis.

5. Anemia: Usually occurs following hemorrhage. However, could also be Pre-existent. Characterized clinically by cutaneous-mucosal pallor of the conjunctivae, gums, tongue, palates, palms of the hands and soles of the feet. Biologically, it is a hemoglobin level less than or equal to 10 g/dL in pregnancy.

Patient Satisfaction with Intrapartum and Postpartum Nursing Care: Buea Regional Hospital Annex.

6. Puerperal Psychosis: Psychic disorders usually during the late postpartum. About (1- 2)/1000 women who deliver suffer from postpartum blues which when severe can lead to delirium, mania, depression and other schizophrenic states [10]. Suicidal thoughts are not uncommon.

7. Puerperal Neuropathiess Characterised by nervralgia, cramps and

Sometimes paralysis of the femoral and obturator nerves.

8. Spontaneous Symphysiotmy: This refers to a disjunction of the pelvic bones at the pubic symphysis following delivery. Clinically it is painful and normal function is impaired. On an x-ray, there is a lateral luxation of the pubic symphysis as shown below.

Figure 1:

An abdomino-pelvic x-ray (front view), showing a disjunction of the pelvic bones following a

Lateral luxation

2.1. NURSING CARE AND RESPONSIBILITIES

A. Introduction

The unique function of a nurse is to assist an individual, sick or well, by performing those activities contributing to his/her recovery (or even to a peaceful death), that he/she will perform unaided if he/she had the necessary strength, will or knowledge to do this, in such a way as to gain independence as soon as possible [26].

In general obstetric nursing care, the objectives are aimed at reducing maternal and neonatal mortality through a careful follow-up during labour and delivery, as well as prevention and management of eventual complications during the postpartum period

Therefore understanding the role of nursing care during these periods is integral.

B. Nursing role during labour and delivery

The goal of nursing care during the birth process is to instill maximum physical and emotional wellbeing of both the woman and the foetus. This goal includes the transition of woman to mother and foetus to baby [32].

To implement proper care, the nurse must be familiar with normal physiology of labour, deviations from the norms and adjustments, self-confidence and skill required to cope with the stressful and emergency conditions. However, knowledge and technical ability are not sufficient in themselves the nurses must also address the psychological aspect of care by conveying warmth and empathy [33].

B.1.) On Admission

First impressions are vivid [26]. Parturients and their partners need to feel welcomed.

· The nurse greets them in a calm and pleasant manner.

· The patient is taken into the labour ward for assessment and evaluation, together with her belongings (delivery accessories, baby's wears)

· The nurse helps the patient undress and gets into hospital gown.

· The patient is made comfortable and may lie in the left lateral decubital position.

· The labour ward needs to be tidy, well lit and airy enough to accommodate patient and
her husband. Room kept at comfortable temperature levels between (37.8 - 40) ^oC.

· A warm blanket placed over the patient and one wrapped around her feet are very comforting.

· The nurse then develops a rapport and establishes the nursing database, comprising of a concise patient obstetrical and medical history.

· After obtaining essential information from the patient, the nurse may then begin intrapartal assessment and evaluation [32].

B.2.) Intrapartum Clinical Assessment and Evaluation

B.2.1. Nursing Management of First Stage of Labour [33]

· First the vital signs are taken and noted. These include: temperature, blood pressure, pulse rate, respiratory rate. At this time, the foetal heart tones are auscultated using a foetoscope (normal foetal heartbeats of (140-160)/min.)

· Anthropometric measurements are equally taken and noted. These are: corporal weight, height, abdominal girth, fundal height (FH) from which the estimated foetal weight (EFW) can be derived using Steven Johnson's formula [35]:

Figure 2: Estimated Foetal Weight

EFW = I 155 x (FH - n) + 275 ]g

Where : n = 12 if head is not engaged n = 11 if head is engaged FH = Fundal height EFW = Estimated Foetal Weight (normal) = (2.500 - 3.800)g

· A clean-voided midstream of urine specimen is collected and a dipstick test rapidly conducted for proteins, ketones and glucose [25].

· Number of uterine contractions is noted every after 10 minutes while simultaneously appreciating the intensity and duration of each contraction. In specialized centres a cardio-tocogram is preferable used to monitor the effects of such contractions on the

foetal heartbeats. This is an essential element in the assessment of materno-foetal wellbeing.

· Aseptic vaginal exams are done after every 2 hours using a pair of sterile gloves and an antiseptic solution to assess the cervix, the presenting part and the membranes.

· At a cervical dilatation of 4cm, 2-4 regular contraction in 10 minutes each lasting 40-60 seconds; a partogram should be opened. This vital tool is of imperative significance as it effectively detects dystocic labour (obstruction and cephalo-pelvic disproportion) as well as acute foetal distress. It also sets landmarks (the alert and action lines) where an intervention must be carried out to guarantee materno-foetal wellbeing. Such interventions could be induction of labour mechanically or pharmacologically, augmentation of labour, assisted delivery by forceps or vacuum extractor, an emergency cesarean section [33].

· Cervical assessment is better evaluated using the Bishop Scoring system as shown below: [35]

Table 1: The Bishop Scoring System

SCORE FACTOR	0	1	2		3	Dilatation (cm)
0	1 - 2	3 - 4	> 5		Effacement (%)
30	40 - 50	60 - 70	> 80		Station
-3	-2, -1	0	+1, +2		Cervical Consistency
firm	medium	soft			Cervical Position
posterior	median	anterior

· A bishop score <7/13 requires that labour should be stimulated using mechanical or pharmacological methods.

· If patient has not had child education classes, the latent phase is time when the nurse can have anticipation guidance, teaching on breathing techniques to cope with such contractions. Breathing techniques can promote relaxation of abdominal muscles and

Patient Satisfaction with Intrapartum and Postpartum Nursing Care: Buea Regional Hospital Annex.

increase size of the abdominal cavity lessening discomfort during contraction of uterine wall.

· Dietary intake must be limited to sips of clear fluids and ice chips at frequent intervals. Cleaning of the mouth with toothbrush or glycerin swabs help to counteract the dry and thirsty sensations of the mouth.

· IV fluids may be ordered to counteract dehydration and provide energy. An infusion of 500ml of 5% Dextrose, or 500ml of Hartman's solution depending on the indication is administered to keep veins open.

· Analgesia may be administered during a well-established contraction if the patient is not to give birth within the next 1 to 2 hours. If analgesia is administered the patient must remain in bed for safety [24].

· The patient is advised to void at least every 2hours. If patient is not on IV medications, or the presenting foetal part not engaged or membranes not ruptured, she has bathroom privileges otherwise she uses a bedpan. A foley's urinary catheter may be used in case of inability to void [45].

· Showers or bed baths may be taken depending on progress of labour. Allowing warm water to strike lower part of the back may be very relaxing

· A cleansing enema may be ordered on admission because some women experience loose stools prior to active labour.

· If the amniotic membranes have not ruptured previously, they may be ruptured artificially as a mechanical means of inducing labour. The time of rupture, colour and odour of the amniotic fluid is taken and noted. Note that this is accompanied by a continuous monitoring of predicting parameters of maternal and foetal wellbeing [25].

B.2.2 Nursing Management of Second Stage of Labour [31]

· Nurse provides comfort and support during the patient's pushing effort and encourages her to push harder and not let any breath out or to put all her effort into the push and not into making noise.

· When the patient feels an uncontrollable urge to push (bear down), the nurse can help by encouraging her positioning.

· Most patients respond positively to touch in labour. They appreciate deft, gentle handling by the staff. The patient's awareness of the soothing qualities to touch changes the labour process and many patients develop hyperesthesia during labour.

· Breathing techniques are used to increase abdominal pressure thus assisting in expelling the foetus.

· It is important to note that tension and fear are part of the cycle of pain and everything possible should be done to reduce it. This includes giving information both before and during labour .

· Constant presence is vital. Words of praise, comfort, encouragement and reassurance will vary from nurse to nurse [35].

· Mobility and positions for labour: The freedom to move and adopt different positions is an important way of helping women to cope with the pain of labour and may aid progress [35].

· Distraction is another means of increasing relaxation and coping with discomfort. During early labour, light cards or other games may serve as distraction.

· Time of birth is noted. Baby's birth weight, cranial perimeter, brachial and thoracic perimeters, and the APGAR score are noted.

· Immediately after birth, the care given focuses on assessing and stabilizing the newborn. As the head is being delivered, suctioning of the baby is done. Moist gauze sponges are used to wipe the nose and the mouth.

· Where the baby is placed should be warm, hygienic, vitamin K is administered for hemostasis. Gentamycine eye drops given as prophylaxis against neonatal conjunctivitis. The clamped umbilical cord is cleaned with alcohol and covered with sterile gauze.

· Brief assessment of the baby can be performed when the mother is holding the baby. This includes checking baby's airway.

· Baby should be dressed in the appropriate baby's wears as fast as possible to minimize hypothermia.

· To ensure correct identification the nurse gives the mother matching identification bands in the delivery room.

·

To enhance attachment, breastfeeding can be encouraged if the mother and the baby desire.

· While waiting for signs of placental separation, the nurse gently palpates the uterus to check for ballooning caused by uterine relaxation and subsequent bleeding into the uterine cavity [22].

B.2.3. Nursing Management of Third Stage of Labour [25]

This process is an active one due to the high risk of haemorrhage involved. It is therefore usually referred to as Active Management of Third Stage of Labour (AMTSL) divided into 7 well-defined stages.

1. Firstly immediately after expulsion of the baby, verify absence of a second foetus by palpating the abdomen.

2.

Figure 3:

Active Management of third satge of labour.

A patient here is being injected intra-muscularly with 4ml of 10 I.U. Syntocinon.

Secondly, administer 10 IU of Oxytocin intramuscularly as shown below.

Figure 5: Examination of the placenta.

This midwife is inspecting the shiny amnion making sure it is intact.

3. Thirdly, wrap the maternal umbilical cord around the clamp and wait for the next uterine contractions as shown below:

4.

Delivering the placenta by continuous traction on the umbilical cord.

Figure 4:

Exercise continuous traction on the umbilical cord 45^o below the horizontal to prevent detachment from the placenta, meanwhile also continue applying a counter pressure against the uterus pushing it upwards and 45^o above the horizontal.

5. After delivery of the placenta, massage the uterus.

6. Examine the placenta, as shown below:

In examining the placenta, check both the maternal and foetal faces. In the maternal face: - Look out for calcifications whether there are blood clots, fibrosis etc.

- Inspect the membranes for missing portions.

- Examine the cotyledons (16-18 irregular lobes of connective tissue separated by septa formed during placentogenesis) .

In the foetal face:

- Check if the shining amnion is intact.

- Inspect the blood vessels embedded in the chorion

- Carefully check for proper insertion of the umbilical cord.

· Finally weigh the placenta, which is usually 1/6^th the weight of the foetus ( 500g). The Nurse disposes of the placenta according to the wish of the mother. Women usually carry it home and dispose of it according to their custom [25].

· Lacerations are repaired or episiotomies sutured. The vulva area is gently cleansed
with warm sterile water or normal saline and sterile pads applied to the perineum.

· The nurse should record the following information about the delivery of the placenta. Exact time, whether it was delivered spontaneously, which side of the placenta presents.

· Examination of cervix, perineum cleaned, woman's gown changed and woman placed comfortably to rest.

· Following the delivery, the woman might feel chilled and shake uncontrollably. She should be covered with a warm blanket to provide warmth.

· Nurse should note reaction of the mother and help her to adjust.

C. Nursing role during the postpartum period

After delivery, both the mother and the baby will have health concerns that need to be addressed attentively. Although pregnancy is considered to be wellness oriented, the nurse needs critical thinking skills to provide safe, high quality nursing care [31].

C.1. Immediate postpartum care [23]

The first four hours after delivery is a critical period. Postpartum haemorrhage is most likely to occur. Thus the following should be done [25].

1. Check blood pressure every 15 minutes for 1-2 hours until it is stable, then every 4- 12hours.

2. Check uterine fundus, lochia and episiotomy alongside vital signs.

3. Check signs of haemorrhage.

4. Monitor for bladder distention and record first voiding.

5. Monitor interaction with infant. If signs of bonding are not present, determine possible aetiology: pain, complication, or psychological instability.

6. Relieve discomfort in an oedematous perineum, distended bladder, perineal lacerations, vaginal haematoma, and engorged breasts.

7. Avoid leaving patient alone.

C.2. Subsequent Care [31]

· Provide a quiet and comfortable environment for the mother.

· Check breast, fundus, lochia, stitches if present, bladder, bowels and legs at least once every shift .

C.2.1. Perineal care.

· Teach patient perineal care using a Sitz bath .

· Teach patient how to use perineal pads, anaesthetic sprays or ointments for relief of pain.

· Teach patient how to contract her buttocks when sitting to prevent complications [26]. C.2.2. Voiding

· Check voiding patterns if patient's urethra or bladder is traumatized may be by a fistula, catheterization should be done.

· Teach patient how to void every several hours to keep her bladder empty. C.3. Breast care .

· Assess conditions of patient's breast and nipples for redness, ulcerations and firmness.

· Teach patient how to wash her breasts and nipples with warm water and avoid removing the protective skin oil.

· Teach patient how to wear brassieres or breast binders that provide good support day and night .

· Lactation suppressants may be given to non-breastfeeding mothers.

· Check breasts for signs of engorgement, (swollen, tender, shiny breast tissue) for engorged breasts, use hot compress to improve comfort, express some milk, a mild analgesic to improve comfort.

· Teach patient ideal positioning for breastfeeding.

· Teach patient the importance of breastfeeding, making sure she knows the advantages of effective breastfeeding:

v' It is costless in monetary terms.

v' It is always available.

v' It is rich in immunoglobulins A and hence prevents infections.

v' It contains nutrients in their correct proportions.

v' It is being stored under ideal temperatures.

C.4. Care of baby.

Complete clinical examination of the mother is important in order to know her state.

C.5. Newborn care.

· A newborn physical assessment is done at least three times within the first 12 hours of life.

· Verify notification of baby.

· Thermoregulation may be maintained by skin to skin contact, using a warm blanket and radiant warmer.

· Teach mother about infant stimulation techniques, signs and symptoms in the infant that indicate possible problems, baby's bath and cord care [25].

· The mother's wellbeing is inter-dependent with that of her baby as they adjust to
multiple physical cognitive and psychosocial changes during the puerperium period.

2.2. PATIENT'S PERCEPTION OF NURSING CARE (PATIENT SATISFACTION)

There exist scientific ways of measuring health care quality [34].

These tools have mostly been used by health professionals to review and improve the quality of care they provide.

A reliable indicator is by means of information gotten from the patients or an operational process that is converted into a rate, percentage or time that shows how well providers are taking care of their patients. Quality measures give information about how well providers care for some but not all of their patients. Quality care enhances patient's satisfaction and their use of services.

It is known that the nursing profession has only recently began to look at what the term caring really means [5]. In current care environments, the measurement of patients satisfaction defined by some investigators as patient's perception of quality of care has become important as hospitals compete for patients and struggle to control cost.

Nursing care has been found to be the most important variable influencing overall patient satisfaction. Caring is now viewed as a central component of nursing intervention necessary for cure to take place, the moral and ethical basis of nursing and the essence of nursing [26].

Majority of studies shows that nurses place more emphasis on task dimensions than the affective dimensions. Patients value the affective dimension and want nurses to be kind, friendly, considerate, careful and gentle as well as provide proficient and timely technical skills [33]. Several patient characteristics influence perception of care: age, gender and degree of pain. Male patients focus on physical aspects of care and female patient focus on emotional aspects. Patients in pain need more care [5].

The determination of nursing care effectiveness in improving client outcomes is accompanied through outcome measures [26]. Health care consumers are well able to define the quality of care they receive. The increased emphases on quality improvement in health care agencies bring with it the recognitions that quality is a dynamic costumer perception. Dissatisfaction results when customer expectations are not met.

It is known that patients perceived different levels in terms of quality of care [34]. The quality depends on certain contextual intervening conditions pertaining to the broader environments, perception may thus be considered from four dimensions:

v' The medical technical competence of the caregiver,

v' The physical-technical conditions of the care organizations,

v' The degree of identity-orientation in attitudes and

v' Actions of the caregiver and the socio-cultural atmosphere of the care organization. The nurse-patient relationship according to research sets the tone of care experience and has a powerful impact on patient satisfaction. The patients see how the nurses interact based on their observations. In addition, nurses' attitudes towards their work, co-workers and organizations affect patient and family judgment

If we want to improve quality of care we provide, we must be able to measure the performance; nevertheless health care providers have limited ability to obtain feedback regarding performance in their daily work due to:

? a lack of information system and lack of agreement on how to measure the quality of care.

v' resistance to raise service standards is understandable when nurses perceive leaders as doing too little to remove obstacles to provide excellent health care services. Broken equipment, linen shortages, short staffing, inadequate support in the phase of disrespectful doctors, all of these and more obstacles cause nurses to say «don't pin patient satisfaction on us, we don't have enough support we need to provide the care we want to provide» [8].

METHODOLOGY

3.1. Study design

This was a descriptive study on the outcome using both qualitative and quantitative research methods. A cross section survey was chosen for the study. Systematic random sampling was used for selection of the study participants.

3.2. Study period:

This study was conducted over a period of 4 months (March to June 2009).

3.3. Study site

This study was carried out in the Fako Division of the Southwest Region of Cameroon specifically at the Maternity unit of the Buea Regional Hospital annex.

Figure 6: Sketch diagram of BRHA.

1 2 3

4

5

6

8

8

8

8

9

Legend

1.	Nursery	5.	Toilet and sink
2.	Vestry	6.	Labour room
3.	Nurse's station	7.	Postnatal wards
4.	Delivery room	8.	Bathroom and Toilet

The hospital has various units: the emergency unit, surgical unit, theatre, medical unit, HIV/AIDS and Tuberculosis treatment centers, the maternity, family planning center, the pharmacy and mortuary departments.

The maternity unit of this hospital was used for the study. It is a first referral unit of choice, made up of a variety of staff : Doctors, Nurses, and support staff. It is headed by a Head of Personnel. (see organigram of hospital below)

Financial Unit

Pharmacy

Personnel

Head of Stores accountant Unit

Director of medical

Services Assistant

HIV/AIDS and TB
Centers

Surgical Unit Emergency Unit

Maternity Medical Unit

Board of
Directors

Family Planning
Center

Head of
Personnel

Administrative
Unit

Figure 7. Organigram of the BRHA

3.4. Study population

Women in the maternity ward who are receiving postpartum care after delivery in the Hospital. The questionnaire was in the English language and was self-administered. Illiterate patients had the questionnaire read and translated to them in pidgin and the responses were indicated by the researcher.

3.5. Sampling method

The sampling method used was systemic random sampling. Women present in the ward who had been delivered of their babies at least one day ago either per vagina or emergency caesarian sections were served the questionnaire

3.5.1. Inclusion criteria

Women who put to birth per vagina or through emergency caesarian section and had been in the ward for at least 24 hours were included in the study.

3.5.2. Exclusion Criteria

Women who did not meet the above criteria were excluded from the study.

3.6. Sample size

We chose a convenient sample size of 37 including all age groups.

3.7. Data collection procedure

The main tool for data collection was a self-administered questionnaire. Before data collection was done, a letter of authorization was collected from the Dean of the Faculty of health sciences, University of Buea. Questionnaires were then administered from the 23^rd of April to the 12^th of May 2010.

3.7.1. Validity of the instrument

The questionnaire was pretested in Mount Mary maternity. Some questions were then modified or reformulated to adapt to the local conditions.

3.7.2. Data Entry and Analysis

Data was entered and analyzed using Microsoft Excel 2010 and the Statistical Package for the Social Sciences, SPSS version 14.0. Descriptive statistics including frequency, means, percentage and standard deviation were employed. The results were presented in tables, pie charts and bar charts.

3.8. Ethical considerations

v' Informed consent.

v' Respondents were given a verbal consent before the questionnaires were administered to them.

v' Confidentiality and privacy

v' Respondents remain anonymous and respect given to their privacy.

v' All information collected was kept by the researcher until presentation.

3.9. Budget

This project took an estimated cost of 150.000 CFA francs.

PRESENTATION AND ANALYSIS

OF RESULTS

Patient Satisfaction with Intrapartum and Postpartum Nursing Care: Buea Regional Hospital Annex.

4.0 Introduction

The results of this study have been presented per objective for easy and logical discussion in this chapter.

4.1 Socio-Demographic Data

This involves age distribution, parity status, educational level, marital status, profession and the number of days spent in the maternity.

Figure 8: Age Group Proportions

[16;20[ [20;25[ [25;30[ [30;35[ [35;37[

27.00%

2.70%

Proportions

35.00%

30.00%

25.00%

20.00%

15.00%

10.00%

5.00%

0.00%

18.90%

32.40%

18.90%

Age Groups (years)

4.1.1. Age distribution Table 2: Distribution according to Age.

Age Groups (years)	Mean Age (x)	Frequency (f)	Proportion	f(x)
[16;20[	18	7	18.9%	126
[20;25[	22.5	12	32.4%	270
[25;30[	27.5	7	18.9%	192.5
[30;35[	32.5	10	27.0%	325
[35;37[	36	1	2.7%	36
Total		37	100%	949.5

The greatest proportion of the population (32.4%) is between the age group of (20 and 25)
with a mean age of 25.7

4.1.2. Levels of Education

Table 3: Distribution according to Levels of Education.

Levels of Educations Frequency Proportions

None 1 2.9%

FSLC 16 47.1%

O/L 6 17.6%

A/L 4 11.8%

1st Degree 5 14.7%

DIPES I 1 2.9%

CEP 1 2.9%

Total 34 100%

2.90%

47.10%

17.60%

14.70%

11.80%

Figure 9: Proportions by Level of Education

2.90% 2.90%

None FSLC O/L A/L

DEGREE DIPES I CEP

Majority (47.1%) of the population were FSLC holders.

4.1.3. Professional Distribution

Table 4: Distribution according to Profession.

PROFESSION Frequency Proportions

Accountant 1 2.9%

Applicant 2 5.7%

Business 3 8.6%

Hair dresser 5 14.3%

House wife 10 28.6%

Secretary 2 5.7%

Seamstress 3 8.6%

Student 6 17.1%

Teacher 3 8.6%

Total 35 100%

28.6%

30.0%

25.0%

20.0%

17.1%

14.3%

15.0%

8.6%

.6%

8.6%

10.0%

5.7%

5.7%

2.9%

5.0%

0.0%

Proportions

Figure 10: Professional Distribution

Low and no income earners constituted the majority with house wives making up 28.6% of
the total population.

4.1.4. Marital Status Distribution

Table 5: Distribution according to Marital Status.

Marital status Frequency Proportion

Married 25 67.6%

Single 12 32.4%

Total 37 100%

Figure 11: Marital status

32.40%

67.60%

Married Single

A greater proportion of the population (67.6%) were married. 4.1.5. Number of days spent at Maternity

Table 6: Distribution according to Number of days spent at Maternity.

Number of days Frequency Proportion

1 9 24.3%

2 8 21.6%

3 or more 20 54.1%

Total 37 100%

24.30%

54.10%

21.60%

Figure 12: Duration of Hospitalisation

1 day

2 days

3 days or more

A majority (54.1%) spent 3 or more days in the hospital.

Patient Satisfaction with Intrapartum and Postpartum Nursing Care: Buea Regional Hospital Annex.

4.1.6. Distribution according to Parity Table 7: Distribution according to Parity.

PARITY Frequency Proportion

Primipares 17 45.9%

Multipares 20 54.1%

Total 37 100.0%

Figure 13: Parity Distribution

54.10%

45.90%

Primipars Multipares

54.1% of the participants were multipares.

4.1.7. Mode of Delivery Table 8: Distribution according to Mode of Delivery.

MODE OF DELIVERY Frequency Proportion

Normal delivery 24 64.9%

Emergency C/S 13 35.1%

Total 37 100%

Figure 14: Mode of Delivery

Normal delivery Emergency C/S

64.90%

35.10%

64.9% of the participants delivered per-vagina

4.2. Intrapartum Nursing Care Assessment 4.2.1. Nurses' Attitude on Admission

Table 9: Distribution according to Nurses' Attitude on Admission.

Attitude Frequency Percentage

Friendly and welcoming 31 83.8%

Not very welcoming 2 5.4%

Unwelcoming 4 10.8%

Total 37 100%

Majority (83.8%) said nurses were friendly and welcoming.

4.2.2. Nursing Comfort Measures

Table 10: Distribution according to Nursing Comfort Measures.

Comfort and Support? Frequency Proportion

YES 23 63.9%

NO 13 36.1%

Total 36 100%

Comfort Measure Frequency Proportion

Placing hand in anus 2 8.3%

Words of comfort 16 66.7%

Back rubs 1 4.2%

Medications 2 8.3%

Sensitisation 1 4.2%

Cautioning 1 4.2%

Prayer and counsel 1 4.2%

Total 24 100%

Most patients (63.9 %) benefited from comforting measures and among them 66.7%
received words of comfort and encouragement.

4.2.3. Breathing Techniques Taught

Table 11: Distribution according to Breathing Techniques Taught.

Received Teachings? Frequency Proportion

YES 20 60.6%

NO 13 39.4%

Total 33 100%

60.6 % received teachings on breathing techniques.

4.2.4. Environmental Hygiene

Table 12: Distribution according to Environmental Hygiene.

Environment Frequency Proportion

Clean 34 94.4%

Unclean 2 5.6%

Total 36 100%

Majority (94.4%) affirmed that the maternity was clean.

4.2.5. Time spent with patients

Table 13: Distribution according to Time spent with patients.

Time accorded? Frequency Proportion

YES 28 87.5%

NO 4 12.5%

Total 32 100%

How often if YES? Frequency Proportion

At regular intervals 11 39.3%

On emergency 4 14.3%

During examination and drug administration 13 46.4%

Total 28 100%

87.5% of the patients acknowledged that time was spent with them during labour and
46.4% of this time was spent during examinations and drug administration.

4.2.6. Interpretation of Patients' feelings

Table 14: Distribution according to Interpretation of Patients' feelings.

Interpretation? Frequency Proportion

YES 13 40.6%

NO 19 59.4%

Total 32 100%

A lesser proportion (40.6%) of the respondents had the interpretations of their feelings
while 59.4% of them did not have.

4.3. Postpartum Nursing Care Assessment 4.3.1. Monitoring Vital signs

Table 15: Distribution according to Monitoring Vital signs.

Vital signs checked? Frequency Proportion

YES 24 64.9%

NO 13 35.1%

Total 37 100%

How often if YES? Frequency Proportion

Regularly every 5 mins 2 9.1%

Every 30 mins 5 22.7%

Once a day 9 40.9%

Twice a day 5 22.7%

Immediately after delivery 1 4.5%

Total 22 100%

A majority (64.9%) had their vital signs checked and 40.9% of such checks were done just
once daily.

4.3.2. Patient Education

Table 16: Distribution according to Patient Education.

Topic Taught Frequency Proportion

Genital care 9 24.3%

How to breast feed 6 16.2%

How to care for baby's cord 3 8.1%

How to bathe/care for baby 5 13.5%

Feeding 11 29.7%

Hygiene 5 13.5%

Total 39 100%

Proportions

30.00%

25.00%

20.00%

15.00%

10.00%

0.00%

5.00%

24.30%

Figure 15: Patient Education

16.20%

8.10%

Topics Taught

13.50%

29.70%

13.50%

Education was mostly given on feeding (29.7%).

4.3.3. Examination of Baby

Table 17: Distribution according to Examination of Baby.

Baby examined? Frequency Proportion

YES 10 27.0%

NO 27 73.0%

Total 37 100%

How often if Yes? Frequency Proportion

At least once every shift 4 40%

Once a day 6 60%

Total 10 100%

Most babies (73.0%) were not examined postpartum. For the few who were examined 60%
of such examinations was once daily.

4.3.4. Examination of Mother

Table 18: Distribution according to Examination of Mother

Mother examined? Frequency Proportion

YES 18 48.6.0%

NO 19 51.4%

Total 37 100%

Checks performed Frequency Proportion

Amount of bleeding 18 48.6%

Breast examination 11 29.7%

Genitals 5 13.5%

Conjunctiva 17 45.9%

Fundal height 11 29.7%

More than half of the population never had any checks at all, and among such checks, 48.6%
was monitoring the amount of bleeding.

4.4. Assessment of Patient Satisfaction

4.4.1. Rating during Intrapartum (using the Likert's Scale)

					Table 19: Rating during Intrapartum
RATING		Mean Value			Frequency		Proportion
Very good		1			34		20.2%
Good		2			71		42.3%
Fair		3			42		25.0%
Poor		4			21		12.5%
Total responses					168		100%
RATING	Ability to give Information (%)		Care and Concern (%)	Skills and Competence (%)		Restful Atmosphere (%)		Coordination of Care (%)
Very good	14.7		18.9	24.2		18.8		25.0
Good	35.3		35.1	48.5		46.9		46.9
Fair	20.6		35.1	21.2		28.1		18.8
Poor	29.4		10.8	6.1		6.3		9.4
Total	100		100	100		100		100

Proportion

40.0%

60.0%

50.0%

30.0%

20.0%

10.0%

0.0%

14.7%

Ability to give
Information

35.3%

20.6%

29.4%

Figure 16: Rating during Intrapartum

18.9%

35.1%

Care and
Concern

35.1%

10.8%

24.2%

Skills and
Competence

48.5%

21.2%

6.1%

18.8%

Restful
Atmosphere

46.9%

28.1%

6.3%

25.0%

Coordination
of Care

46.9%

18.8%

9.4%

Very good Good

Fair

Poor

A greatest proportion of the respondents (42.3%) indicates that the nursing care was good, that is; 35.3% for good nursing ability to pass on information, 35.1% for good nursing care and concern, 48.5% for good nursing skills and competence, 46.9% for a good restful atmosphere and coordination of care. Thus giving a Mean value of 2.3 and a standard deviation of (ä=0.9).

4.4.2. Rating during Postpartum(using the Likert's Scale)

			Table 20: Rating during Postpartum
RATING			Mean Value		Frequency		Proportion
Very good			1		10		7.1%
Good			2		48		34.0%
Fair			3		30		21.3%
Poor			4		53		37.6%
Total responses					141		100%
RATING	Information given (%)	Nursing attention (%)		Responsiveness to calls (%)		Reliable services (%)		Recognition of opinions (%)
Very good	0.0%	11.1%		9.9%		6.9%		3.9%
Good	20.0%	30.6%		46.7%		41.4%		26.9%
Fair	10.0%	25.0%		16.7%		17.2%		34.6%
Poor	70.0%	33.3%		26.7%		34.5%		34.6%
Total	100%	100%		100%		100		100%

46.7%

34.6%

34.6%

Proportion

70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

80.0%

70.0%

20.0%

10.0%

0.0%

30.6% 33.3%

25.0%

11.1%

26.7%

16.7%

9.9%

41.4%

34.5%

17.2%

6.9%

26.9%

3.9%

Information given Nursing attention Responsiveness to

calls

Reliable services Recognition of

opinions

Very good Good Fair Poor

Figure 17: Rating during Postpartum

A majority of the respondents (37.6%) indicated that the postpartum nursing care was poor, that is; 70% for poor nursing ability to communicate, 33.3% lacked nurses' attention and 34.6% of patients' opinions were not recognized. However, for the 34.0% who rated the care given as good, 46.7% had good response to calls and 41.4% for good reliability of nurses to perform their services. Thus giving an overall Mean value of 2.9 and a standard deviation of (ä=1.0).

4.5. Patients' Recommendation of the Maternity

The respondents made recommendations solely based on the nursing they received.

		Table 21: Patients' Recommendation of the Maternity
Recommendations		Mean values Frequency	Proportion
Strongly agree	1	9	25.0%
Somewhat agree	2	19	52.8%
Somewhat disagree	3	4	11.1%
Strongly disagree	4	4	11.1%
Total		36	100%

Strongly disagree

Strongly agree Somewhat agree Somewhat

disagree

Figure 18: Patients' Recommendations

52.8%

60.0%

50.0%

Proportions

40.0%

25.00%

30.0%

20.0%

10.0%

0.0%

11.10% 11.10%

A majority of the respondents (52.8%) somewhat agreed to recommend the Maternity to their family members and friends. Hence giving an overall Mean value of 2.1 and a standard deviation of (ä=0.9).

4.6. Patients' Opinion on how satisfaction can be improved.

The chart below represents various ways on which patient satisfaction can be improved based on the patients' perspective.

Table 22: Patients' Opinion on how satisfaction can be improved.

PATIENT'S OPINION		Frequency	Proportion per Individual	Proportion on total answers
Authorities should sanction stubborn nurses		1	3.4%	1.7%
Bathe babies and improve on child care policy		10	34.5%	16.7%
Be more comforting and caring		7	24.1%	11.7%
Be more friendly, polite and truthful		11	37.9%	18.3%
Be understanding, respectful and collaborate with patients		7	24.1%	11.7%
Improve on mother care policy		15	51.7%	25.0%
Improve on hygiene and mend toilets		3	10.3%	5.0%
Improve on number of nurses for rapid intervention		3	10.3%	5.0%
Teach what patients don't know		3	10.3%	5.0%
TOTAL		60		100%

DISCUSSION, CONCLUSION AND

RECOMMENDATIONS

5.0. Introduction

From the preceding chapters, we have reviewed literature on labour and delivery, postpartum, the nurses responsibilities during these periods and measuring quality of care using patient satisfaction. From the data collected and analysed, the results will be discussed in this chapter related to the above sub topics. Discussion therefore is on demographic data, nursing care offered during intrapartum and postpartum periods, and patients satisfaction with the care given and ways in which patient satisfaction can be improved.

5.1. Discussion of results

5.1.1. Choice of study area

Our study area was the Buea Regional hospital Annex, it was chosen because it is acting as a teaching hospital and is expected that the care given to the patients here should be standard. Also it acts as a referral point for health centers patients coming from all over, it is relatively cheaper thus receives more people than any other health service in the Buea locality. Assessing patients' satisfaction will help to improve the nursing care in this great unit of the hospital.

5.1.2. Socio-Demographic Findings

The mean age was 26 with the most represented age group being 20-25. This could possibly be justified by the fact that the most fertile period in a woman's life is when she is between 22-30 years old. The mean age for the study population falls between this age group.

Majority of the population (47.1%) had FSLC as their highest level of education with most of them being low income earners. 34.3% of them (housewives and applicants) had nothing doing. The study population was made up of people with low level of education and low social class because the more educated and better placed people prefer to go to other healthcare providers in or out of town. Many participants (17.1%) were students.

A greater proportion of the study population constituted married women while (32.4%) were single. The high rate of sexual activity during the late teenage and early adolescent ages as well as increased sexual promiscuity nowadays could possibly account for the high proportion of single mothers in this study.

54.1% were multipars while 45.9% were primipars. Though most of them 64.9% had their babies per vagina, a high percentage (35.1%) had their babies through emergency caesarian section. The fact that the hospital is a central referral unit could probably account for this.

Most of the patients (54.1%) had spent more than three days in the hospital. This could be explained by the fact many patients so desired to voluntarily prolong their stay.

5.1.3. Nursing Care Findings

A) During Intrapartum.

According to the data collected, it could be seen that most of the women, 83.8% were welcomed in a friendly manner. This implies that the nurses in this unit generally are soft and have a warm attitude towards their clients. This addresses the psychological aspect of care since knowledge and technical ability only are insufficient [33].

Concerning provision of comfort, a majority 63.9% said the nurse provided them with comfort measures this shows that the nurses here have some concern and empathy for their patients. With most of them giving words of comfort, 8.3% were given analgesics and another 8.3% said they had anal touch which made them feel more comfortable.

Most of the patients received teachings on how to breathe in and push. Though this is mostly done in the antenatal clinics it is important to do it in the labour ward as this is an important aspect in the management of labour [31].

94.4% said the maternity was clean and once again highlights the importance of environmental hygiene in nursing care.

As for the time spent with patients, 46.4% said nurses spent time with them during emergencies or when called, 39.3% said nurses spent time with them during drug administration while only 14.3% said nurses spent time with them at regular intervals. This demonstrates that the nurses are hardly always by their patients and so only see them when they have a procedure to carry out. This is not a positive nursing attitude since constant presence is very vital [35].

In this study, 59.4% of the respondents said the nurses did not interpret the meaning of their feelings to them and this could possibly explain the high levels of patient dissatisfaction. Conlusively, the nursing care offered during intrapartum is average.

B.) During Postpartum.

In the study, it was discovered that only 64.9% of the women had their vital signs checked after delivery. A great proportion of 45.1% never had their vitals checked. Only 33.6% of the study population had their vital signs checked regularly or 30 minutes after delivery. This is poor nursing practice as the first four hours after delivery is a critical period and vital signs are an important indicator of adverse changes [25].

From this survey it was observed that postpartum teachings were very poor as more than half of the patients were not taught anything. Only 24.3% had teachings on how to care for their perineum, 16.2% were taught how to breastfeed their babies, 8.1% were taught how to care for the umbilical cord, 13.5% of the population were taught how to bath their babies, 29.7% were taught on good feeding habits and only 13.5% were taught on hygiene. All these show the lack of zeal in postpartum follow-up and care.

After delivery, both the mother and the baby will have health concerns that need to be addressed attentively [31] but from the analysis of the data collected, 73% of the babies were not examined. Of the 27% who said their babies were examined, 60% had their babies examined just once a day. Thus the babies were not being given full attention.

Concerning postpartum checks done on the mothers, 48.6% were checked for bleeding and this proportion is quite small considering the complications of postpartum haemorrhage. A small proportion 29.7% had their breasts examined. This proportion is too small as women who could have breast engorgement or breast infections will not be easily identified and possibly screened for breast cancer [31]. Only 13.5% had their genitals examined. Genital examinations are very important in evaluating postpartal adaptation [23]. Blood loss during the birth process is common and so checking the conjunctivae will be indicative if the woman is anaemic. Paradoxically only 45.9% had their conjunctivae checked. 29.7% of the women were checked for uterine involution which was not enough.

From the above analyses it can be concluded that the mothers and their babies are not well followed up after delivery rendering postpartum nursing care poor.

5.1.4. Patients' Satisfaction with Nursing Care

A.) During Intrapartum.

Five indicators were used to determine patients satisfaction with nursing care: Nurses' ability to inform patients, Nursing concern and care, Nursing skill and competence, A restful atmosphere provided by the nurse and the coordination of care.

In this study, the majority (35.3%) rated the nurses ability to pass on information as good, 20.6% as fair ,24.9% as poor and 14.7 % as very good. This implies that the majority were fairly satisfied with the information they received. This is a true picture because if we relate it to the information they were given during this period, most of them (60.6%) were taught breathing techniques as seen on Table 11 and many of them (40.6%) did not have explanations of what they were going through as shown on Table 14. From the suggestions the patients gave, the attitude of the nurse or mode of passing on the information too could be a factor which will rate the information as being fairly satisfactory.

For Nursing care and concern, an equal majority 35.1% rated it good and fair (fairly satisfied and fairly unsatisfied) while 10.8% were unsatisfied. Summarily, more people (54%) were fairly satisfied .This could be explained by the fact that many women (63.9%) were given comfort measures during the pain and difficulty they went through. (See Table 10)

As concerns the skill and competence of the nurse, a majority rated it good meaning that they were fairly satisfied. Also a large proportion (24.2%) rated it very good implying that they were satisfied with the nurses' skill. From the nursing care given, majority said the nurse was there to administer their medications and respond to emergencies. This is in line with most studies which indicate that the nurse focuses on tasks [33].

Most respondents rated nurses' ability to provide a restful and quiet atmosphere as being good. This is justified by the 94.4% of the patients who acknowledged that the labour ward was clean as shown on Table 12.

For coordination of care, most of the respondents (46.9%) rated the teamwork spirit of the nurses as good, 25.0% as very good, 18.8% as fair and 9.6% as poor. This brings us to the conclusion that the respondents were fairly satisfied with the coordination of care.

A Likert's scale was drawn for the six points and the Mean value gotten signified that the nursing care was good. This implies that the participants were fairly satisfied with the care they received during the intrapartum period. Hence more effort must be put in so as to fully satisfy the patients.

B.) During Postpartum.

The indicators used were information given to the patients, nurses' attention towards patients, nurses' responsiveness to calls, nurses' reliability to perform services and recognition of the patients' opinion.

As concerns the information given to them, 70% of the population rated it poor. This implies that they were unsatisfied with the information which was given to them. 20% rated it good, 10% fair and no body rated it very good. Their dissatisfaction was due to the fact that little or no information was given to them at postpartum. From Table 16, 29.7% of the population had a teaching on at least one subject among whom only 24.3% were taught on genital care and only 16.2% on breastfeeding despite the fact that 45.9% of the population were primipara with little or no experience on this. A few were taught on how to care for the baby's umbilical cord. 13.5% were taught on baby's care, 29.7% of them were taught on good feeding habits. A majority of them were those who underwent caesarian sections and were restricted from solid meals. This is in line with studies which prove that patients value value postpartum information [7].

From the data collected, 46.7% of the respondents rated the nurses' ability to respond to calls as good. This implies that a good number of the nurses attended promptly to the calls of their patients. Though a good proportion 26.5% said they were unsatisfied with the way the nurses responded to their calls. This implies that most of the patients were fairly satisfied with the nurses ability to respond to calls.

Majority of the patients were fairly satisfied with the nurses reliability to perform services but a large proportion (34.5%) were dissatisfied with the nurses' reliability. 17.2% were fairly unsatisfied with the nurses reliability. A minority (9.9%) were satisfied with the reliability (see Table 20). From this, we could conclude that the respondents were fairly satisfied with the nurses' reliability.

For nurses involvement of the patients to the care, it was generally unsatisfactory as 34.6% graded their involvement as poor and 34.6% graded it as fair . Very few of the patients (26.9%) rated their involvement as good and a small proportion (3.9%) were satisfied with their involvement. From a recent undefended thesis , more patients want to participate though the nurses do not encourage them [38]. This is could certainly account for their unsatisfaction.

Patient Satisfaction with Intrapartum and Postpartum Nursing Care: Buea Regional Hospital Annex.

From the data collected and analyzed , a Likert's scale was developed and the mean value gotten which was approximately 3 and was considered fair. This implies that most of the respondents were fairly unsatisfied with the care offered at postpartum.

5.1.5. Patients' Recommendation of the Maternity service

The patients were asked if they will recommend the maternity based solely on the nursing care which they had received. The mean value gotten corresponded to a majority who somewhat agree to recommend the maternity to their family members and friends. This anchors the fact that the respondents were generally fairly satisfied with the nursing care provided.

5.1.6. Ways to Improve Patient Satisfaction

In the opinion of the respondents, in order to increase patient satisfaction with nursing care, nurses should improve on patient education, mother and child care policy, comfort, care and understanding measures. This is similar to a research done by Lomoro and collaborators in 2002 on improvement of quality of care where emphasis were laid on health education on childcare.

5.1.7. Testing of Hypothesis

Testing of hypothesis depends on the data that was collected. The hypothesis reads «Patients receiving intrapartum and postpartum care in BRHA are not satisfied with the nursing care they receive.»

From the data collected, it is evident that the participants were fairly satisfied with the intrapartum nursing care and unsatisfied with postpartum nursing care. Overall, they were fairly satisfied with nursing care and thus, the hypothesis is valid.

Patients will be more satisfied if nurses can employ measures to reinforce postpartum care.

5.2. Conclusion

For most women, intrapartum is usually a time of excitement, anticipation, anxiety fear and pain while postpartum is a time for physiological and psychological adjustment for both the mother and her baby. The nursing care offered to them should be one which is safe, positive and satisfying to the mother.

From the research, participants were fairly satisfied with the care offered to them during intrapartum. This is because the nurses were generally friendly and welcoming, patients were taught breathing exercises, were supported and provided with a clean environment. Contrarily, participants received minimal care offered during postpartum and were therefore dissatisfied. The overall patient perception with the nursing care offered by this maternity service was fairly satisfactory.

The participants further suggested that in order for their care to be more satisfactory, nurses should improve on the information they give their patients, their attitude towards patients and the zeal for their work.

Nursing care should thus be improved on in order to improve patients satisfaction.

5.3. Recommendations

v' Nurses in this unit should have refresher courses for the care of their intrapartum and postpartum patients so that they will be able to increase their knowledge on proper care of these patients.

v' The hospital should implement regular checks on the nursing care given to patients that the nurses will have a sense of duty consciousness.

v' Studies on patient satisfaction should be done in the other units of the hospital so that a global change is done to improve care in this hospital.

v' Government should recruit qualified staff to ensure quality care is given to patients.

For further research

1. Factors responsible for the low quality of nursing care offered during postpartum.

1. W.H.O. Basic Document. 1992. 39^th edition.

2. Mollas Donaldson. Measuring the Quality of Healthcare. 1999. National Academy Press Washington D.C.

3. Page L.A. The new midwifery science and sensitivity practice. 2000. Churchill Livingston Imprint of Elvier Ltd.

4. Shields Donna. Nursing Care in Labor and Patient Satisfaction, a descriptive study. Journal of Advanced Nursing, 1999. 3(6) 535-50.

5. Guzzetta Cathie E. Essential Readings in Holistic Nursing. 1998. Aspen publishers.

6. Lisa P. Patient compliance and satisfaction with nursing care during delivery and recovery. Journal of Advanced Nursing, 2002. 16(2) 60-66.

7. Lin C. Patient satisfaction with nursing care as an outcome variable dilemma for Nursing evaluation researchers. Journal of Professional Nursing, 1996. 12(4) 207-216.

8. Newhouse R., Poe S. Measuring Patient Safety. 2005. Jones & Barlette Publishers, London.

9. Janet C. Perception of childbirth experience and its relationship to early postpartum parenting. Journal of Advanced Nursing, 1999. 8 (10) 1257-1264.

10. Bryatin J. Women's perception of Nursing support during labor. Journal of Obstetrics & Gynaecology and Neonatal Nursing, 2006. 23(8) 638-44.

11. Peterson W.E., Sward W., Charles C. Adolescents' perception of inpatient postpartum Nursing Care, a qualitative health research. 2007.

12. www.indexmude.com

13. W.H.O. Department of making pregnancy safe. 2004. 39^th edition.

14. Woodward C.A. Strategies for Assisting Health workers to modify and improve skills. 2000. Oxford university press, New York USA.

15. W.H.O. Developing World has acute shortage of health workers. 2007.

16. Perla T. Patient compliance and satisfaction with care during delivery and recovery. Journal of Nursing Care Quality, 2003. 10(8) 56-60.

17. Philips Celeste. Family centered Maternity care. 2003. Jones & Barlette Publishers, London.

18. American Academy of Pediatrics and the American College of Obstetricians and Gynecologists: Guidelines for Perinatal Care, 5th ed. 2002. Washington, DC, AAP and ACOG.

19. American College of Obstetricians and Gynecologists Committee Opinion No. 267: Exercise during pregnancy and the postpartum period. 2002. 99:171. ACOG.

20. Bernal AL: Overview of current research in parturition. 2000. 86:213.

21. Kilpatrick SJ, Laros RK. Characteristics of normal labor. 1989. 74:85, [PMID: 2733947]

22. Cohen W, Friedman EA (eds). Management of Labor. 1983. Baltimore, University Park Press.

23. Mayerhofer K, Bodner-Adler B, Bodner K, et al. Traditional care of the perineum during birth: A prospective, randomized, multicenter study of 1,076 women. Journal of Reproductive Medicine, 2002. 47:477, [PMID: 12092017].

24. Berman Mimi Cohen C. Obstetrics and Gynaecology, 2^nd ed. 1997. Lippincot Williams & Wilkins Company Ltd. publishers U.S.A.

25. Simpson K.R., Creehan P.A. Perinatal Nursing, 3^rd ed. 2008. Lippincot Williams & Wilkins Company Ltd. publishers U.S.A.

26. Delaune, Suc C., Lander P.K. Fundamentals of Nursing Standards and Practice. 1998. Delmar publishers, U.S.A.

27. Hobfol S. E. Stress, Social support and Woman. 1986. Hemisphere publishing corporation.

28. UNICEF/OMS/FNUAP. Guidelines for Monitoring the Availability and Use of Obstetric Services. 1997. UNICEF: New York.

29. FNUAP et AMDD. Reducing Maternal Deaths: Selecting Priorities, Tracking Progress, Distance Learning Courses on Population Issues. 2002. Turin: UN System Staff College.

30. W.H.O. Standard classification of hypertensive disorders in Pregnancy. 2003.

31. Littleson V. Lynna, Engebretson Joan C. Maternity Nursing Care. 2009. Plengane Learning Publishing Corporation, Canada.

32. Rosdah C. B. , Kowalsi M. Textbook of basic Nursing, 9^th ed. 2008. Lippincot Williams & Wilkins Company Ltd. publishers U.S.A.

33. Dujardin B, De Schampheleire I, Sene H, et al: Value of the alert and action lines on the partogram. 1992. Lancet 339:1336, [PMID: 1350000]

34. Williams A.M. Quality measurement. Journal of Advanced Nursing, 1998. 27(4) 808-816.

35. Corbett C.A., Callister. Nursing support during labor. Clinical Nursing research. 2000. 9(1) 70-83.

36. Bryatin J. Womens' perception of Nursing support during labor. Journal of Obstetrics & Gynaecology and Neonatal Nursing, 2006. 23(8) 638-44.

37. Merlyn D. Harris. Handbook of Home Health care administration. 2005. 4^th ed. Jones & Barlette Publishers International Barbhouse, London.

I am Chwinui Mbeinkong, a final year nursing student of the department of nursing in the University of Buea. I am carrying out a research on patient satisfaction with nursing care offered during and after labour and delivery. The information required from you is strictly for academic purposes. I will be very grateful if you make an effort to answer each question honestly. All information will be treated with confidentiality. Thanks for your cooperation

Please put a tick ( ? ) where necessary or fill the blanks where appropriate.

Section A. Socio-demographic Data

1) Age:

2) Educational level: FSLC O/L A/L Degree

others

3) Marital status:

4) Profession:

6) How many days have you been in the hospital? 1 2 3 or more

8) How many times have you been pregnant? ....................................

9) Mode of delivery: Normal vaginal Caesarean section

Section B. Nursing care

? During Labour and Delivery

1) How did the nurse treat you on admission?

A) Friendly and welcoming B)not very welcoming C) unwelcoming

2) Nurse provides comfort and support during pain and discomfort? YES NO

If yes what did she do?

4) Were you taught how to breathe and how to push? YES NO

6) Were you provided a clean environment? Yes NO

8) Did the nurse spend time with you in the labour ward? YES NO
If yes, how often?

At regular intervals On emergency During examination

10) Did the nurse help you to interpret the meaning of your feeling and showed concern?

YES NO

Dear Respondent,

7) Were your vital signs checked immediately after delivery? YES NO
If yes, how often?

Regularly, every 5mins. Every 30mins. Once daily twice daily.

? After Labour and Delivery

APPENDIX 1: DATA ENTRY FORM

		Figure 19

1) Information: how clear and complete were the nurse's information about what you were going through?

2) Concern and caring by the nurses: Courtesy and respect, friendliness and kindness?

3) Skills and competence of the nurse: How well were things were done?

4) Restful atmosphere provided by the nurses: Amount of peace and quietness?

5) Coordination of care: team work between the nurses and other staff?

II. After Delivery

6) Information given: Concerning breast care, perineal care, breast feeding?

7) Attention of nurses to your condition: how often did the nurses checked on you?

8) Nurse's responsiveness to calls: How quick were they to respond to your calls?

9) Reliability to perform promised services

10) Recognition of your opinion: how much you were involved (participated) in decision making?

Section C. Patient Satisfaction

Please rate some things about the nursing care offered during your hospital stay in terms of whether they were very good ,good, fair or poor.

I. During labour and delivery Very

Good Good Fair Poor

8) Which of the following topics did the nurse teach you on?

Genital care

How to breast feed

How to care for baby's cord How to bathe/care for baby

Feeding Hygiene Others

10) Did the nurse come around to examine (physical assess) the baby? YES NO

If yes, how often?

At least once every shift once a day more than twice a day

12) Which of the following checks did the nurse do?

Amount of bleeding Breast examination Genitals

Conjunctiva

Height of uterus Others

Based on the nursing care I Strongly Some what Some what Strongly

Will recommend this maternity agree agree disagree disagree

To my family and friends

Section D. Possible ways of improving patient satisfaction patients

In your opinion, perspective what should the nurses do in order to improve the quality of care and make you more satisfied.

THANK YOU!!!

APPENDIX 2: CONSENT FORM