PRO FORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

SUBMITTED BY:

Ms. ROOPASHREE.S

1STM.Sc (N)

OBSTETRICS AND

GYNAECOLOGICAL NURSING

2012-2013 BATCH.

ORIENTAL COLLEGE OF NURSING,

BANGALORE-560010.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE,

KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR SYNOPSIS

1.

NAME OF THE CANDIDATE AND ADDRESS       

Ms.ROOPASHREE.S, Oriental College of Nursing, #43/52,2ndMain,IndustrialTown, West Of Chord Road, Rajajinagar, Bangalore-10

2.

NAME OF THE INSTITUTION

ORIENTAL COLLEGE OF NURSING #43/52,2nd Main, Industrial Town, West Of Chord Road, Rajajinagar, Bangalore-10

3.

COURSE OF STUDY AND SUBJECT

1st Year M.Sc. Nursing, Obstetrics and gynaecological Nursing.

4.

DATE OF ADMISSION OF THE COURSE

28/06/2012.

5.

TITLE OF THE STUDY

“A correlative study to assess the degree of umbilical cord coiling and its effect on perinatal outcome among newborns in selected maternity hospitals at Bangalore”.

6.

BRIEF RESUME OF THE WORK 6.0 Introduction 6.1 Need for the study

6.2 Review of related literature

6.2.1 Statement of the problem 6.3 Objectives of the study 6.3.1 Operational definitions 6.3.2 Assumptions 6.3.3 Hypothesis 6.3.4 Sampling criteria i) inclusion criteria

ii) exclusion criteria

Enclosed Enclosed Enclosed Enclosed Enclosed Enclosed Enclosed Enclosed

Enclosed

Enclosed

7

MATERIALS AND METHODS

1 Sources of data: Adolescen 7.1. Sources Of Data: Data Will Be Collected From the newborns within one hour of birth, Bangalore. 7.2. Method Of Data Collection: Structured rating scale . 7.3.Does The Study Require Any Investigations Or Interventions To Be Conducted On The Patients Or Other Humans Or Animals?  No 7.4.Has Ethical Clearance Been Obtained From Your Institution? YES. Ethical Committee’s Report Is Here With Enclosed.

8

LIST OF REFERENCES

Enclosed

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1.

NAME OF THE CANDIDATE AND ADDRESS

MS.ROOPASHREE.S

Oriental College Of Nursing

#43/52,2ndmain,Industrialtown, West Of Chord Road, Rajajinagar, Bangalore-10

2.

NAME OF THE INSTITUTION

ORIENTAL COLLEGE OF NURSING #43/52,2nd Main, Industrial Town, West Of Chord Road, Rajajinagar, Bangalore-10.

3.

COURSE OF STUDY AND SUBJECT

1st Year M.Sc Nursing

Obstetrics and Gynaecological Nursing.

4.

DATE OF ADMISSION OF THE COURSE

28/06/2012.

5.

TITLE OF THE TOPIC

“A Study To Assess the Degree Of Umbilical Cord Coiling And Its Effect On Perinatal Outcome Among Newborns In Selected Maternity Hospitals”.

6. BRIEF RESUME OF THE INTENDED WORK

6.0 INTRODUCTION:

“Your unconditional love and your child’s cord blood - a potential lifeline

for the future”.

Birth is a miracle and each baby is life’s perfect creation. Pregnancy is often a time of hope for the future. Process of pregnancy and child birth are very much a personal journey. Each woman experiences the beauty of creating and giving birth to a child.1

In pregnancy umbilical cord is the essential vitalizing direct interlink between a mother and her child, which is always depicted as the relationship and an emotional bonding of motherhood, which is a beautiful experience for a women.2

The umbilical cord is the connecting cord from the developing embryo or fetus to the placenta. During prenatal development, the umbilical cord is physiologically and genetically part of the fetus and normally contains two arteries and one vein, buried within Wharton’s jelly. The umbilical vein supplies the fetus with oxygenated, nutrient-rich blood from the placenta. Conversely, the fetal heart pumps deoxygenated, nutrient-depleted blood through the umbilical arteries back to the placenta.3

The umbilical cord, containing as it does two arteries and a vein, is the supply line that connects the placenta to the fetus. The blood vessels are arranged in a helical fashion resulting in twisting or coiling of the umbilical cord. Both undercoiled and overcoiled cords have been found to be associated with adverse pregnancy outcomes. A coiling index has been devised to quantitate the degree of coiling. This is calculated by counting the number of complete coils of the vessels and dividing that by the length of the cord.4

The umbilical cords of 657 neonates were examined and the coiling index determined by dividing the total number of complete vascular coils by the length of the cord in cm. Obstetrical history, delivery data, and neonatal outcome were also evaluated. The frequency distribution of umbilical coiling index was normal (10 th and 90th percentile and mean +/- SD = 0.17, 0.37,and 0.26 +/- 0.09 coils/cm, respectively). Maternal risk factors for abnormal vascular coiling were extremes of age for hyper-coiling, obesity, gestational diabetes mellitus, and preeclampsia for non-coiling. Hyper-coiled and non-coiled cords were significantly associated with adverse perinatal outcome (p < 0.001) and cesarean delivery (p < 0.0001). Neonates whose mothers are old or young, obese, diabetic, or have preeclampsia are likely to have hyper-coiled or non-coiled umbilical blood vessels.5

6.1 NEED FOR THE STUDY:

The association of hyper coiling (more than 1 coil per 5 cm) and thinning with consecutive constriction of the umbilical vessels (thin cord syndrome; TCS) and intrauterine fetal death (IUFD). 303 cases of consecutive fetal autopsies over a 5-year period, including spontaneous and induced abortions of the 2nd trimester of pregnancy, were examined using a standardized protocol. The mean maternal age was 28.5 years and the mean gestational age was 19.1 weeks (range: 12.6 to 24.5 weeks). 36% of all cases were induced abortions because of congenital malformations. 167 cases (55.1%) were spontaneous abortion specimens. Careful pathologic examination of the umbilical cord is recommended to detect TCS and to reduce the cases with unexplained intrauterine death.6

A study was conducted in Western Bank, Sheffield, S10 2TH, United Kingdom. The umbilical cord is the only communication between the fetus and the placenta and, not surprisingly, lesions or conditions affecting it may have detrimental effects in both. One important feature of the umbilical cord is its coiling index (UCI), with hypo- and hyper coiling being associated with fetal thrombotic vasculopathy, intolerance of labor, intrauterine growth restriction, cord stricture, thrombosis of cord and chorionic blood vessels, and fetal demise.The aim of this study was to compare UCI measured in a segment of cord 10 cm long (UCI-10) and over its total length (UCI-T). 150 consecutive placenta reports in which both measurements were recorded were retrieved from the files and analyzed. Gestational age ranged from 16 to 42 weeks, with a mean of 33.67 ± 5.96 weeks and a median of 36 weeks. Mean UCI-10 was 0.4360 ± 0.2625 coils/cm and mean UCI-T was 0.3530 ± 0.2022 coils/cm; the difference between these measurements was highly statistically significant (P < 0.0001). Counting the number of umbilical cord coils in 10 cm led to an overestimation of the UCI-T by 23.5%.7

A study was conducted in Oakland, USA to measure the normal umbilical coiling index that is one coil/5 cms, i.e., 0.2 +/- 0.1 coils completed per cm. They reported the frequency and clinical correlations of abnormally coiled cords among 1329 cases referred to their placental pathology services. 21% of cords were overcoiled 13% were under coiled. Abnormal cord coiling was seen at all gestational ages. Principal clinical correlations found in over coiled cords were fetal demise (37%), fetal intolerance to labor (14%), intra uterine growth retardation (10%) and chorioamnionitis (10%). For under coiled cords, the frequencies of these adverse outcomes were 29%, 21%, 15%, and 29%, respectively. Abnormal cord coiling was associated with thrombosis of chorionic plate vessels, umbilical venous thrombosis, and cord stenosis. Thus, abnormal cord coiling is chronic state, established in early gestation, that may have chronic (growth retardation) and acute (fetal intolerance to labor and fetal demise) effects on fetal well being. And antenatal detection of abnormal cord coil index by ultra sound could lead to elective delivery of fetuses at risk, thereby reducing the fetal death rate by about one-half.8

A study was conducted in Utrecht, the Netherlands; the aim of study was to review the literature on umbilical cord coiling relevant articles in English published between 1966 and 2003 were retrieved by as Medline search and cross referencing. The normal umbilical cord coiling index (UCI) is 0.17(+/- 0.009) spirals completed per cm. abnormal cord coiling, i.e., UCI <10th centile (<0.07) or >90th centile (>0.30) is associated with adverse pregnancy outcome. Hypo coiling of the cord is associated with increased incidence of the fetal demise, intrapartum fetal heart rate deceleration, and operative delivery for fetal distress, anatomic –karyotypic abnormalities and chorioamnionitis. Hyper coiling cord is associated with increase incidence of fetal growth restriction, intra partum fetal heart rate deceleration vascular thrombosis and cord stenosis.. In the future ultrasonographic evaluation of the umbilical cord and the UCI may become an integral part of fetal assessment in high-risk pregnancy.9

A prospective cross sectional study was conducted in Cornell university New York USA, the purpose of study was to evaluate the sonographic accuracy to determine the umbilical coiling index (UCI) during the routine fetal anatomic survey in the second trimester. In 300 consecutive women with singleton pregnancies and absence of gross fetal anomalies who had a routine second-trimester fetal anatomic survey, a distance between 2 pairs of coils was measured from the longitudinal images of the umbilical cord, and the antenatal UCI (a UCI)was calculated. The a UCI was compared with true UCI results obtained after birth. 236 patients had adequate sonographic umbilical cord images, and all required demographic, antenatal, and labor data collection to meet the inclusion criteria. A statically significant correlation between a UCI and true UCI was found (P<0.0001; r=0.643). The mean a UCI was 0.402(80% confidence interval, 0.382), and the true UCI at birth was 0.203found showed 12.3% and mean (80% confidence interval, 0.176). The sonographic evaluation showed 12.3%and 8.9% of hypocoiled and umbilical cords, respectively. The sensitivity values of sonography to predict hypocoiling and hypercoiling at birth were 78.9% and 25.4%, respectively.10

A prospective cross sectional study was performed in University of Campinas – UNICAMP, Campinas, Brazil and was performed in 221 pregnant women at different gestational ages. The purpose of the study was to evaluate inter- and intra-observer variability in sonographic measurements of the cross-sectional area of the umbilical cord and the diameters of its vessels in low-risk pregnancies of 12 to 40 weeks of gestation. Measurements were carried out also by a second observer to evaluate inter-observer variability and repeated once again by the first observer to assess intra-observer variability. The results showed that inter-observer and intra-observer variability did not show any significant difference between examiners. A good linear correlation between the measurements and reliability was obtained, with values of R, ICC and Cronbach's alpha all above the standard limits. It is possible to conclude that inter- and intra-observer variability in the measurements of the umbilical cord and its vessels was small; their reliability and agreement were good.11

From the above reviews, it is noted that the mothers with complication during pregnancy have greater chance of getting child with certain level of impairment. The extend of impairment depends upon the degree of umbilical cord coiling. Hence the researcher felt that umbilical cord coiling index helps to identify and treat the impairment earliest.

6.2 REVIEW OF LITERATURE

A retrospective study was conducted in Seoul, Korea. 251 pregnancies taken in which a fetal anatomic survey with a recorded UCI was performed at 22-28 weeks gestation. The subjects were divided into normocoiled, hypocoiled, and hypercoiled groups and compared perinatal outcomes. This study was conducted to determine whether or not the umbilical cord coiling index (UCI) during the late second trimester of gestation is associated with perinatal outcomes. 226 patients were included. The incidence of preterm deliveries in hypocoiled group was 35%, which was significantly greater than the normocoiled groups (p=0.041). The incidence of neonates with low birth weights in the hypocoiled group was 36.4%, which was significantly greater than the normocoiled groups (p=0.044). In the hypocoiled group, 27.3% of newborns were admitted to the NICU which was significantly greater than the normocoiled and hypercoiled groups (p=0.041). After the adjustment by logistic regression analysis, only preterm delivery were significantly increased in hypocoiled group (OR=9.6, 95% CI=2.09-44.07).12

A prospective study was conducted by Morteza Tahmazebi and Reza Alighanbari designed to evaluate the relationship of sonographic measurements of umbilical cord thickness, cross-sectional area, and coiling index with pregnancy outcome From January 2010 to January 2011, among 255 singleton pregnant women who were referred for routine pregnancy USG after 20 weeks of gestation, 223 fulfilled the study criteria. In these patients, the diameter, cross-sectional area, and coiling index were measured in a free loop of umbilical cord. The pregnancies were followed till delivery, when birth weight, presence of meconium staining and 5-min Apgar score were recorded. A statistically significant correlation was observed between small umbilical cord thickness and cross-sectional area and low birth weight (LBW), with sensitivity of 52.9% and 57.9%, specificity of 95.0% and 94.4%, positive predictive value of 52.6% and 52.0%, and negative predictive value of 95.0% and 95.0%, respectively. This study examines the value of umbilical cord thickness, cross-sectional area, and coiling index in predicting pregnancy outcome.13

The study was done to know whether abnormal umbilical coiling index is related to adverse perinatal outcomes. 107 umbilical cords were examined and umbilical coiling index was calculated. The outcome measured were intra uterine growth retardation meconium staining, birth weight, apgar score, ponderal index. They concluded that hypocoiled cords were associated with low apgar score, low birth weight and meconium staining.14

The study was done to correlate the perinatal outcome with the umbilical coiling index. About 130 umbilical cords were studied and the umbilical coiling index was calculated by dividing number of coils in the cord by the total length of cord in centimeters. It was concluded that the cords having umbilical coiling index< 5th percentile (hypocoiled cords) were associated with low Apgar score, intrauterine death and small for date babies. The cord with umbilical coiling index of > 95th percentile i.e., hypercoiled were associated with meconium staining, intra uterine growth retardation, low apgar score.15

An Analytical Study was conducted in Puducherry JIPMER Campus, India by T. Chitra, Y. S. Sushanth to measure umbilical coiling index (UCI) postnatally and to study the association of normocoiling, hypocoiling and hypercoiling to maternal and perinatal outcome. 1000 antenatal women who went into labour were studied and umbilical coiling index calculated at the time of delivery. It’s associations with various maternal and perinatal risk factors were noted. The statistical tests were the Chi-square test and assessed with SPSS version 13.0 software and statistically analyzed. P value of less than 0.05 was regarded as statistically significant. The mean umbilical coiling index was found to be 0.24 ± 0.09. Hypocoiling (<0.12) was found to be significantly associated with hypertensive disorders, abruptio placentae, preterm labour, oligohydramnios, and fetal heart rate abnormalities. Hypercoiling (>0.36) was found to be associated with DM, polyhydramnios, cesarean delivery, congenital anomalies, and respiratory distress of the newborn.16

A cohort study was conducted in Japan which included cases with cord abnormalities (314 cases) and without them (487 controls), both of which were delivered in our hospital between June 2005 and December 2006. The relationship between cord abnormalities and the intrapartum fetal heart-rate (FHR) pattern were retrospectively investigated focusing on VD. Analysis of FHR patterns was performed for 30 uterine contractions at the end of the first stage and throughout the whole of the second stage of labor. FHR patterns were analyzed for the presence of VD, atypical and pure VD. The frequency of each FHR patterns per uterine contraction was assessed. The type of atypical VD was diagnosed in sequence as loss of variability during VD, overshoot, slow return of the FHR to the baseline, VD with no acceleration and biphasic deceleration. Pure VD was typical VD without signs of atypical.17

6.2.1 STATEMENT OF THE PROBLEM

“A correlative study to assess the degree of umbilical cord coiling and its effect on perinatal outcome among newborns in selected maternity hospitals at Bangalore”.

6.3. OBJECTIVES

1. To assess the degree of umbilical cord coiling.

2. To assess the effect of umbilical coiling on perinatal outcome.

3. To find the association between the degree of umbilical cord coiling, perinatal outcome

and selected demographic variable.

6.3.1 OPERATIONAL DEFINITIONS

ASSESS - It refers to statistical measurements of umbilical cord coiling by using Umbilical coiling index scale and perinatal outcome using newborn assessment scale.

UMBILICAL CORD COILING - umbilical cord coiling is defined as a complete 360 degree spiral course of umbilical vessels around the Wharton’s jelly

measured by using umbilical cord coiling index scale and interpreted as hypocoil ,normal

coil and hypercoil.

PERINATAL OUTCOME - It refers to the degree of wellbeing of the newborn measured by using newborn assessment scale developed by the researcher and interpreted

as mild impairment, moderate impairment and severe impairment.

NEWBORN - Child born through normal vaginal delivery and is within one hour of birth along with the umbilical cord.

6.3.2 ASSUMPTION

· Umbilical cord coiling may have adverse effect on the perinatal outcome

6.3.3 HYPOTHESIS

H1 .There is a significant relationship between degree of umbilical cord coiling and perinatal

outcome.

H2.There is a significant association between degree of umbilical cord coiling, degree of

perinatal outcome and selected socio-demographic variables.

6.3.4 SAMPLING CRITERIA

i. INCLUSION CRITERIA

Newborns who are,

· Alive with the cord attached

· Within one hour of birth

ii. EXCLUSION CRITERIA

· Child born through caesarean section or instrumental delivery

6.3.5 DELIMITATIONS

Study is delimited to

· 4 weeks of data collection period.

7. MATERIALS AND METHODS

7.1. SOURCE OF DATA : Newborns and their umbilical cord in full length

7.2 METHOD OF DATA COLLECTION

· RESEARCH APPROACH : survey approach

· RESEARCH DESIGN : Non experimental comparative design

· SETTINGS : Selected maternity units

· POPULATION : Newborns with their umbilical cord in full length

· SAMPLE :Newborns with their umbilical cords in full length

· SAMPLE SIZE :50 Newborns with umbilical cord

· SAMPLING TECHNIQUE :Convenient sampling technique

· METHOD OF DATA COLLECTION

: Structured rating scale

· TOOL FOR DATA COLLECTION:

· Umbilical cord coiling rating scale

· Newborn assessment rating scale

· METHOD OF DATA ANALYSIS:

The researcher will use appropriate statistical technique for data analysis and present in the form of tables and diagrams

Data will be analyzed using descriptive and inferential statistics

Descriptive statistics: Frequency and percentage distribution to describe the socio- demographic variables

Inferential statistics: Mean, mean percentage and standard deviation to assess the degrees of umbilical cord coiling and degree of perinatal outcome in newborn.

- Correlation coefficient to find the relationship between the effects of umbilical coiling on perinatal well being.

-chi-square test to find association between findings and the selected demographic variables.

· DURATION OF STUDY : 4 weeks

· RESEARCH VARIABLES : Degree of umbilical cord coiling and

degree of perinatal outcome.

· DEMOGRAPHICAL VARIABLES:

· SOCIO-DEMOGRAPHIC VARIABLES OF MOTHER: Age of mother, place of residence, dietary pattern, weeks of gestation, educational status, occupation, family income.

· SOCIO-DEMOGRAPHIC VARIABLES OF NEWBORN: Preterm or term, complications at birth, mode of delivery

· PROJECTED OUTCOME: The study will be successful in early identification of

perinatal outcome of newborns and in reducing complications in the newborn.

7.3 Does the study require any investigation or intervention to be conducted on the patient or other human beings or animals?

Yes the study requires t investigation on umbilical cord and newborn.

7.4 Has ethical clearance been obtained from your institution?

Yes, ethical clearance has been enclosed.

8. LIST OF REFERENCES

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http://searchwarp.com/swa76469.htm

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Elsevier; 2007.

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Department of obstetrics and Gynaecology, United Arab Emirates University 2000.

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Department of pathology, Kaiser Medical Center, Oakland, USA

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11. Cristiane Barbieri, Jose G Cecatti, Carla E Souza, Emilio F Marussi and Jose V Costa.

Inter and Intra observer variability in sonographic measurements of the cross sectional area of the umbilical cord, Reproductive Health,2008.

http://www.reproductive-health-journal.com/content/5/1/5

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second trimester of gestation and gestational outcomes Int J Med Sci 2011 ; 594-598.

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13.Morteza Tahmasebi and Reza Alighanbari. Indian J Radiol Imaging. 2011 Jul-Sep; 21(3):

195–198. doi:  10.4103/0971-3026.85367

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Department of Pediatrics, Division of Neonatology, University college of Medical Sciences,Delhi.

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15. Khong TY, 2011evidenced based pathology.SA Pathology, Women's and Children's

Hospital, North Adelaide. 2010Dec.

http://www.ncbi.nlm.nih.gov/pubmed/21080869

16. Department of Obstetrics & Gynecology, Faculty of Medicine and Health Sciences, United

Arab Emirates University, Al-Ain

http://www.hindawi.com/journals/ogi/2012/213689/

17. Department of Obstetrics and Gynecology, Showa University School of Medicine, To Japan

http://lib.bioinfo.pl/pmid:19215545

9. Signature of the candidate :

10. Remarks of the guide :

11. Name and designation :

11.1 Guide :

11.2 Signature :

11.3 Head of the department :

11.4 Signature :

12.

12.1 Remarks of chairman/principal :

12.2 Signatures :