Maternity Case Study

7/27/2019 Maternity Case Study

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1.2 Statement of the problem

"Problem statement expresses the dilemma or disconcerting situation that

needs investigation and incorporate a rationale for a new inquiry ".

(Polit& Beck 2010, page 150)

Deputy Ministry of Health Malaysia announce in The Star (Saturday 29

October 2011) that Malaysians are the fattest in Asia. The most important

issue here is 43.7% of these people are aged over 18 years old. This is very

distressing because they belong to reproductive age, furthermore among

them might be woman who is pregnant.

Although data from the Mingguan Malaysia (15 Julai 2012: Ruangan

Kesihatan) stated that obesity in Penang was ranked 14th out of 15th state

in Malaysia which means Penang is sparsely populated state with obesity.

However, researchers decided to do research in Maternity Hospital Pulau

Pinang because this condition is still not fully resolved yet. Researchers

observed there are still many pregnant women with obesity come for follow-

up or delivery. Among them, we still experienced the problems during

pregnancy and at birth even though there is efficient and effective midwifery

care together with medical services.

Table 1: Percentage and rank of obesity within state in Malaysia 2011


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Researchers strongly believe that maternal obesity is a condition which

should be taken into serious consideration and preventive measures should

be carry-out to avoid any complications that may occur. Researchers hope

with the findings from this research, it would be beneficial the pregnant

women and maternity care and services.


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1.3 Significant of the research

The important or significant of this research can be divided into several

groups namely, the significant interest to pregnant woman, midwife and

Ministry of Health (MOH).

1.3.1 Significance to mother

The finding from our research will contribute to the principles of risk

management theories thus help to improve the health status of maternal

obesity at the maximum level and detect any abnormalities so that early

treatment can be given to help reduce the morbidity (safe motherhood).

1.3.2 Significance to midwives

The benefices from this research can reduce the adverse outcome toward

mother and fetus. Adequate midwife especially in Klinik Kesihatan can

continue the personal life care programme with more intensive care and

effectiveness. Besides that, the proper effective communication or

consultation regarding balanced diet can be given. Therefore, the obstetric

outcome problem can be reduced efficiently.

1.3.3Significance to Ministry Of Health

The significant outcome to our Ministry of Health Malaysia is to prepare a

better strategy for health care of pregnant mother during pregnancy. It can

help our government to achieve its goals in implementing Millennium

Development Goal (MDG) 4 and Millennium Development Goal (MDG) 5.


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1.4 Purpose / objective of the research

1.4.1 General objective

General objective from this study is to explore the impact of women with high

pre-pregnancy body mass index (BMI) and the obstetric outcomes.

1.4.2 Specific objective are:

1) To describe the social demographic status of the study sample.

2) To determine effect of maternal obesity on obstetric outcome.

3) To identified if there is any relationship between demographic data and

obstetric outcomes.

1.5 Research questions

1.5.1 What are the social demographic characteristic of the study sample?

1.5.2 What are the complications that happen to mother and neonatal if

pregnant women suffering from obesity?

1.5.3 Is there any relationship between demographic data and obstetric

outcomes?

Study variables

1. Independent variable is women with obesity. It include age, race, parity and

weight at first booking.

2. Dependent variable is obstetric outcome. It`s divided to during pregnancy

such as Hypertension, GDM, Risk Coding (Green, yellow and red). During

labour it included shoulder dystocia, operative delivery, prolonged labour and

perineal tear (1, 2, 3, 4). Neonate is for big baby and Apgar score.


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1.6 Operational definition / definition of term

1.6.1 Impact

~ A powerful effect that something, especially something new, has on a

situation or person.

(Cambridge, International Dictionary of English)

1.6.2 Maternal

~ Pertaining to the mother, especially during pregnancy or shortly after

childbirth.

(Bailliere`s Midwives Dictionary, 2008)

1.6.3 Obesity

~ Excessive development of fat throughout the body, increase in weight

beyond that considered desirable with regard to age, height and bones

structures obesity can affect physical and mental health.


~ Obesity is defined by the excessive accumulation of fat which can be

measured using the body mass index (BMI) with a BMI above 27.5 kg/m2.

(Ministry of Health Malaysia)


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1.6.4 Maternal obesity

~ Maternal obesity (defined as obesity during pregnancy) increases health

risks for both the mother and child during and after pregnancy.

(World Health Organization 2009)

~ Maternal obesity is defined when mother with BMI more than 23.0 kg/m2.

(Ministry of Health Malaysia)

1.6.5Obstetrics

~ The branch of medicine that concern management of women during

pregnancy, childbirth, and the puerperium.


1.6.6 Outcome

~ The condition of a patient at the end of therapy or a disease process,

including the degree of wellness and the need for continuing care,

medication, support, counselling, or education. The result of an action.

(Cambridge, International Dictionary of English)


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1.7 Limitations of the study

According to our research in Maternity Hospital Pulau Pinang, there are

several disadvantages regarding information such as weight measurements

of pregnant women. This happened because of the Maternity Hospital Pulau

Pinang not take the mother's body weight measurements during admissions.

This flaw will make our research cannot identified the rates of obesity that

occured among pregnant women in Maternity Hospital Pulau Pinang.

However, we are determined to continue this study by taking the relevant

data that we were already mentioned in problem statement.


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2 CHAPTER 2: REVIEW OF THE LITERATURE

2.1 Introductions

High pre-pregnancy BMI is associated with adverse obstetric outcome.

Maternal complications include pregnancy induced hypertension, gestational

diabetes, increased risk of interventions like operative delivery. Perinatal

complications included macrosomia. (Satpathy et al 2008).

2.2 Theoretical groundwork related to research topic

The weight gain for a normal BMI of pregnant woman should be 12.5 kg

throughout the pregnancy. This normal weight gained during pregnancy is

due to the physiology changing and fetus development in the uterus.

Besides that, the weight gained from the mother also affected by the

increasing amount of amniotic fluid, the weight of placenta and oedema at

the end of pregnancy. However this is not the main cause that triggered

maternal obesity.

In Myles Textbook of Midwifery (Fraser & Cooper, 2009), the raise in weight

for the 20 first weeks should be in 0.5 kg in every month and from the 20

weeks onward the weight gain should be 0.5 kg every week.

According to Ismail Mohammad Nor et.al (2002) found in their research that

the terrible diet pattern and lifestyle which is unhealthy is the factor that

influencing the weight gains. This is frequently happen when unbalanced diet

such as fast food like KFC, McDonalds, carbonated drinks and many more

taken incautiously. Furthermore, they also fell within the group who dont

practise exercise regularly which later on will embrace obesity.


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According to Jolly et.al (2003) maternal obesity is independent risk factor of

fetal macrosomia. It is a common adverse infant outcome related to

Gestational Diabetes Mellitus, especially if unrecognized and untreated of

Gestational Diabetes Mellitus. Macrosomia increases the risks of shoulder

dystocia, clavicle fractures, and brachial plexus injury and is also associated

with depressed 5-min Apgar scores and increased rates of admission to

neonatal intensive care unit. Furthermore according to Dixit et.al (2008)

maternal obesity also increase the risk of Hypertension during pregnancy

due to increased risk of caesarean delivery.

Due to the study that was conducted in Penang, our group researcher will

use the BMI calculation as proposed by the Malaysia Ministry of Health

where the reading for the obesity proposed was a BMI which overweight and

obesity. The comparison can be seen on the table 1 and 2 in page 10.


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The table below shows the difference between BMI is recommended by the Health Ministry of M

World Health Organization 2009.

Classification BMI ( kg / m2 )

Underweight < 18.5

Normal Range 18.5 - 24.9

Overweight > 25

Pre Obesity 25.0 - 29.9

Obesity 30.0 - 34.9

Obesity 11 35.0 - 39.0

Obesity 111 > 40

Table 1 : BMI World Health Organization 2009

Classification BMI (

Underweight < 18.5

Normal Range 18.5

Overweight 23.0

Obesity >27.5

Table 2 : BMI Health Ministr


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2.3 Review of previous research

Hypertension is defined as high blood pressure (i.e., repeatedly elevated

blood pressure exceeding 140 over 90 mmHg a systolic pressure above

140 with a diastolic pressure above 90). There were 40 % increased risks of

pre-existing chronic hypertension in pregnant, obese women compared to

normal weight or lean pregnant women. The risk of PIH or gestational

hypertension is significantly greater if the pregnant woman is overweight or

obese (Yogev & Catalano, 2009).

Diabetes mellitus is a group of metabolic diseases characterized by high

blood sugar (glucose) levels that result from defects in insulin secretion, or

insulin action, or both. There are three 45 % increased risk of pre-gestational

diabetes in pregnant, obese women compared to normal-weight or lean

pregnant women (Dietl, 2005). Furthermore, women who are overweight or

obese pre-pregnancy are more likely to develop gestational diabetes mellitus

(GDM) during pregnancy (Reece, 2008).

According to (Guelinckx et al, 2008) the most common effect of maternal

obesity on the mother during labour is an increased risk for caesarean

section with rate for obese pregnant woman was 35.2% as compared to

22.3% of normal weight.


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According to (Arendas et al 2008) infants born to obese women are

significantly more likely to weight at 4000 g or more than 4500 gm. Also a

high prevalence of obesity results from a complex interaction between

changes in the populations lifestyle, involving a higher energy and fat

consumption and an increasingly sedentary existence, the effects of these

changes being particularly severed if the population has an inherited

metabolic predisposition to fatness. (Lewis et al, 2010).


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3 CHAPTERS 3: METHODOLOGY

3.1 Study setting

The study was carried out at the Department of Obstetrics and Gynaecology,

Hospital Pulau Pinang. It is because many obstetric problematic cases are

referred to Maternity Hospital such as maternal obesity.

3.2 Study design

The study designs that is carried out in this study were in form of quantitative

which is non-experimental by observational and cross sectional studies.

3.3 Populations and sample

3.3.1 Population

Populations are pregnant women with BMI 23.0 who received treatment

and delivered in Maternity Hospital Pulau Pinang especially pregnant women

whos treated at third class ward.

3.3.2 Sample and sampling method

A sample of 30 obese women with BMI more than 23.0 were selected using

convenient sampling method. All obese mothers whom delivered at MHPP

especially in third class ward is selected as our sampling.


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3.4 The research instrument

Our research group design a data collection sheet as our research tools. It

divides into 2 sections. In section 1 that is demographic data which consist of

4 items. Section 2 is about obstetric outcome and divides into 2 categories

which include of maternal and obstetric outcome. Researchers have 2

section in maternal outcome it include 3 item during antenatal, 4 item during

labour and 2 item in neonatal outcome section. The data is taken from

Delivery Register

.

3.5 Ethical consideration

We had permission letter from the Head of Department of Obstetrics and

Gynaecology and consent for samples. Approval is obtained from National

Medical Research Register (NMRR) and CDC. All samples were informed

that data emerging from the study is kept confidential, anonymity is assured,

and that they could withdraw from the study without prejudice. All samples

gave their informed consent.

3.6 Procedure for data collections

The 13 items in 2 sections which is written is used as well as data from the

Register Entry of Hospital /Institution PER-PD 101 (Pin.2/2009). Antenatal

card KIK /1(a) / (96), Labour summary which is related to the demographic

data and obstetric outcome during pregnancy and during labour. The data is

collected by our group member. The study is already done in last period of

April to June 2013.


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3.7 Data analysis and interpretations

The data collected is analysed using statistical software which is Trial SPSS

version16. For first objective we use frequency test by measures of central

tendency of demographic data. Then for second objective we use frequency

test by measures of central tendency to measured outcomes. For third

objective we use Chi-square to identify relationship between demographic

data and the obstetric outcomes. The data is analysed and the results of the

study is obtained.


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CONCLUSION

Obesity caused significant complications during pregnancy for the mother and

fetus. Interventions promoting pre-pregnancy weight loss and the prevention of

excessive weight gain during pregnancy must begin in the pre-conception period.

Health care workers need to counsel their obese patient about the risk and

complications by obesity and the importance of weight loss before pregnancy.

Women need to be informed about both maternal and fetus complications.


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4. RESEARCH PLANNING

No

Research activities Nov Dec Jan Feb Mac April May Jun July

1 Preparation of research

proposal

2 Rectify research proposal

3 Present research

proposal and research

application letter

4 Approval by ethics

committees

5 Pilot study

6 Review instrument

7 Data collection

8 Data analysis

9 Write research report

10 Hand in research report

11 Research oral

presentations

12 Research poster

presentations

Table 1: GANTT Chart for completion of research report Advanced Diploma In

Midwifery 2/2012

Appendix 1


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Informed consent form (Versi bahasa)

(Code No. :)

1. Kami pelajar kebidanan di Kolej Kejururawatan Pulau Pinang dan sedangmenjalankan kajian penyelidikan sebagai sebahagian daripada keperluan

untuk kursus kami, Diploma Lanjutan Perbidanan. Kumpulan penyelidikankami terdiri daripada 6 orang;

a) Azmuhaini Binti Musa (Leader)b) Murni Binti Marodzakhic) Nur Izzatul Afizainizam Binti Che Sidekd) Siti Noraini Binti Mustafae) Rohana Binti kamisf) Zurina Binti Abu Bakar

2. Tujuan kajian dijalankan, untuk mengetahui dengan lebih mendalam

mengenai kesan wanita obesity semasa hamil dan obstetric outcome diHospital Bersalin Pulau Pinang. Kita mahu untuk mencari cara yang lebihbaik untuk mengurangkan komplikasi daripada wanita obesity semasa hamil.

3. Anda perlu mengetahui bahawa penyertaan anda di dalam kajian ini adalahdengan cara sukarela. Sekiranya anda ingin menarik diri sebelum atausemasa kajian ini dijalankan adalah dibenarkan.

4. Segala maklumat yang kami perolehi daripada pihak puan akan dirahsiakan.Sebarang maklumat mengenai anda hanyalah mempunyai nombor diatasnyadan bukannya nama anda.

5. Jika anda mempunyai sebarang soalan, anda boleh bertanya penyelidik kamisekarang atau kemudian dan selepas kajian telah bermula. Cadangan initelah disemak dan diluluskan oleh Ketua Jabatan Obstetrik dan Ginekologi.

6. Saya telah membaca maklumat di atas dan saya bersetuju secara sukarelauntuk menyertai sebagai peserta dalam kajian ini.

7. Sekian, terima kasih.

Tandatangan peserta : _____________

Tandatangan penyelidik : _____________

Tarikh : _____________

Appendix 1


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Informed consent form (versi bahasa )

(Code No. :)

1. Kami pelajar kebidanan di Kolej Kejururawatan Pulau Pinang sedangmenjalankan kajian penyelidikan sebagai sebahagian daripada keperluan

untuk kursus kami, Diploma Lanjutan Perbidanan. Kumpulan penyelidikankami terdiri daripada 6 orang;

g) Azmuhaini Binti Musa (Leader)h) Murni Binti Marodzakhii) Nur Izzatul Afizainizam Binti Che Sidekj) Siti Noraini Binti Mustafak) Rohana Binti kamisl) Zurina Binti Abu Bakar

2. Tujuan kajian dijalankan, untuk mengetahui dengan lebih mendalam

mengenai kesan wanita obesity semasa hamil dan obstetric outcome diHospital Bersalin Pulau Pinang. Kami mahu mencari cara yang lebih baikuntuk mengurangkan komplikasi daripada wanita obesity semasa hamil.

3. Anda perlu mengetahui bahawa penyertaan anda di dalam kajian ini adalahdengan cara sukarela. Sekiranya anda ingin menarik diri sebelum atausemasa kajian ini dijalankan adalah dibenarkan.

4. Segala maklumat yang kami perolehi daripada pihak puan akan dirahsiakan.Sebarang maklumat mengenai anda hanyalah mempunyai nombor diatasnyadan bukannya nama anda.

5. Jika anda mempunyai sebarang soalan, anda boleh bertanya penyelidik kamisekarang atau kemudian dan selepas kajian telah bermula. Cadangan initelah disemak dan diluluskan oleh Ketua Jabatan Obstetrik dan Ginekologi.

6. Saya telah membaca maklumat di atas dan saya bersetuju secara sukarelauntuk menyertai sebagai peserta dalam kajian ini.

7. Sekian, terima kasih.

Tandatangan peserta : _____________

Tandatangan penyelidik : _____________

Tarikh : _____________

Appendix 2


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(Versi Bahasa) (Kod No:____)

ADVANCED DIPLOMA IN MIDWIFERY

PENGUMPULAN DATA THE IMPACT OF MATERNAL OBESITY ON

OBSTETRIC OUTCOME IN MHPP

Kepada para pelanggan yang dihormati, diharap Puan dapat meluangkan sedikit

masa untuk menjawab soalan-soalan di dalam borang ini.

Seksyen 1: Demografic Data :-

1. Umur ( Sila isikan )

2. Bangsa ( Sila tandakan di kotak yang berkenaan )

Melayu

Cina

India

Lain-lain

3. Bilangan anak

4. Berapakah berat badan

semasa lawatan pertama ke klinik?

Anak 1

Anak 2

Anak 3 dan seterusnya


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Seksyen 2 :Kesan daripada masalah kegemukan semasa hamil

1. Maternal

During pregnancy YES NO

a) Hypertension

b) Gestational Diabetic Mellitus

c) Risk coding - Green

- Yellow

- Red

During labour YES NO

Shoulder Dystocia

Operative labour

Prolonged Labour

Perineal - Intact

45 kg ke bawah

46 62 kg

63 79 kg

80 kg ke atas


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- 1 tear

- 2 tear

- 3 tear

- 4 tear

2. Neonate YES NO

Baby weight > 4kg

Apgar score

- 7 10

- 6 4

- 3 0

APPENDIX 3


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THE STAR 29 OKTOBER 2011

APPENDIX 4


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THE STAR 29 OKTOBER 2011

APPENDIX 5


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MINGGUAN MALAYSIA 1 /7/2012 RUANGAN KESIHATAN

APPENDIX 6


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UTUSAN MALAYSIA 15/11/2010 RUANGAN KESIHATAN

ARKIB : 15/11/2010

60 peratusrakyat Malaysia gemuk - Menteri

15/11/2010 5:26pm

KUALA LUMPUR 15 Nov. - Tigapuluhperatuspenduduk dinegarainimempunyaiberatbadanberlebihanmanakala 30 peratuslagiobes, kataMenteriKesihatanDatuk Seri LiowTiong Lai.

Beliauberkata, iamerangkumisemuaperingkatumur, manakalajumlahkanak-kanak

yang mengalamimasalahkegemukan pula menunjukkanpeningkatan yangmembimbangkansejakakhir-akhirini.

"Kita perlulihatkesihatanbadantusebagaisesuatu yangpentingkeranaiaadalahpintumasukkepadasegalajenispenyakit yangberpuncadaripadacarapemakanandangayahidup yang kurangsihat.

"Fenomenainimembimbangkankeranaiasecaralangsungberkaitandenganpeningkatanrisikopenyakitseperti diabetes, sakitjantung, buahpinggang, darahtinggi,barahdansebagainya,katanyakepadapemberitaselepasmerasmikanPersidanganAhliLembagaPelawat

Hospital 2010 di sinihariini.

Sehubunganitu, Tiong Lai menggesarakyatsupayamengamalkanpemakanan yangseimbangselainmengamalkangayahidupsihatdenganmelakukanaktivitifizikaltermasukbersenam, berjogingdanbersukan. - Bernama

Artikel

Penuh: http://www.utusan.com.my/utusan/info.asp?y=2010&dt=1115&pub=utusan_

malaysia&sec=Terkini&pg=bt_20.htm#ixzz2NXhaPhQj UtusanMelayu (M) Bhd

APPENDIX 7


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UTUSAN MALAYSIA 6/11/2008 RUANGAN KESIHATAN

ARKIB : 06/11/2008

Ibugemukrisikobayibesar

Susunan ROSMAWATI MION

WANITA perlumengawalberatbadansemasahamil.Sebabnya,jikaberatbadanmerekabertambahsebanyak 18 kilogram (kg)hanyaketikamerekahamil, merekaberhadapandengandua kaligandarisikomelahirkanbayibesarberbandingwanitahamil yang lain.

Menurutkajian yang dilakukanparapenyelidik AS keataslebih 40,000wanitanegaraitudanbayimerekamenunjukkan, satudaripada lima wanita yangbertambahberatbadansecaraberlebihankalahamilmempunyaipeluanglebihbesaruntukmelahirkanbayiseberat 4 kg keatas.

Malah, kajianitujugamendapatiwanita yang bertambahberatbadansebanyak 18 kgsemasamengandunglebihcenderungmempunyaibayibesarwalaupunmerekatidakmenghidapdiabetisgestasiiaitudiabetisjangkapendek yangberkaitdengankehamilandandiketahuimampumenambahkanrisikomelahirkanbayibesar.

Disebabkanterlalubanyakwanita yang bertambahberatbadanlebih 18 kgsemasahamil,

makaamatpentingkesedarankesihatandiberikankepadagolonganwanitadalamusahamengelakkanberlakunyapertambahanberat yang berlebihanitu, kata Dr. Teresa HillierdaripadaPusat Kaiser Permanente untukPenyelidikanKesihatan di Portland, Oregon.

Kajian yang dilakukan TeresadanbeberaparakansekerjanyaitutelahditerbitkandalamjurnalObstetrikdanGinekologi.

Teresa berkata,pertambahanberatbadanberlebihanbukanhanyameningkatkanrisikountukmendapatkanbayibesar, malahbayi-bayimerekaitujugaakanmenghadapimasalahmempunyaiberatbadanberlebihanatauob

esdalamhidupnya.

Menurutpakar-pakarObstetrikdanGinekologi di American College, bayi-bayi yangmempunyaiberatmelebih 4 kg semasadilahirkandianggapbesar.

Bayi yang besarakanberhadapanrisikosukardilahirkan, meningkatkanpeluang vaginaibukoyak, pendarahan,ibuterpaksamenjalanipembedahancaesariandanbayijugamempunyairisikobahunyatersekatdantulangselangkapatahkaladilahirkan.


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Teresa danrakansekerjanyatelahmengkajirekodperubatan 41,540 wanita yangbersalin di Washington, Oregon danHawaidaritahun 1995 hingga 2003.

Semuawanitatersebuttelahmenjalaniujiandiabetisgestasidan 5.4peratusdaripadamerekadirawatkeranamempunyaimasalahtersebutdenganmelakukan

program diet, senamandansuntikan insulinjikaperluuntukmengawalkandunganguladalamdarahmerekasepanjangkehamilan.

Secarakeseluruhannya, kajiantersebutmendapati 20peratusdaripadawanitaberkenaan yang bertambahberatbadansebanyak 18 kg, iaituhad terakhirpertambahanberatbadanketikahamil yang disarankan di AStelahmelahirkanbayibesar.

Jelas Teresa, kurangdaripada 12 peratuswanita yang mempunyaiberatbadan normaldidapatijugamelahirkanbayi yang besar.

Kumpulan berisikotinggiadalahmereka yang bertambahberatbadanlebihdaripada 18kg danmempunyaidiabetisgestasi.Hampir 30peratusdaripadawanitainimelahirkanbayibesarberbanding 13.5peratuswanitadengandiabetisgestasi yang beratbadan normal semasahamil.

Kajianitujugamencadangkansemuawanitaperlumengelakkanberatbadanberlebihanketikahamil.Dan, wanita yangdirawatuntukdiabetisgestasijugaperluberusahamemastikanberatbadanmerekabertambah di bawah 18 kg.

Andatidakbolehmerawatglukosdanmengambilsambillewamasalahpertambahanberatbadan, katanya.

Pertambahanberatbadansemasahamiltelahmeningkatsejakduadekadkebelakanganinidansesetengahpenyelidikmengesyakiiamungkinakanmenyebabkanberlakunyagejalaobesiti di kalangankanak-kanak. - Reuters

Artikel

Penuh: http://www.utusan.com.my/utusan/info.asp?y=2008&dt=1106&pub=utusan_

malaysia&sec=Keluarga&pg=ke_02.htm#ixzz2NXn9TfvV

UtusanMelayu (M) Bhd

REFERENCE


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Castro, L. C. & Avina, R. L. (2002). Maternal Obesity And Pregnancy Outcomes.

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Dietl, J. (2005). Maternal Obesity And Complications During Pregnancy. J.

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Reece, E. A. (2008). Obesity, diabetes, and links to congenital defects: A review of

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Satpathy HK, Fleming A, Frey D, Barsoom M, Satpathy C, Khandaravala J. Maternal

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Maternity Case Study