CHAPTER ONE

1.0 EXECUTIVE SUMMARY

1.1 BACKGROUND INFORMATION
According to the American Academy of Pediatrics' Committee on Fetus and Newborn and the
American College of Obstetricians and Gynecologists' Committee on Obstetric Practice (1996), the
Apgar score should be used to assess the condition of an infant at birth. These committees also warn
that the Apgar score should not be used as the only measure to evaluate the possibility that
neurological damage occurred during the birthing process. In addition to low Apgar scores, (3 or less
for longer than 5 minutes); an infant who is asphyxiated prior to delivery would demonstrate severe
metabolic or mixed acidemia (pH < 7.00) via umbilical artery blood sample and additional
neurological manifestations such as seizure activity, coma, hypotonia, and finally, evidence of
multiorgan dysfunction (Committee on Fetus and Newborn, American Academy of Pediatrics, &
Committee on Obstetric Practice, American College of Obstetricians and Gynecologists, 1996).
Furthermore, research conducted over 30 years ago (Apgar, 1966; Apgar & James, 1962) provided
initial evidence to disclaim the reliability of Apgar scores for predicting long-term outcomes of any
type (e.g., developmental and neurological). Prediction of long-term outcomes was never a goal of the
Apgar scoring system. Rather, the goal was to make certain that infants were systematically observed
for their need for immediate care at birth. Poor Apgar score may be caused by prolonged labour,
uterine contraction, cephalopelvic disproportion and malpresentation.
One of the dangers of poor Apgar score to the infants is the mortality after delivery. Apgar score is
standardized method of evaluating the baby’s condition by observing respiratory effort. Score is
assessed in 1 minute and 5 minutes after birth. Medical aid should be sought, if the score is less than
seven (Michie, 1993).

1
Table 1: Apgar Scoring
SCORE
Sign 0 1 2
Heart Rate Absent Less than 100 beats/ More than 100 beats/
Minute Minute
Respiratory Effort Absent Slow, irregular Good or crying

Muscle Tone Limp Some flexion of limbs Active

Reflex response to None Minimal Grimace Cough or sneeze

stimulus

Colour Blue, Pale Body Pink, Extremities Completely pink

blue

At 1 minute after the baby’s birth, an assessment of general condition is done and will repeat this
assessment of general condition at 5 minutes. This involves consideration of five signs and the degree
for which they are present or absent.
The factors assessed are heart rate, respiratory effort, muscle tone, reflex response to stimulus and
colour. A score of 0, 1 or 2 is awarded to each of the signs in accordance with the guidelines. In the
scoring system, the Apgar (Apgar 1953) is recognized and used universally. Of the five signs, the heart
rate and the respiratory effort are most important. Colour is least important and some centres have
discontinued the recording of this part of the score making the maximum score 8 rather than 10 (Myles
Textbook for Midwives African Edition).
Documentation of this modified system requires to be indicated, e.g. Apgar minus colour score=7. A
normal infant in good condition at birth will achieve an Apgar of 7-10. A score below seven indicates
that the baby requires some form of resuscitation (Oxorn, 1986).
The system has proved valuable in identifying the neonate with compromised health (Lotko, 1986). In
the previous study (Lotko, 1986) attribute asphyxia to prolonged labour which could otherwise be
prevented.
There are several ways that can be used to prevent poor Apgar score but the most important one
suggested by (Oxorn, 1986) is the use of partograph to evaluate labour. A study carried out in eight
hospitals in Thailand, Malasia and Indonesia showed that the partograph appropriate management and
reducing unnecessary intervention and complication of labour.

2
1.2 PROBLEM STATEMENT
A 15 month long study carried out by WHO (Bwibo-1994) of more than 35,000 women delivering in
eight hospitals; Indonesia, Thailand and Malaysia was focused on labour management and reducing
maternal and fetal morbidity. The study showed importance and use of partograph. In Kenya a study
was carried out in Mater Hospital on women delivery, the findings of the study were rated at 7% of
problem which arose due to labour management (Journal, 1992).A large number of mothers who
delivered and had complications like;prolongedlabour and malpresentation resulted in poor Apgar
score.According to the,medical records in maternity ward in KapkatetDistrict Hospital in the year
2009 total deliveries were 3360 of which 630 had poor apgarscore,a percentage of 19%.In 2015
January to October 2015 a study was done by DrKavisa and DrKimeu internship student indicated that
30% of babies in nursery were diagnosed with poor apgarscore.This has provoked the need to carry
out the study to find out factors that have led to increased poor apgar score.

1.3 STUDY JUSTIFICATION

Since 2009 the hospital management through full participation of Gynecologist and pediatrician have
tried through Continous Medical Education (CME)to put in place mechanism to reduce incidence of
poor apgarscore; like empowerment of midwives, facilitation of early referrals and departmental
continous medical education. However there is still remained increase in number of babies with poor
apgarscore. Recent study shows increase of 30% compared to 2009 19%.The findings of this study
will assist in establishing problems related to poor apgar score.
1.4 STUDY QUESTIONS
1. How many mothers having children with poor Apgar score had prolonged labour?
2. How many had partographscharted and well documented?
3. Was there any early rapture of membrane?
4. How many had meconium stain?
5. How many of those mothers attended antenatal clinic?
6. Was gestation by date recorded?
7. How many had antenatal profile done and completed.

1.5 HYPOTHESIS
Poor maternal effort and malpresentation contributes to poor Apgar score.

3
1.6 PURPOSE OF STUDY
To find out the factors contributing to poor Apgar score in infants delivered at Kapkatet District
Hospital.

1.7 STUDY OBJECTIVES

1.7.1 BROAD OBJECTIVES
To determine factors that contribute to poor APgar score in infants delivered at Kapkatet District
Hospital.

1.7.2 SPECIFIC OBJECTIVES

i. To find out the duration of first stage and second stage of labour for mother who delivered
ii. To find out mode of delivery
iii. To find out if partographs were used during labour
iv. To find out the reason of poor Apgar score
v. To find out any other factors that caused poor Apgar score

4
CHAPTER TWO
2.0 LITERATURE REVIEW
2.1 INTRODUCTION

Over 3 million stillbirths occur globally each year, nearly all of which are in low-income countries.
Stillbirth rates are particularly high in sub-Saharan Africa, where up to 14% of deliveries could result
in stillbirths. These rates are relatively higher in West Africa. Apgar scores are used to assess the
condition of the newborn in the first critical minutes of life and can be useful in evaluating neonatal
resuscitation and survival, especially in low resource settings. About 8-38% of babies delivered in
West Africa may have low Apgar scores. Over two-thirds of babies with very low Apgar scores may
result in perinatal mortality. Stillbirths and Apgar scores are important indicators of the quality of
obstetric care. Non-infectious maternal and obstetric risk factors for stillbirths that are likely to be
important in sub-Saharan Africa include socio-demographic and reproductive factors, hypertensive
states in pregnancy, gestational age at delivery, birth weight and type of vaginal delivery. For example,
preterm births and low birth weight infants are associated with increased risks of stillbirths, and nearly
a fifth of such babies are stillborn.

The vaginal route remains the commonest mode of delivery in all health care facilities. A few studies
have reported the prevalence of adverse birth outcomes and the maternal and reproductive factors
associated with these outcomes in sub-Saharan Africa. However, data regarding the contribution of
socio-demographic and obstetric risk factors to stillbirths and very low Apgar scores of babies
delivered vaginally remains very sparse. Increasing attention for these factors and focusing on
interventions to reduce adverse vaginal birth outcomes will contribute immensely towards the
attainment of Millennium Development Goal 4 on under-five mortality.

Poor Apgar is relatively rare complication for infants delivered. It can result in significant morbidity of
neonates (May 1994), (Swell, 1988) states that the longer the labour continues malpresentation present
the greater hazard to fetus, which may lead to pre-natal death.

5
2.2 CONTRIBUTORY FACTORS
Prolonged labour, which is defined as labour exceeding 24 hours traditionally. But if actively managed
is termed as prolonged if delivery is not imminent after 12 hours of established labour. (Oxorn, 1986)
described every stage labour, he defined prolonged latent phase as that which exceeds 20 hours in
primi-gravida. He defined prolonged second stage as when after cervix has reached full dilatation, it
takes more than 2 hours before the baby is delivered.
Malpresentation, which is defined as any presentation of fetus other than the vertex may be breech (a
longitudinal lie of the fetus in which the buttock present in the lower pole of uterus, pelvic, uterine,
fetal or incidental) face (cephalic presentation in which the spine and the head of the baby are
extended and the face lies lowest in the pelvis). Brow or shoulder ( a cephalic presentation in which
the altitude of the head is midway between flexion and extension may be caused by obstructed labour
or android pelvis) failure to diagnose the condition can lead to poor Apgar score.
Fetal distress, a clinical manifestation of fetal hypoxia is due to interference with maternal respiration
as in fits, epilepsy, or inadequate circulation in case of cardiac failure. Causes of foetal distress include
intracranial trauma and severe rhesus incompatibility leading to cross anemia.

2.3 INCIDENCE
In a study by (May 1994), it was found that poor Apgar score occurs in approximately 1% to 7% of
laboring women. The study include primigravida and multigravida.

2.4 AETIOLOGY
Poor Apgar score may be caused by prolonged labour and malpresentation. Also it may be caused by
fetal malposition, premature rupture of membranes, cephalopelvic. Disproportion and excessive use of
anaesthesia or sedation which decreases motility of uterus. (May 1994).
2.5 DELIVERY OUTCOMES
It is explained that inactive phase of labour, primary dysfunctional labour occurs when there is steady
progress in cervical dilatation but at a rate slower than 1.2 centimetres per hour in primigravida and
2cm in multigravida. Of women experiencing this, approximately 60% will deliver vaginally, without
assistance and the remainder 40% may require argumentation of labour, forceps application or
caesarian delivery (May, 1994).
Prolonged labourcephalopelvic disproportion malpresentation and poor management of labour may
cause intra-uterine hypoxia, which will determine the status of the baby at birth. Hypoxia may lead to
birth asphyxia and thus may describe the factors that contribute to poor Apgar score. Since the later
provides a guide to the severity of birth asphyxia. (Michie, 1993
6
2.6 PREVENTION
There are several ways that can be used to prevent poor Apgar score, but the most important one
suggested by (Oxorn, 1986) is the use of partograph to evaluate labour. A 15month study carried out
by WHO (Bwibo, 1994) of more than 35,000 women delivering in eight hospitals in Indonesia,
Malaysia and Thailand was focused on improving labour management and reducing maternal and fetal
morbidity. The study showed that the partograph successfully distinguished labour requiring
intervention from those that did not, permitting appropriate management and reducing unnecessary
interventions and complications of labour.
Apgar score is an important delivery room tool since 1952. This acts as standardized method of
grading new infant at 1 minute and 5 minute of life (Oxorn, 1986). In Apgar scoring system, 5 signs
are assessed. These include heart rate, respiratory rate, muscle tone, reflex irritability and colour. A
score of 0,1 or 2 marks is given for each sign and the points are then totaled (Michie, 1993). It s
explained further that normal infant in good condition could achieve Apgar score at 7-10 and if one
has score of below 7 requires some forms of resuscitation. (Gill, 1994) states that a total score of 10
indicates that the infants are in the best possible condition) a moderate depressed infant’s score 0-4
and is considered to be asphyxiated.
The system has proven valuable in identifying the neonate with compromised health (Letko, 1996) in
the previous study, (Oxorn, 1986) attribute asphyxia to prolonged labour which could otherwise be
prevented.

2.7 RELIABILITY OF APGAR SCORES

According to Jepson, Talashek, and Tichy (1991), the Apgar score as a “tool” (to measure newborn
adaptation to extrauterine life) lacks sensitivity and specificity. Sensitivity measures how well the tool
captures the infant's condition at birth (stable vs. depressed) and specificity refers to how well the tool
measures the differences between the values of the scores (0–2 for each of the five categories).
Additionally, various authors have noted that great variability exists in how individual health care
providers score the assessment (Clark &Hakanson, 1988; Livingston, 1990). Clark and Hakanson
(1988) compared the consistency (inner-rater reliability) of Apgar scoring among various health care
disciplines. In their study, groups of health care providers were visually shown case presentations and
then asked to assign Apgar scores to the infants who were presented. Pediatricians and pediatric house
staff had a consistency rating of 68%, obstetricians and obstetric house staff had a consistency rating
of 46%, intensive care nursery staff had a consistency score of 42%, obstetric nurses 36%, and
community hospital nurses a consistency rating of 24%.

7
Livingston examined how consistent two health care providers were in assigning scores when
compared to one another. In this study, the consistency of scores ranged from 55% to 82% with heart
rate having the best rate of consistency at 82% for the 1-minute scores (Livingston, 1990). For the 5-
minute score, consistency ranged from 36% to 100%, again heart rate having the highest rate of
consistency. Heart rate measures likely have greater consistency due to the ease of understanding and
defining exactly what is being assessed. When consistency scoring was compared between full-term
and premature newborns, health care providers were found to have better consistency when assessing
full-term newborns (Livingston, 1990). Additionally, full-term newborns may represent the “normal”
in health care provider's minds; hence, full-term newborns may be more likely to receive a “normal”
score, which accounts for the higher rate of consistency in term newborns than in preterm newborns.

Another concern is determining who has responsibility for assigning the Apgar score once the infant is
born. According to both Apgar (1966) and the Regan Report (1987), the person assisting with the
delivery of the infant should not assign the Apgar score. While in some respects the delivering
individual seems the most logical choice, bias may be introduced into the score value, because the
individual who attends the delivery may have a vested interest in the outcome.

Secondly, the newborn may be given to additional personnel immediately after delivery. This makes
determining the Apgar score considerably more difficult for the health care provider who is assisting
the delivery, necessitating leaving the mother's bedside briefly to assign the score. Additionally, if the
infant remains with the mother for the first 5 minutes of life, the health care provider must later
remember to document the score, often from memory. Both circumstances have the potential to
introduce further bias to the already poor consistency of the Apgar score.

Often the nurse or someone from the department of neonatology assigns the Apgar score. Most
frequently in a normal, full-term delivery, this would be the nurse. Nurses, at least in the Clark and
Hakanson (1988) study, had a poor consistency rate. Questions regarding the accuracy of the Apgar
score play a role in limiting the long-term predictive value.

2.8 INTENDED USES OF THE APGAR SCORE

As the Apgar score was developed and refined over the years since its inception, the intended use has
always been the same: to evaluate a newborn's condition at birth. Some clinicians like to use the Apgar
score as a guide to their resuscitative efforts; however, this is not an intended use of the Apgar score.
The novice practitioner may mistakenly believe that resuscitative efforts should not begin until the 5-

8
minute Apgar score is determined. Experienced clinicians realize this would severely delay
resuscitative efforts and compromise the potential for full recovery of neurological function. It is
important to be both careful and consistent with language.

9
CHAPTER THREE
3.0 RESEARCH METHODOLOGY
3.1 RESEARCH DESIGN
The study will be non-experimental retrospective study design. The researcher will formulate a
questionnaire and then fill out the necessary information from old delivery records. No interviews will
be done. Only identification numbers will be recorded on questions and diagnosis of contributing
factors will be a through confirmation on management of labour by use of partograph and poor Apgar
score if it will be less than seven.

3.1.1 STUDY AREA

The research will be carried out at Kapkatet District Hospital. The district borders Kericho to the
North, Molo to the Northeast, Bomet to the East, Sotik to the South and Nyamira to the West. The
district lies between approximately latitude 0.250 and 0.40 south of the Equator and between longitudes
350. It lies between 1800m and 3000m above sea level. The temperature ranges from 180C-200C.
Coldest months begin in July with an average of 160C, hottest season from December to February with
approximately 200C. It has varying rainfall ranging from 2020mm-1700mm annually. The district is
divided into six divisions namely Bureti, Roret, Kimulot, Konoin, Cheborgei and Cheptalal
respectively.
Politically, the district is sub-divided into two local authorities namely; Bureti county council and
Litein town council. The councils are further divided into wards for easy administration and dispersion
of services.

The research will be carried out at Kapkatet District Hospital.

3.2 TARGET POPULATION
Sample population will consist of old delivery records of women who will deliver at Kapkatet District
Hospital from 1st to 31st Dec. 2015 twelve months.

3.3 SAMPLE
3.3.1 SAMPLING TECHNIQUE
Systematic sampling technique will be used. This method will allow the researcher to retrieve files that
have information with respect to the study.

10
3.3.2 SAMPLE SIZE
Andrew Fishers method of 1994 will be used for population less than 10,000
i.e.
n n
nf = +
1 N
nf = Desired size
n=400 which is constant
N=the study population or estimated population less than 10,000
Population size of the total number of files during the year 2010 was 3,000
400 400
Nf= =
1+ 3300 1+0.1
400 ×10
¿
1.1× 10
4000
¿
11
nf = 364
364 of the files will be eligible for the study but 40 will be considered due to limited time and financial
constraints.

3.4 SELECTION CRITERIA

3.4.1 INCLUSIVE CRITERIA
Old maternity files recorded and infants who will have poor Apgar score and gestation age more than
37 completed.

3.4.2 EXCLUSIVE CRITERIA

All medical files and maternity files of infants with good score of above 7.

3.5 DATA MANAGEMENT

3.5.1 DATA COLLECTION TOOL
A questionnaire will be formulated and pretested on clients records before the actual data collection.
The necessary corrections will be made after pretesting and also a gestational wheel will be used to
calculate the completed weeks of pregnancy at a time of birth.

11
3.5.2 DATA COLLECTION PROCEDURE.
3.5.3 I will seek permission from the hospital administration for the research to be carried out. Data
will be done using delivery records 2015Jan-Dec. 2015 One questionnaire by each chart will be
filled out by the researcher.

3.5.4 DATA ANALYSIS

Data collected will be tallied by manual calculation. A scientific calculator will be used in tabulating
the data collected in form of percentages.
3.6 LIMITATIONS AND ASSUMPTIONS OF THE STUDY
3.6.1 LIMITATIONS
Time factor will be one of the limitations since the researcher will have so many things to do at once
yet there will be limited scheduled time for carrying out the research.
Literature review will be a problem to the researcher because she will not find enough research articles
relating to the topic.
Some important information will not be recorded in many of the delivery records; hence, the
researcher will not be able to include some mothers in the study. These will limit the number of
sample and affect the findings.
It will take time for the researcher to find some of the old records because they may not be kept in
order.
It is important to recognize the limitations of the Apgar score. The Apgar score is an expression of the
infant’s physiologic condition at one point in time, which includes subjective components. There are
numerous factors that can influence the Apgar score, including maternal sedation or anesthesia,
congenital malformations, gestational age, trauma, and inter-observer variability. In addition, the
biochemical disturbance must be significant before the score is affected. Elements of the score such as
tone, color, and reflex irritability can be subjective, and partially depend on the physiologic maturity
of the infant. The score may also be affected by variations in normal transition. For example, lower
initial oxygen saturations in the first few minutes need not prompt immediate supplemental oxygen
administration; the Neonatal Resuscitation Program targets for oxygen saturation are 60–65% at 1
minute and 80–85% at 5 minutes (3). The healthy preterm infant with no evidence of asphyxia may
receive a low score only because of immaturity (7, 8). The incidence of low Apgar scores is inversely
related to birth weight, and a low score cannot predict morbidity or mortality for any individual infant
(8, 9). As previously stated, it also is inappropriate to use an Apgar score alone to diagnose asphyxia.

12
The researcher had to look at several different records to find full information which would have been
easy if it was recorded correctly in appropriate record books.
The history of onset labour will be difficult to document since some mothers will find it difficult to
know exactly when labour will begin.
The researcher will often not find the reason why mothers come late to the hospital. There is no way to
check on omitted information since the researcher will have only written records to refer to while
collecting data for this study.

3.6.2 STUDY ASSUMPTIONS

The study will put into assumption factors that the researcher is expected to be contributory factors to
poor Apgar score.

3.7 VARIABLES
3.7.1 INDEPENDENT VARIABLES
Poor Apgar Score

3.7.2 DEPENDENT VARIABLES

Contributing factors to poor apgar score.

3.8 ETHICAL CONSIDERATION

1. Data collection will be kept confidential since no name or inpatient number will be indicated in the
questionnaire. Instead, a code will be used on actual research information which the researcher alone
will understand. This code will correspond to identifying information in a separate secure file.
2.Approval for the study will be sought from Ethical Committee of Kapkatet District Hospital.

13
REFERENCE
1. Apgar V. A proposal for a new method of evaluation of the newborn infant. Current
Researches in Anesthesia and Analgesia. 1953;32:260–267. [PubMed]
2. Apgar V. The newborn scoring system: Reflections and advice. Pediatric Clinics of North
America. 1966;113:645–650. [PubMed]
3. Apgar V, James L. Further observation of the newborn scoring system. American Journal of
Diseases of Children. 1962;104:419–428. [PubMed]
4. Bwibo, N.O (1994). WHO Partograph reduces complication of labour and childbirth. AFYA:
A journal of medical and health workers, 28 (3), 99-101.
5. Behnke M, Eyler F, Carter R, Hardt N, Cruz A, Resnick M. Predictive value of Apgar scores
for developmental outcome in premature infants. American Journal of Perinatology.
1989;6:18–21. [PubMed]
6. Blackman J. The value of Apgar scores in predicting developmental outcome at age five.
Journal of Perinatology. 1988;8:206–210. [PubMed]
7. Clark D, Hakanson D. The inaccuracy of Apgar scoring. Journal of Perinatology. 1988;8:203–
205. [PubMed]
8. Gill W.L (1994) Essentials of Normal Newborn Assessment and Score. In A.H Decherney and
M.L Pernoll, Current Obstetrics and Gynaecology Diagnosis Treatment. (PP 223 – 239).
Norwalk CT: Appleton and Lange.
9. Gibson C, Tibbetts S. Interaction between maternal cigarette smoking and Apgar scores in
predicting offending behavior. 1998. Psychological Reports, 83, 579–586. [PubMed]
10. Jepson H, Talashek M, Tichy A. The Apgar score: Evolution, limitations, and scoring
guidelines. Birth: Issues in Perinatal Care. 1991;18:83–92. [PubMed]
11. Letko, M.D. (1999, May). Understanding the Apgar Score. Jognn Journal of Obstetrics,
Gynecology.
12. May, K.A (1994). Intrapartum Complications. In K.A. May and L.R. Mahmeister (Eds)
Maternal and Neonatal Nursing: Family-Centered Care (PP. 661-725) Philadelphia: J.B
Lippincott Company.
13. Michire M.M (1993). The baby at Birth. In V.R. Bennett and L.K. Brown. Myles Textbook for
Midwives. 12th Edition (PP. 491 – 504). Edinburg: Churchill Livingstone.
14. Oxorn. H. (1986). Human Labour and Birth. Norwalk CT: Appleton and Lange.

14
15. Shiers C.V (1999). Prolonged Pregnancy and Disorders of Uterine Action. In V.R Benneth and
L.K Brown (Eds) Myles Textbook for Midwives (13th Edition) (PP 489-506) London: Harcourt
Publishers Limited.
16. Sweat B.R. (1988). Disordered Action.
17. Wolf M, Beunen G, Casaer P, Wolf B. Neonatal neurological examination as a predictor of
neuromotor outcome at 4 months in term low-Apgar-score babies in Zimbabwe. Early Human
Development. 1998;51:179–186. [PubMed]
18. Wolf M, Beunen G, Casaer P, Wolf B. Neurological findings in neonates with low Apgar in
Zimbabwe. European Journal of Obstetrics, Gynecology, & Reproductive Biology.
1997;73:115–119. [PubMed]
19. Wolf M, Wolf B, Bijleveld C, Beunen G, Casaer P. Neurodevelopmental outcome in babies
with a low Apgar score from Zimbabwe. Developmental Medicine & Child Neurology. 1997;
39:821–826. [PubMed]

15
APPENDICES
APPENDIX I – QUESTIONNAIRE
FACTORS THAT CONTRIBUTE TO POOR APGAR SCORE IN INFANTS DELIVERED AT
MATERNITY WARD, KAPKATET DISTRICT HOSPITAL

Subject No.
1. Infants age score in:
a. 1 minute
b. 5 minutes
c. 10 minutes
d. Birth Weight

2. Gestation. Age on the day of birth

a. LMP
b. EDD
c. G.A

3. Date and time of admission

DATE TIME
a. Labour began
b. Admission to hospital
c. Admission to labour ward

4. First vaginal examination

a. Time
b. Cervical dilatation

5. Date and time of delivery

a. Date
b. Time
6. Referral Yes/No: If yes from………………………………………
Hours of labour……………………………

16
 7. Mode of delivery
SVD OXYTOCIN C/SECTION C/SECTION AND
OXYTOCIN

8. Causes or factors recorded ………………………………………………..

9. Had a partograph
Yes
No
10. If yes, time started…………………………………………………………

11. First FHT

a. Good
b. Irregular
c. Absent
12. Meconium recorded during labour………………………………………….
13. Had still birth
Yes
No
14. Baby died before leaving delivery room
Yes
No
15. Was the partograph documented?
Yes
No
16. Reasons for poor Apgar score recorded on the partograph
……………………………............................................................................................................
............................................................................................................................

17
A LETTER SEEKING AUTHORITY TO CONDUCT RESEARCH STUDY IN: MATERNITY
WARD AT KAPKATET DISTRICT HOSPITAL

JOYCE CHEPKORIR
SCHOOL OF NURSING SCIENCES
P.O BOX 19676
NAIROBI
DATE………………………

THE CHAIRMAN
ETHICAL AND RESEARCH COMMITTEE

Dear Sir/Madam,

REF: AUTHORITHY CONDUCT RESEARCH MATERNITY WARD

Iam a student pursuing a degree course leading to award of Bachelor of Science Nursing in the
University of Nairobi. I here by seek authority to conduct a research on your institution.
The title will befactors that contribute to poor apgar score in infants delivered at maternity ward, Kapkatet
District Hospital. The research proposal will be executed from Jan-May 2016
The findings of this research will be useful in reducing factors that contribute to poor apgar score in infants
delivered at maternity ward, Kapkatet District Hospital. Policy makers in the area may utilize the findings and
recommendations of the study to address this problem.
I would be grateful for your due action.
Yours faithfully,

JOYCE CHEPKORIR CHEPKWONY

18
Appendix II - Budget
ITEM QUANTITY COST (KSH) TOTAL COST
(KSH)
1.STATIONARIES
i. Fullscaps 1 ream 300 300
ii. Pens 6 20 120
iii. Printing papers 4 ream 450 1800
iv. Pencils 6 30 180
v. Ruler 2 30 60
vi. File 6 50 300
vii. calculator 1 700 700
viii. flash disc 1 1000 1000
TOTAL 27 items 2580 4460
2.TYPE SETTING 56 pages 30 1680
i. questionnaires 450 5800 5800
ii. proposal 1 80 80
iii. document 3 120 360
TOTAL 510 items 6000 7920

19
 SCHEDULE OF ACTIVITIESP
Nov Dec JAN FEB MARCH APRI MAY
TIME 1 2 3 4 5 6 7 8 9 10 11 1 13 1 15 1 17 1 19 2 21 2 23 2 25
2 4 6 8 0 2 4

Proposal
Development
Training
research
assistant
Pretesting
Pretes data
analysis
Data
collection
and entry
Data analysis
Report
writing
Final data
presentation
Feedback to
the hospital

20