Background: Normal labor is a vital physiological process necessitating ongoing evaluation and interventions. Continuous nurse education is crucial for effective maternal care, and training in obstetrical emergencies enhances outcomes for mothers and newborns. 

Aim: evaluate the effect of the instructional package on maternity nurses’ knowledge regarding nursing care of first stage of normal labor and partogram. 

Subjects and Methods:

Design: A quasi-experimental design with a one group pre-posttest. 

Setting: The current study was conducted at labor unit at Beni-Suef University and Beni-Suef Specialist Hospitals. 

Sample: A convenience sample consisting of all 50 maternity nurses. 

Tools: A structured interviewing questionnaire, which includes 3 parts: 

1. Discusses the training and experience of maternity nurses. 

2. Evaluates their understanding of general nursing care during first stage. 

3. Analyzes their knowledge of the Partogram. 

Results: 56% of the studied nurses had less than 5 years of experience and 28.0% attended training courses regarding the stages of normal labor. Post-intervention assessments indicated substantial improvements in maternity nurses' knowledge of normal labor. Recognition of true labor pain increased from 8% to 70%, understanding of uterine contractions from 12% to 72%, and knowledge about nursing care during the first stage of labor rose from 24% to 88%. Correct reporting of cervical dilatation improved from 14% to 68%, while knowledge of labor progress components went from 20% to 72%. Understanding of complications addressed by the partogram increased from 22% to 74%. All changes were statistically significant (p-value 0.000). 

Conclusion: Improvements in maternity nurses' knowledge of partogram and nursing care during the first stage of normal labor were noted after the intervention, with levels of knowledge correlating positively with years of nursing experience before and after the instructional package. 

Recommendations: Distribute the clarified pamphlet for maternity nurses to acquire a correct knowledge regarding partogram and nursing care of first stage of labor.

The World Health Organization (WHO) defines normal labor as spontaneous, low-risk from onset through delivery, with both mother and newborn in normal status [1]. Normal delivery occurs between 37 and 42 weeks of pregnancy, usually with the baby in a vertex position [2-6]. The exact mechanisms initiating labor are unclear, although it is thought to be influenced by factors such as uterine stretch, hormonal changes including progesterone withdrawal and estrogen dominance, increased sensitivity to oxytocin, and prostaglandin release [7-11].

Theories of labor, such as the uterine stretch theory, oxytocin theory, progesterone deprivation theory, prostaglandin theory, and the aging placenta theory, aim to explain the onset of labor. The uterine stretch theory posits that as the uterus, a hollow muscular organ, stretches due to fetal growth, it will contract to expel its contents, leading to physiological changes that initiate labor [12-16].

Ongoing education and training are crucial for nurses to provide competent care to pregnant women. An instructional package on obstetrical emergencies aims to enhance management, improve unit efficiency, and outcomes for both women and newborns, supporting immediate management decisions [17-20]. Merrill’s First Principles of instruction provides a meta-model for task-centered learning with five key principles, emphasizing authentic problem engagement in nursing contexts, particularly during emergencies in normal labor [21-25].

Activation of prior knowledge is crucial for understanding normal labor, alongside the demonstration and application of this knowledge by nurses. Simulation training is essential in preparing for labor and emergencies, as many deaths stem from management failures due to inadequate education and training. This training aims to enhance both learning effectiveness and the transfer of knowledge [26-29].

Instructional package strategies in standards-based classrooms emphasize high expectations for all students, effective time usage, various grouping methods, a safe environment, and physical organization. Key elements include addressing nurses' prior knowledge and misconceptions, utilizing multiple forms of representation, incorporating instructional technology and tools, and fostering nurses' ownership of learning. Significant learning derives from effort rather than innate ability [30].

Multiple forms of classroom representation, including pictures, words, symbols, diagrams, tables, and graphs, enable nurses to understand that different representations can convey the same concept. Instructional technology such as manipulatives, calculators, and computers is readily available and aligned with session objectives, ensuring nurses receive adequate support for effective learning [31]. Additionally, nurses take ownership of their learning, engaging in self-assessment and receiving directive feedback to improve their understanding and practice, with opportunities for revision to facilitate mastery [30].

To enhance nurses' engagement in instructional sessions, it is vital to use questions that stimulate responses and encourage participation, linking sessions to their personal labor experiences with varied materials [27]. Nurses must take responsibility for their actions towards women in labor and infants, applying critical thinking guided by clinical standards and quality improvement initiatives [32]. The use of instructional packages can improve clinical scenarios, increase safety, reduce errors, and refine nurses' clinical judgments. Ongoing learning is crucial for student nurses to stay informed about labor mechanisms, hormonal effects, normal labor signs, and care for mothers and newborns across cognitive, affective, and practical domains [33].

Aim Of the Study

The current study aimed to evaluate the effect of the instructional package on maternity nurses’ knowledge regarding nursing care of first stage of normal labor and partogram.

Research Hypothesis

Following the implementation of the instructional package, maternity nurses’ knowledge regarding nursing care of first stage of normal labor and partogram through instructional package will be improved.

Research Design: 

A quasi-experimental design with a one group pre-posttest.

Settings: 

Labor unit at Beni-Suef University and Beni-Suef Specialist Hospitals.

Subjects: 

All maternity nurses in the labor unit during the data collection comprised 23 nurses from Beni-Suef University Hospital and 27 nurses from Beni-Suef Specialist Hospital.

Tools of data collection: 

Tool I: A Structured Interviewing Questionnaire: 

This tool was applied before and after the instructional package sessions to assess the effect of the instructional package on the nurses' level of knowledge. This tool was designed by a researcher after reviewing the related current and previous literature and translated to the Arabic language and included three parts as the following:

Part one: 

General characteristics of the maternity nurses, which included, years of experience and any training courses regarding the stages of normal labor.

Part two: 

Maternity nurses' knowledge regarding the nursing care of the first stages of normal labor. This tool was designed by a researcher after reviewing the related current and previous literature. It consisted of 15 questions to assess the maternity nurses’ general knowledge regarding the first stage of normal labor, such as the definition of normal labor, signs and symptoms of normal labor, mechanism of labor, etc.

Part three: 

Maternity nurses' knowledge of partogram. It consisted of 16 questions to assess the maternity nurses’ knowledge regarding partogram such as definition of partogram, objective of partogram, component of program, etc.

Knowledge scoring system:

Each item was scored: 2 points for complete correct answers, 1 point for incomplete correct answers, and 0 points for incorrect answers or "don't know." Total scores were summed and averaged to categorize knowledge levels as Good Knowledge ≥ 75%, Average knowledge 50% to > 75%, and Poor knowledge > 50%.

Field work:

Revision of assessment tools for content validity by five experts in obstetrics and gynecological nursing highlighted their clarity and applicability, with strong internal consistency (Cronbach’s Alpha = 0.951). A pilot study with 5 nurses evaluated a structured questionnaire, leading to necessary modifications for clarity in knowledge-related questions. Conducted from October 2024 to June 2025, the research included phases of initial interviews and assessments of nurses' comprehension, practices, and attitudes towards early normal labor, utilizing a self-administered questionnaire and observational checklists. An instructional package in Arabic was developed, covering theoretical knowledge and practical skills over four weeks through lectures, discussions, and demonstrations. The evaluation phase used identical pretest tools post-intervention to assess changes in knowledge, practices, and attitudes. Ethical approvals were obtained, and data analysis was performed using SPSS with significance evaluated via chi-square tests and paired sample t-tests.

Figure (1): Illustrates that 56% of the studied nurses had less than 5 years of experience. 

Figure (2): shows that 28.0% of the studied nurses attended training courses regarding the stages of normal labor. 

Table (1): presents the relation between total maternity nurses’ knowledge and their years of work experience through the instructional package. It revealed that the level of knowledge was increased by increasing nurses’ years of experience in both pre- and post-instructional packages. Mean knowledge was 18.00±7.00 pre-instructional package compared to 48.00±4.58 post-instructional package among nurses whose experiences were more than 10 years.

Table (2): Shows that there were improvements in the studied maternity nurses’ knowledge regarding nursing care of the first stage of normal labor post-intervention. Regarding signs of true labor pain, 8% of them reported a correct and complete answer pre-instructional package compared to 70% post-intervention. Regarding the importance of uterine contraction, 12% of them had a correct and complete answer pre-instructional package compared to 72% post-intervention, and 24% of them reported a correct and complete answer about nursing care during the first stage of normal labor pre-intervention compared to 88% post-intervention. The table also proves that there was a highly statistically significant difference for all aspects of the studied maternity nurses’ knowledge regarding the first stage of normal labor at a p-value of 0.000 between pre- and post-intervention.

Table (3): Shows that there were improvements in the studied maternity nurses’ knowledge regarding partogram post-intervention. Regarding the normal rate of cervical dilatation, 14% of them reported the correct and complete answer pre-intervention compared to 68% post-intervention. Regarding the components of progress labor, 20% of them had correct and complete answers pre-intervention compared to 72% post-intervention, and 22% of them reported correct and complete answers about the complications that were avoided by the partogram pre-intervention compared to 74% post-instructional package. The table also proves that there were highly statistically significant differences for all aspects of the studied maternity nurses’ knowledge regarding partograms at p-value 0.000 between pre- and post-intervention.

Figure 1: percentage distribution of years of experience of the studied maternity nurses

Figure 2: percentage distribution of the studied maternity nurses’ attendance training courses regarding the stages of normal labor

Table 1: Relation between total maternity nurses’ knowledge and their years of work experience thorough instructional package

Table 2: Distribution maternity nurses’ knowledge regarding general nursing care of first stage of normal labor through pre and post- instructional package (n=50)

* A highly statistically significant difference P ≤ 0. 001

Table 3: Distribution maternity nurses’ knowledge regarding Partogram through pre- and post- instructional package (n=50)

* A statistically significant difference P ≤ 0.05                 

** A highly statistically significant difference P ≤ 0. 001

All nurses are expected to master labor standards covered in the instructional session, with support provided for those with special needs. Entry into the lesson is granted to all nurses, fostering learning opportunities. Effective wait time is utilized to encourage meaningful participation, and nurses can experience labor achievement through the application of effective effort [33]. 

In nursing education, comments and concerns raised by nurses are acknowledged and linked to their existing knowledge about normal labor, promoting learning. Nurses utilize their experiences to enhance their understanding, with opportunities for respectful discussion and scaffolding of learning. Misconceptions are anticipated and addressed through redirection, allowing nurses to explore and correct their own misunderstandings collaboratively [34].

The current study aimed to evaluate the effect of the instructional package on maternity nurses’ knowledge regarding partogram and nursing care of the first stage of normal labor. In relation to nurses’ knowledge about nursing care of the first stage (pre/post), the present study stated that more than three-quarters of the studied nurses had complete correct answers about the definition of labor, about signs of true labor, the definition of show, and the physiological changes of the first stage of normal labor post instructional package. This result was supported by Shokry et al. (2022) in their recent study titled “Effect of supportive measures guidelines on nurses’ practices during labor, Ain Shams, Cairo, Egypt,” which reported that the majority of the studied nurses had correct answers regarding signs of true labor, mechanism, and stages of normal labor post guidelines [35].

Moreover, the current study matched Bhullar & Kaur (2022), which studied "A pre-experimental study to assess the effectiveness of STP on knowledge regarding partographs among staff nurses in selected hospitals" and indicated that more than three-quarters of the studied nurses had improvement in knowledge after the structured teaching program [36]. That agreement is due to the presence of continuous training & the effectiveness of the instructional package. Contrariwise, this finding was disagreed with by Kaur & Saini (2020), who conducted a study entitled "Knowledge and practices regarding Partograph among staff nurses working in labor room, Amritsar, Punjab" and revealed that two-thirds of the studied nurses had correct knowledge regarding the definition of labor, physiology, and signs of labor [37].

Concerning knowledge about partogram items during nursing care of the first stage of normal labor of the studied nurses, the present study clarified that more than three-quarters of the studied nurses had complete correct answers about the definition of partogram, the definition of the active phase, normal fetal heart rate, and components of progress of labor at the post-instructional package, and there was a highly statistically significant difference of studied maternity nurses regarding partogram through the instructional package. This result was supported by Ali et al. (2021), whose study "Effect of Educational Program about Partograph on Maternity Nurses Knowledge at Quena University Hospital—Egypt" indicated that the majority of studied nurses had correct knowledge about what a partogram is, the normal range of FHR, the time of starting the active phase, and the basic component of a partograph. At post-program education, there was a highly statistically significant difference in the post-program education [38]. 

Also, this result was agreed with by Lata & Verma (2025). Their study, entitled "A pre-experimental study to assess the effectiveness of a structured teaching program on knowledge and practices of partograph among staff nurses of labor rooms working in selected hospitals of Dis. Mandi (H.P), 2024-2025," revealed that there was improved knowledge of maternity nurse’s post-test and that there was statistically significant post-program [39]. Additionally, Sharma & Devi (2019), who studied "Assess knowledge and practice regarding partograph among staff nurses: a pre-experimental study," reported that there were statistically significant differences regarding knowledge of maternity nurses about the program at post-program [40]. 

Also, this result was agreed with Ali et al., (2021) that indicated that there was a highly statistically significant difference between the total knowledge score and the nurses' educational level in pre-intervention [38]. In addition to this, this result was matched with Ahmed et al. (2023), who studied the "Effect of Educational Program on Maternity Nurses' Knowledge and Practices Regarding Non-Invasive Fetal Well-Being Assessment Methods" and indicated that there was statistical significance between educational level and total knowledge score at the pre-educational program p-value [41]. This might be reflecting the positive effect of the instructional package on improving nurses’ knowledge regarding nursing care of the first stage of normal labor. The current study was in agreement with Kaur & Saini (2020), who conducted a study entitled “Knowledge and practices regarding Partograph among staff nurses working in labor room, Amritsar, Punjab” and revealed that there was a statistically significant difference between the studied nurses’ total knowledge and their training courses [37].

The study revealed that nurses' knowledge about partograms and first-stage labor nursing care improved after implementing an instructional package. This increase in correct knowledge and decrease in inaccuracies can be attributed to the package's teaching methods, reinforcement, and the use of educational materials such as brief, clear Arabic booklets [42-53]. These booklets support various educational forms and align with Edgar Dale’s Pyramid of Learning, showing that retention is maximized through diverse teaching approaches, including discussion [54-73].

Regarding the relation between their total knowledge and years of work experience of the studied nurses (pre and post), the present study showed that there was an improvement in nurses’ knowledge among all levels of years of experiences, however, no statistically significant difference between the studied maternity nurses’ total score of knowledge and years of experiences neither pre nor post instructional package implementation. Contrariwise, the current study disagreed with Wodaj et al. (2023), who studied "Evidence-based intrapartum care practice and associated factors among obstetric care providers working in hospitals of four Wollege Zones, Oromia, Ethiopia." Showed that there was a statistically significant difference between demographic characteristics, such as years of experience and knowledge about intrapartum care [74].

Occasionally, the present result was in agreement with Murn (2019), who conducted a study entitled “Mothering the mother: An Educational Program for Nurse-Provided Continuous Labor Support, USA” and found that there was no statistically significant difference between the studied nurses’ total knowledge and their years of experience, post educational program [75].

Based on the findings of the present study, it can be concluded that there were improvements in the studied maternity nurses’ knowledge regarding partogram and nursing care of the first stage of normal labor post-intervention. The level of knowledge was increased by increasing nurses’ years of experiences in both pre and post instructional package 

Recommendation

Distribute the clarified pamphlet for maternity nurses to acquire a correct knowledge regarding partogram and nursing care of first stage of labor.