by elizabeth joseph thesis submitted to
TRANSCRIPT
i
“A STUDY TO ASSESS THE EFFECTIVENESS OF LOWER LIMB MASSAGE ON
PHYSIOLOGICAL LOWER LEG/S EDEMA AND COMFORT DURING THIRD
TRIMESTER AMONG GRAVID MOTHERS IN A SELECTED COMMUNITY,
BENGALURU”
BY
ELIZABETH JOSEPH
Thesis submitted to
Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka
In partial fulfillment of the requirements for the degree of
MASTER OF SCIENCE
IN
OBSTETRICS AND GYNAECOLOGICAL NURSING
Under the guidance of
MRS MARY REXLINE S. M.Sc (N)
Assistant Professor
Department of Obstetrics and Gynaecological Nursing
St.Philomena’s College of Nursing Bengaluru
2018
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ix
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LIST OF ABBREVATIONS
Fig Figure
df Degree of freedom
H1 Research Hypothesis one
H2 Research Hypothesis two
H3 Research Hypothesis three
H4 Research Hypothesis four
N Total number of the sample
NS Non- significant
S Significant
SD Standard Deviation
< Lesser than
> Greater than
ꭓ2 Chi square
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LIST OF TABLES
TABLES
NO
TITLE PAGE
NO.
1. Comparison of pre and post intervention lower leg edema scores among
gravid mothers during third trimester.
64
2. Comparison of pre and post intervention comfort scores among gravid
mothers during third trimester.
66
3. Association between sample characteristics and pretest Erin edema
scores among gravid mothers with physiological lower leg edema during
third trimester
67-68
4. Association between sample characteristics and pretest Comfort scores
among gravid mothers with physiological lower leg edema during third
trimester.
70-71
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LIST OF FIGURES
Figure
No
Title Page
No
1. Conceptual frame work based on Katharine Kolcaba’s theory of comfort.
15
2. Schematic representation of the Research design 48
3. Bar diagram showing percentage distribution of the gravid mothers
according to their age.
53
4. Cylindrical diagram showing percentage distribution of the gravid
mothers according to their Religion
54
5. Bar diagram showing percentage distribution of the gravid mothers
according to their educational status
55
6. Bar diagram showing percentage distribution of the gravid mothers
according to their occupational status.
56
7. Bar diagram showing percentage distribution of the gravid mothers
according to their type of family
57
8. Bar diagram showing percentage distribution of the gravid mothers
according to their weeks of gestation
58
9. Bar diagram showing percentage distribution of the gravid mothers
according to maternal weight gain during pregnancy
59
10. Bar diagram showing percentage distribution of the gravid mothers
according to their pervious number of deliveries.
60
11. Bar diagram showing percentage distribution of the monthly income
of the gravid mothers.
61
12. Bar diagram showing percentage distribution of the gravid mothers
according to their pervious knowledge about lower limb massage.
62
13. Bar diagram showing Frequency and percentage distribution of pre
and post intervention lower leg edema scores among gravid mothers
during third trimester.
63
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14. Bar diagram showing percentage distribution of pre and post
intervention comfort scores among gravid mothers during third
trimester.
65
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ABSTRACT
The present study was conducted to assess the effectiveness of lower limb massage on
physiological lower leg/s edema and comfort during third trimester among gravid mothers in
Koramangala community, Bengaluru. The objectives of the study were to assess the level of
physiological lower leg/s edema and comfort during third trimester among gravid mothers, to
evaluate the effectiveness of lower limb massage on physiological lower leg/s edema and
comfort during third trimester among gravid mothers, to find out the association between the
pre interventional physiological lower leg/s edema scores and comfort scores with selected
sample characteristics. The Conceptual frame work was based on Katharine Kolcaba’s theory
of comfort which provides a comprehensive framework for achieving the objectives of the
study.
The research design selected for this study was pre experimental one group pre-test post test
design. Purposive sampling technique was adopted to select 30 samples. Lower limb
massage was performed for 5 continuous days for two times a day (morning and evening) for
a duration of 15 minutes for each leg. Post test was conducted on the fifth day. The mean
post-test physiological leg/s edema scores with a SD (4.23 ± 0.67) was less than pre-test
(10.8 ± 0.96) scores. The calculated paired ‘t’ value (14.52) was greater than the table value
(2.05) at p< 0.05. The mean post – test comfort score with SD (4.1±1.6) was less than the
pre-test score (8 ± 1.26). The calculated paired ‘t’ value (8.9) was greater than the table value
(2.05) at p< 0.05. There is no significant association found between the pre interventional
edema scores and comfort scores with sample characteristics.
xvi
Thus the findings of the study concluded that lower limb massage is effective in the
reduction of physiological lower leg/s edema and promotion of comfort during third
trimester.
KEYWORDS: Physiological lower leg/s edema, lower limb massage, third trimester,
comfort.
1
CHAPTER –I INTRODUCTION
“Pregnancy and childbirth are joyful life events in the life of a woman.”
Pregnancy is a unique, exciting and often joyous time in women’s life, as it highlights the
women’s amazing creative and nurturing powers while providing a bridge to the future.
Pregnancy is carrying fetus or embryo in the womb of the mother. It begins at
fertilization and end at the delivery of the fetus. Pregnancy lasts for 40 weeks.1
Physiological lower leg edema is common in third trimester of pregnancy. During
pregnancy, body produces approximately 50% more blood and body fluids to meet the
needs of the developing baby. Swelling is normal in pregnancy that is caused by this
additional blood and fluid. Normal swelling is also called as edema during pregnancy.
Women may suffer from various discomforts.2
Minor ailments are common during pregnancy and non-pharmacological therapies should
be considered as the first-line treatment, if appropriate such as positioning, exercises, and
lower limb massage. Use of medication during pregnancy is a secondary choice because
it has adverse effect on fetus. Lower leg edema is an almost universal finding in late
pregnancy occurring secondary to increased venous pressure in legs, obstruction of
lymphatic flow and reduced plasma colloid osmotic pressure. Gestational edema is the
development of an excessive accumulation of fluid in the tissues without co-existing
hypertension or proteinuria. Physiological lower leg edema causes discomfort during
pregnancy.3
2
Physiological lower leg edema is one of the cutaneous manifestations of pregnancy. The
weight gain during pregnancy and gravity slow the circulation of blood and body fluids
particularly in lower limbs. The swelling or edema is a common discomfort of pregnancy.
It is estimated that about 75% of women experience this excessive accumulation of fluid
around the leg and ankles during pregnancy.2
Physiological edema results from hormones induced sodium retention. Leg edema in
lower extremities may be unilateral or bilateral. Edema may also be present when the
enlarged uterus intermittently compresses the inferior vena cava during recumbency,
obstructing outflow from both femoral veins. Dorsum of the foot, medial malleolus, and
anterior 2/3rd of tibia are the common sites of physiological edema3.
Growing uterus puts pressure on the pelvic veins and the vena cava (the large vein on the
right side of the body that carries blood from the lower limbs back to the heart). The
pressure slows the return of blood from the legs, causing it to pool, which forces fluid
from the veins into the tissues of the feet and ankles. For this reason, edema is most likely
to double during the third trimester. It may be particularly severe for women
with excessive amniotic fluid or those carrying multiples. Edema also tends to be worse
at the end of the day and during the summer. After the delivery, the swelling will
disappear fairly rapidly as the body eliminates the excess fluid by urinating frequently
and sweating a lot in the first few days following childbirth.4
3
Lower limb massage has been found to decrease the level of physiological lower leg
edema. Lower limb massage means manipulation of superficial and deeper layers of
muscles and connective tissues of the limb by using different massage techniques for a
duration of 20 minutes. Lower limb massage stimulates lymphatic circulation and
decreases swelling. Massaging the leg from toes to calf muscles providing gentle pressure
with the finger tips may help to shift water out of the tissue.2
Excessive fluid retention as evidenced by marked gain in weight or evidence of
preeclampsia has to be excluded. Physiological edema causes pain and difficulty in
walking. Lower limb massage is a non pharmacological method to reduce the
physiological edema and provide comfort to the patient. Pregnancy is presumed to be a
major contributing factor in the increased incidence of varicose veins in women, which
can in-turn lead to venous insufficiency and leg edema.4
Due to venous insufficiency impaired pumping ability of the heart increases hydrostatic
and hydraulic pressure in the extremities caused by poor circulation, and venous pooling
will result in capillary leak and interstitial fluid accumulation in the dependent area such
as lower extremities. Lower limb massage is a non pharmacological method to reduce
the physiological lower leg edema. Lower limb massage stimulates lymphatic circulation
and decreases edema. Massaging the leg from toes to calf muscles providing gentle
pressure with finger tips may help to shift fluid out of the tissue.5
This study aims to reduce physiological lower leg/s edema by lower limb massage and
make the gravid mothers more comfortable during their pregnancy.
4
NEED OF THE STUDY
One of the common and annoying problems during pregnancy is physiological legs
edema that may cause activity restrictions during pregnancy.6 Leg edema from venous
insufficiency is not dangerous but it can cause symptoms such as pain, feeling of
heaviness, night cramps, and paraesthesia4. It is estimated that about 75% of women
experience excessive accumulation of fluid (edema) around the legs and ankles during
pregnancy.2
Oedema in lower limbs, unilateral or bilateral, is described as leg edema. An expansion
of interstitial fluid volume may not be discovered readily , but an excess of numerous
liters shows visible and palpable swelling. Lower limb and foot swelling is known as
peripheral edema. Pitting edema provides way on palpation, leaving persistent
impressions in the skin; brawny edema offers resistance but leaves no impressions. It can
be very normal for leg to swell during pregnancy as released hormones cause the body to
retain fluid and salt. The face may swell, as can the legs. In addition dependent
physiological lower limb oedema which means water retention in the interstitial space of
the lower extremities is a frequent unpleasant accompaniment to pregnancy. Additionally,
Peripheral edema is associated with numeral activity restrictions.4
Edema is usually evident early in the morning and lost during the day. It is important to
differentiate this edema from renal, cardiac, or pre-eclamptic edema. Edema is a common
discomfort during late pregnancy. It typically involves the lower limbs but occasionally
appears as swelling or puffiness in the face or hands. Pregnancy is presumed to be a
5
major contributory factor in the increased incidence of varicose veins in women, which
can in turn lead to venous insufficiency and leg oedema. While this condition is not
painful, it can be uncomfortable and swelling may make it difficult to put on socks or
shoes for them to fit properly. This swelling can be caused by prolonged periods of sitting
or standing and pregnancy.5
Swelling, or edema, during pregnancy is normal but can leave the expectant mother
feeling uncomfortable. In new research, foot massage has been found to decrease lower-
leg edema6.
Swelling (oedema) in pregnancy happens because body is holding onto more fluid than
usual. The increased pressure in the leg veins, and pressure from the growing baby on the
big veins in groin, adds to the problem6. Swelling is common about half of the pregnant
women experience it around their ankles, particularly in the last few months of
pregnancy. It may be found in fingers, face and the lower back may become swollen too7
Edema is a palpable swelling produced by expansion of the interstitial volume or an
increase in extracellular volume. The swelling in the legs usually gets worse towards the
end of the day, especially in feet. Gravity makes fluid collection at the lowest point in the
body. Hot weather and being tired can also make swelling worse.6
Pregnancy is one of the most important periods in human life with hormonal,
psychological, vascular, metabolic and immunologic changes. It occurs as a result of the
6
enlarged uterus intermittently apply pressures on the inferior vena cava during
recumbency, which impedes venous return; prostaglandin- induced vascular relaxation;
and reduced plasma colloid osmotic pressure. Leg oedema could be a benign
inconvenience with unknown etiology. Leg edema is a frequent presenting complaint that
demands diagnostic and referral strategies. In recent years, there has been utilization of
non-pharmacological interventions to complement modern technological medicine. It is
established popular among nurses in clinical practice. Non-pharmacological interventions
of leg oedema comprise mostly symptom reduction rather than cure.8
Pregnancy is often a time when chronic pain is exacerbated, or when acute pain, needs
prescription. Medication cannot correct the cause of the pain; instead it alters the person’s
experimental perception of the pain. In addition, medication exposes both mother and
fetus to risk. Massage during pregnancy should be pleasurable (not painful) and will
promote feeling of calmness, well-being, and relaxation. The incidence of physiological
edema during pregnancy is about 80% in India. It is recommended to provide simple,
evidence-based holistic/ alternative remedies for women who experienced non emergent
pain during pregnancy.7
Massage therapy is a natural and effective way to reduce the symptoms of edema without
any side effects. Foot massage can relieve pain and improve the blood circulation.
Prenatal massage has been used for centuries to reduce stress, improve overall health, and
relieve muscle tension. Pregnant women have often received ambivalent responses from
7
the health committee, regarding the purpose and safety of the massage during pregnancy.
Studies have proved that prenatal massage therapy can be a very instrumental tool in
women’s prenatal care and should be given with careful consideration. Massage therapy
works by directing pressure at the skin and muscle area affected by edema. The
lymphatic system is activated during the process and the fluid drains away naturally.
Prenatal massage is truly beneficial for pregnant women and the baby, while easing the
pain and discomfort of pregnancy, delivering a safe, relaxing, and effective massage.8
Physiologic edema can be reduced by intermittently lying on the left side (which moves
the uterus off the inferior vena cava), by intermittently elevating the lower extremities,
and by wearing elastic compression stockings.9
Changes in blood flow during pregnancy are likely to play a role in development of
venous insufficiency and thrombo embolic events. Venous insufficiency and varicose
disease were observed in 43% and 72.7% of pregnant women, respectively. Additionally,
50% of pregnant women complained of lower limb edema. One mechanical factor that
affects venous return is the growing uterus. In the supine position, the uterus presses on
the inferior vena cava, resulting in reduced venous return. However, the major factors
causing pregnancy-related blood vessel changes are pregnancy-related hormonal and
physiological changes. The total volumes of blood, plasma, and erythrocytes increase
during pregnancy to provide an increased blood supply to the uterus and placenta. The
total blood volume of 4000 ml prior to pregnancy increases to 5300 ml at week 36 of
gestation. During pregnancy, the number of white blood cells and blood coagulation also
increase. Furthermore, a reduction in vein wall tension can cause stagnation of blood and
swelling of the legs and women with a predisposition may develop varicose veins.
8
Additionally, vein dilatation and exposure to collagen fibers can cause endothelial
damage and lead to blood clot formation Foot massage has a positive effect on edema in
late pregnancy. Foot massage is different from reflexology. Foot massage is more general
because the manipulation of soft tissue which involves movement of extravascular fluid
without disturbing intravascular fluid. Twenty minutes of foot massage given for 5 days
to an experimental group proved effective in reducing leg circumference compared to the
control group.10
The researcher observed that gravid mothers experience physiological lower leg(s) edema
and discomforts during third trimester. Researcher’s own interest, in depth reviews and
suggestions from the experts inspired the researcher to undertake the present study to
assess the effectiveness of lower limb massage on physiological lower leg/s edema and
comfort during third trimester among gravid mothers.
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CHAPTER II
OBJECTIVES
This chapter deals with statement of the problem, objectives of the study, Hypotheses,
operational definitions, assumptions, delimitation and conceptual framework.
STATEMENT OF THE PROBLEM
A Study to Assess the Effectiveness of Lower Limb Massage on Physiological Lower
Leg/S Edema and Comfort during Third Trimester among Gravid Mothers in a Selected
Community, Bengaluru.
OBJECTIVES:
• To assess the level of physiological lower leg/s edema and comfort during third
trimester among gravid mothers.
• To evaluate the effectiveness of lower limb massage on physiological lower leg/s
edema and comfort during third trimester among gravid mothers.
• To find out the association between the pre interventional physiological lower leg/s
edema scores and selected sample characteristics.
• To find out the association between the pre interventional comfort scores and selected
sample characteristics
10
HYPOTHESES
At 0.05 level of significance
• H1: There will be a statistically significant difference in the physiological lower leg/s
edema scores before and after the lower limb massage among gravid mothers during
third trimester as measured by using Erin edema scale.
• H2: There will be a statistically significant difference in the comfort scores before and
after lower limb massage among gravid mothers during third trimester as measured
by using comfort scale.
• H3: There will be a statistically significant association between pre interventional
physiological lower leg/s edema scores among gravid mothers during third trimester
and selected sample characteristics .
• H4: There will be a statistically significant association between pre interventional
comfort scores among gravid mothers during third trimester and selected sample
characteristics.
RESEARCH VARIABLES
Independent variable: Lower limb massage
Dependent variables: Physiological lower leg/s edema and comfort.
Extraneous variables: Age, religion, education status occupation, type of family, weeks
of gestation, maternal weight gain during pregnancy, family income/ month, number of
previous delivery, and previous information about lower limb massage.
11
OPERATIONAL DEFINITIONS
Effectiveness: In this study, it refers to the extent to which lower limb massage
causes a desired effect in terms of physiological leg/s edema and comfort scores
among gravid mothers during 3rd trimester of pregnancy as measured by using Erin
edema scale and comfort scale.
Physiological leg/s edema: In this study it refers to the swelling assessed on dorsum
of the foot, medial malleolus, and anterior lower 2/3rd of tibia among gravid mothers
during 3rd trimester of pregnancy as measured using Erin edema Scale.
Comfort: In this study, it refers to the state of feeling at ease experienced by gravid
mothers during 3rd trimester of pregnancy as measured using comfort scale.
Third trimester: In this study, it refers to the last 3 months of pregnancy.
Gravid mothers: In this study, it refers to female individuals who were pregnant
with the gestational age between 28-40 weeks.
Lower limb massage: In this study it refers to the sequentially articulated
movements applied to the lower extremities comprising of circular massage from the
anterior lower 2/3rd of the tibia to dorsum of foot, circular massage over the medial
malleolus in clockwise and anti clock wise direction and finger walking massage in
the dorsum of the foot (each for five times) twice a day (morning and evening) for a
total duration of 15 minutes for each leg for a period of 5 consecutive days.
ASSUMPTIONS
• Gravid mothers may experience physiological leg/s edema during third trimester.
• Edema may cause discomfort to gravid mothers during third trimester.
12
• Foot massage may have an effect on physiological leg edema.
DELIMITATION
The study is delimited to gravid mothers who:
• had physiological lower leg/s edema during third trimester of pregnancy .
• were in the Koramangala community.
CONCEPTUAL FRAMEWORK
Conceptualization is the process of forming ideas, design and plans. The conceptual
model act as a guide for the research process in each step.11
The Kolcaba’s theory of comfort considers patients to be individuals, families,
institutions or communities in need of health care. Nursing is described as the process of
assessing the patient’s comfort needs’ developing and implementing appropriate nursing
care plans and evaluating the patient’s comfort after the care plans have been carried
out.12
The main concepts of Kolcaba’s Theory of Comfort are
Health care needs
Intervening variables
Health seeking behaviour
Institutional integrity
13
Best policies and procedures
HEALTH CARE NEEDS
Kolcaba includes health care needs which are defined as those needs identified by the
patient and/or family in a particular nursing practice setting.13
In this study health care needs are discomfort during pregnancy due to physiological
lower leg/s edema.
INTERVENING VARIABLES
Intervening variables are factors that are not likely to change, and over which health care
providers have little control.13These variables include prognosis, financial situation,
social support and others. In this study the intervening variables are age, education,
occupation, type of family, number of deliveries, maternal weight gain during pregnancy,
family income/month, number of previous deliveries, week of gestation, and information
obtained regarding lower limb massage.
HEALTH SEEKING BEHAVIOURS
Health- seeking behaviors are the behaviors of a patient in an effort to find health.13 In
this study the heath seeking behavior is the internal behaviour of accepting lower limb
massage to relieve discomfort caused by physiological leg/s edema.
14
INSTITUTIONAL INTERGRITY
The quality or state of health care organization as complete, whole, sound, upright,
professional, and ethical providers of health care.13 In this study foot massage being a
cost effective procedure is recommended in an institution for a large population in reducing
physiological lower leg edema among gravid mothers.
BEST PRACTICES AND POLICIES
Finally, best policies are protocols and procedures developed by an institution for overall
use after the collection of evidence.13 In this study best practice refers to the
incorporation of foot massage for physiological lower leg/s edema among gravid mothers
during third trimester of pregnancy. In this study best policy refers to the motivation of
administrators to frame policies incorporating foot massage in the health care setting on a
large scale.
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Health care
needs
Discomfort
due to
physiologic
al lower
leg/s
edema.
Nursing
interventions.
-Pretest
-Routine
nursing care
- Lower limb
Massage
Intervening
variables
Age, Education,
Occupation,
Type of family,
Religion,
Family Income
per month in
rupees, Number
of previous
deliveries,
Maternal
weight gain
during
pregnancy,
Weeks of
gestation,
Previous
information
about lower
limb massage
Enhanced comfort
Circular massage
on lower 2/3rd of
the tibia, dorsum
of the foot and
medial malleolus
Health
seeking
Behaviour
Internal
behaviour
Reduction of
lower leg/s
edema due to
lower limb
massage
ERIN EDEMA
SCALE
None, Trace, Mild,
Moderate, Severe.
COMFORT
SCALE.
Very comfortable,
Less comfortable,
Discomfort, Moderate
discomfort, Serious
discomfort, Extreme
discomfort
Post-test
Institutional
integrity
Implementatio
n of lower
limb massage
being a cost
effective
procedure is
recommended
in an
institution for
a large
population.
Best practice
Lower limb massage
being an evidence
based practice can be
recommended in
hospital and
community
Best policies
Framing policies to
incorporate the use of
lower limb massage in
reducing the discomfort
due to physiological
lower leg/s edema
among gravid mothers
in the health care
settings.
External
behaviour
Sample will recommend lower limb massage to other gravid mothers to reduce physiological lower leg/s edema
FIGURE :1 CONCEPTUAL FRAME WORK BASED ON KATHARINE KOLCABA’S THEORY OF COMFORT
Not included in the study
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CHAPTER III
REVIEW OF LITERATURE
A literature is a critical summary of research on the topic of interest . Review of literature
provides a current theoretical and scientific knowledge about a particular problem and
resulting in a synthesis of what is known. Researcher usually undertakes a thorough
literature review to familiarize them with the knowledge base14.
The researcher carried out an extensive review of literature on the research topic in order
to gain deeper insight into the problem as well as to collect maximum relevant
information for building up the present study. This was accomplished by using PubMed,
Google, and survey of the latest journals and books.15
The literature review of the present study is organized and presented under following
headings.
Review of literature for the present study is organized as follows
Literature related to
1. Minor ailments during pregnancy.
2. Physiological leg edema and discomfort during pregnancy.
3. Various complementary therapies used in the reduction of edema
4. Effectiveness of foot massage in reduction of physiological leg edema.
17
Literature related to minor ailments during pregnancy
A descriptive study to assess the prevalence of minor ailments during pregnancy, home
care remedies adopted by primigravida antenatal mothers, and to develop an information
booklet regarding the management of minor ailments was undertaken in a selected
hospital of Delhi. The objectives of the study were to assess prevalence of minor ailments
during pregnancy among primigravida antenatal mothers, to assess the home care
remedies adopted for minor ailments during pregnancy by antenatal primigravida mothers
and to develop an information booklet regarding the management of minor ailments. A
total of 30 antenatal primigravida mothers, were selected from a selected hospital of New
Delhi, using purposive sampling technique. The tools used for data collection were semi-
structured interview schedule to determine the demographic data as well as to assess the
occurrence of minor ailments during pregnancy and home care adopted by them. Data
collection was done on 5 May, 2017 among primigravida antenatal mothers.The study
reveals that, out of 30 antenatal mothers, fatigue was present in 20 (67%) subjects,
micturition was present in 12 (40%) subjects, heartburn was present in 7 (23%) subjects,
anorexia was present in 13 (43%) subjects, backache was present in 18 (60%) subjects,
constipation was present in 10 (33%) subjects, morning sickness was present in 23 (77%)
subjects, headache was present in 15 (50%) subjects, leg cramps were present in 22
(74%) subjects, lack of sleep was present in 11 (37%) subjects, excessive white discharge
was present in 12 (40%) subjects, edema of lower extremities was present in 13 (43%)
subjects, generalized itching was present in 11 (37%) subjects, excessive salivation was
present in 4 (13%) subjects, varicose vein was present in 2 (7%) subjects, carpel tunnel
syndrome was present in 12 (40%) subjects, pruritis vulva was present in 6 (20%)
18
subjects and none of them were having piles. Edema of lower extremities was prevalent
in 43% of primigravid mothers. Significant findings of the study were that all the
antenatal mothers experienced minor ailments during their pregnancy.16
A non-experimental descriptive survey study was conducted on Yenepoya Nursing
College, Mangalore to assess the knowledge on minor ailments of pregnancy and its
management among antenatal mothers. A structured knowledge questionnaire regarding
minor ailments of pregnancy and its management was prepared in order to assess the
knowledge of antenatal mothers. A sample of 100 antenatal mothers were selected by
using non probability purposive sampling technique. The study reveals that 17 percentage
of the mothers had good knowledge, 49 percentage of mothers had average knowledge,34
percentage of the women had poor knowledge. The mean percentage of knowledge of the
antenatal mothers regarding minor ailments of pregnancy and management was 3.33
percentage. The association of the knowledge score with demographic variables were as
follows; age (χ2=0.432,P>0.05), parity (χ2=0.152, P>0.05), religion (χ2=0.005, P>0.05),
education (χ2=0.538, P>0.05), occupation (χ2=0.20, P>0.05), type of family (χ2=0.246,
P>0.05),income (χ2=0.025, P>0.05), and source of information (χ2=0.047, P>0.05). The
result of the study shows that there is no significant association between the knowledge
score with selected demographic variable.17
A cross sectional study was carried out in Anuradhapura district, Sri Lanka. Pregnant
women residing in the Anuradhapura district with a gestational age more than 24 weeks
through 36 weeks were recruited to the study using a two-stage cluster sampling
19
technique. All pregnant women who consented participated in a detailed interview using
a structured questionnaire. Self reported episodes of acute illness during pregnancy were
the main outcome measures. Secondary outcomes were utilization of medical services
and frequency of hospitalizations. The study revealed that Nausea and vomiting during
pregnancy (NVP) was experienced by 325 (69.7%) of the 466 pregnant women studied.
Other common symptoms were backache (152, 32.6%), dizziness (112, 24.0%) and
heartburn/regurgitation (107, 23.0%). Of the 421 pregnant women who reported ill health
conditions 260 (61.8%) women sought medical treatment for these illnesses. Total
number of episodes that needed treatment seeking was 373. Hospitalizations were
reported by 83 (17.8%) pregnant women and the total number of hospitalizations was
109. The leading cause of hospitalization was NVP which accounted for 43.1% of total
admissions and 49.1% of total days spent in hospitals. The study concluded that Minor
maternal ill health conditions affecting day-to-day life have a major burden on pregnancy
period. Evidence based management guidelines and health promotion strategies are
needed to control and prevent these conditions, in order to provide comprehensive, good
quality maternal health care.18
A descriptive study was conducted in Amrita college of Nursing in Kochi to identify the
prevalence of minor ailments of pregnancy and to assess the knowledge
regarding selected minor ailments among antenatal mothers. Descriptive survey design
was used. Sixty antenatal mothers attending Obstetrics and Gynecology OPD, AIMS,
Kochi were selected using quota sampling technique including 30 primigravida and 30
multigravida mothers. Demographic variables and knowledge regarding minor ailments
20
of pregnancy were collected using a semi- structured questionnaire. The prevalence of
minor ailments of pregnancy was identified by a checklist. The study reveals that the
most common minor ailments were frequency of micturition(80%), nausea and vomiting
(80%), fatigue(80%), back pain(70%) and leg cramps(55%). Knowledge regarding minor
ailments of pregnancy was good in 54%, average in 41% and poor in 5%. There was no
significant difference between knowledge and prevalence of minor ailments between
primi and multi gravida. The result of the study suggest that health education should be
provided to all the antenatal mothers regarding minor ailments of pregnancy and
its management.19
A descriptive study was conducted in North Iran to assess the knowledge and practices
of pregnant women regarding minor discomforts during pregnancy. The study was
conducted among 370 healthy pregnant women at four Primary Health Care Centers
(Nazdar bamarni- Nawroz- Brayati- Kurdistan) in Erbil City from October 2014 to
November 2015. Data were collected through interview by using questionnaire.
Questionnaire was designed and divided into four parts; the first part includes socio-
demographic characteristics of pregnant women, the second part contains obstetric
history, the third part deals with knowledge about minor discomforts and the fourth part
comprises ten areas of practical care regarding minor discomforts during pregnancy. The
questionnaire contains 53 items using 3 Likert scales. Reliability was determined by 24
experts. The results showed that the majority of the study sample was between 18-25
years old, secondary school graduates, housewives and nuclear families. The evidence
from this study showed that self management was poor and pregnant women had fair
21
knowledge. Finding of the study revealed that self management practices of pregnant
women regarding minor discomforts were very poor also. The result shows that minor
discomforts were very common, and were reported by 50% - 80% of pregnant women.
Nausea occurred in 80-85% of all pregnancies during the first trimester, heartburn
occurred in 30% to 50% of pregnancies, with prevalence approaching 80% in some
populations. Leg cramps have been reported by 30% of pregnant women, most
commonly in the second and third trimester. They usually affect the calves and occur at
night in 75% of cases. Fifty percent to 70% of all pregnant women may have back pain.
The prevalence of constipation in pregnancy is reported to be between 11% and 38 %.
These minor discomforts might affect the health of mother and fetus lifestyle is affected
by physical and mental functions therefore, if pregnant women are helped to change
behaviors related to lifestyle, it effectively restores their health. 20
A quasi-experimental study was conducted by Nancy College of Nursing, Nainital,
Uttarakhand, India,to find the effectiveness of a structured teaching program on the minor
disorders of pregnancy and their home management. Hundred antenatal mothers were
selected by Consecutive sampling technique. Pre and post test was conducted without
control group. Semi structured interview method was used to collect the reliable data
from the study participants. The tools used for the study were structured demographic
questionnaire and closed-ended questionnaire to assess the knowledge regarding minor
disorders of pregnancy and their home management consecutively recruited from a
selected setting. The study revealed that before the implementation of a planned teaching
program, the antenatal mothers showed a poor knowledge of the common minor
22
disorders (19.56 ± 12.73), whereas after the implementation, the knowledge significantly
improved with the difference of 18.02 ± 0.742 revealing the effectiveness of the planned
teaching program. The study concluded that teaching about minor disorders of pregnancy
and its home management helps the mothers to manage their minor disorders at home
itself and continue their pregnancy more comfortably and securely.21
An Evaluative study was conducted in Karad to assess the knowledge on minor ailments
of pregnancy among primipara mothers, before and after intervention, to assess
effectiveness of Self Instructional Module [SIM] versus health education on minor
ailments of pregnancy and to find an association between knowledge and socio
demographic variables. The study was conducted among 120 Primi para mothers using
pre test post test control group design at Antenatal clinic of Krishna Hospital Karad by
using Random sampling technique. The tool used for gathering data was a structured
interview questionnaire on knowledge of minor ailments of pregnancy and its home
remedies as per trimester wise. The study revealed that all the primipara mothers did not
have 100% knowledge. They require teaching to promote their knowledge and skills
during their pregnancy. Enough knowledge helps them to cope with the minor ailments of
pregnancy. The study reveals that they need SIM on minor ailments of pregnancy and its
home remedies. Study concluded that the Self instructional module (SIM) on minor
ailments of pregnancy and its home remedies was effective.22
23
A descriptive study was conducted in Mangalore to assess the knowledge of primi
mothers on self-management of minor discomfort of pregnancy with a view to develop
information was carried out in Justice K.S Hegde Charitable hospital among 100
primigravida mothers by using purposive sampling technique. The findings of the study
showed that 87% of the Primigravida mothers were in the age group of 21 – 30 years,
37% of the women had high school education, 70% of the subjects were Hindus, 77%
belonged to joint families and 53% were in the gestational age group of 29 – 40 weeks.
Most (59%) of the Primigravida mothers had poor knowledge, 29% had average
knowledge, and 12% had good knowledge regarding minor discomforts of pregnancy and
its self-management. Area wise knowledge of Primigravida mothers reveals deficiency in
most of the areas, but the lowest mean percentage of score is 28.25% with a standard
deviation of 1.74 in the area of knowledge related to Circulatory and Nervous system,
which indicated that the maximum knowledge deficit is in this area. There was significant
association between knowledge of Primigravida mothers age, and educational
qualification. The calculated chi square values were 3.953 and 12.603 respectively which
are more than the table value 3.84 and 7.82 at 0.05% level of significance. The result of
the study proved that Primigravida mothers had poor knowledge regarding minor
discomforts of pregnancy and its self management. The findings of the study showed that
there was a need to educate all women on preparation towards motherhood. 23
24
Literature related to physiological leg edema and comfort during
Pregnancy
A study was conducted in Frontier Nursing University on “comfort over pain in
pregnancy”. Pregnancy is often a time when chronic pain is exacerbated, or when acute
pain appears. Frequently the easiest intervention within reach, for both chronic and acute
pain, is a prescription. However, medication cannot correct the cause of the pain; instead
it alters the person's experiential perception of the pain. In addition, medication exposes
both mother and fetus to risks. To provide simple, evidence-based, holistic/alternative
remedies for women who experienced non emergent pain during pregnancy. The subjects
consisted of 89 primipara and 78 multipara. Holistic/ alternative techniques for increasing
comfort were taught (positioning and massage) to the participants and individualized
during three sessions. Holistic/alternative techniques for increasing comfort were taught
to the participants and individualized during three sessions. Levels of pain and comfort
were measured before and after the treatment, using the validated General Comfort
Questionnaire and Pain Outcomes Profile. Pain scores decreased from an average of
5.8/10 to 3.5/10 (p = .00). Comfort scores increased from an average of 17.5 to 30 (p =
.00 )24
A descriptive, longitudinal correlational study was conducted in Japan. The purpose was
to clarify the relationship between comfort in late pregnancy and maternal role attainment
and childcare during early postpartum. Data was collected using the Prenatal Comfort
Scale, the postpartum Maternal Role Confidence Scale, and the postpartum maternal
satisfaction scale. The sample consisted of 339 participants who had received care at a
25
university hospital located in Sendai city in Japan. Two hundred and fifteen subjects
completed the longitudinal study by answering a questionnaire for the respective Scale
late in their pregnancy or during early postpartum. The subjects consisted of 114
primipara (32±5.4 years) and 101 multipara (33.4 ± 4.9 years ). The result of the study
revealed that in primipara, comfort with motherhood was significantly correlated with
maternal confidence regarding knowledge and childcare skills and maternal satisfaction.
In multipara, comfort in late pregnancy was related to maternal confidence and
satisfaction. Positive effect was related to maternal confidence and maternal satisfaction
in early postpartum. Therefore, a prenatal nursing intervention helps women become
more comfortable with impending motherhood, thereby promoting maternal role
attainment after delivery.25
A study was conducted by Kasturba Hospital, Manipal in India to assess the Prevalence
of Musculoskeletal Dysfunctions among Indian Pregnant Women. Pregnancy triggers a
wide range of changes in a woman’s body leading to various musculoskeletal
dysfunctions. Most commonly reported musculoskeletal discomforts by pregnant women
are low back pain and symphysis pubis pain. The culture and the environmental factors
may influence the discomforts experienced by a pregnant woman. There is a dearth of
literature in India, regarding the common musculoskeletal dysfunctions experienced by a
pregnant woman. A questionnaire method used to identify the musculoskeletal
dysfunction was developed; content was validated and was translated to local languages
through parallel back translation. Two hundred and sixty one primiparous pregnant
women participated in the study and filled the questionnaire in their native language. The
study reveals that among the musculoskeletal dysfunctions reported by the pregnant
26
women, 64.6% reported calf muscle cramps, 37.1% reported foot pain, and 33.7%
experienced low back pain in their third trimester. In the second trimester, common
musculoskeletal dysfunctions experienced by the women were that of calf pain (47.8%),
low back pain (42%), and pelvic girdle pain (37%).The study conclude that
Musculoskeletal dysfunctions and general discomforts very commo nly affect the
activities of daily living of pregnant women. Understanding the common discomforts
during various trimesters of pregnancy will help to develop a comprehensive program for
prevention and cure.26
A survey was conducted in two hospitals (Lahore general hospital and Lady Willington
hospital in Jan. 2015 in Lahore to determine the frequency of lower extremity edema
during third trimester of pregnancy. A self-administered questionnaire was used to check
the lower extremity edema during third trimester of pregnancy in both the hospitals. One
hundred and ten female patients were taken in the beginning of which ten (10) patients
refused to participate whereas one hundred (100) patients willingly opted the inspection.
After collection, data was entered in computers, using SPSS Software, version 20. Data
were cleaned, organized and variables of interest were cross-matched. The majority of
female patients were with the mean age of 26 Years and a standard deviation of 4.00. Out
of 100 women, maximum were Multigravida (65%) and maximum (60%) were in their
9th month of pregnancy. 67% were those in which edema was present and 33% were
without edema. 49% women were having edema around feet, 4% around sacral region,
14% around both regions. 60% women presented with pitting edema, 7% with non-pitting
27
edema. 89% women were having pain in their lower extremities, 76% were having
feeling of heaviness in their lower extremities and 84% were found to have difficulty in
performing functional activities. 58% women were not having prolonged sitting/standing
posture. Maximum women with presence of edema were Multigravida (36%) and parity
status significantly influenced the presence or absence of edema (p-value 0.001).
Maximum frequency of edema (42%) was shown by women of 9th month (p-value 0.68).
Out of 67 women with edema, 34 were having prolonged sitting/standing posture (p-
value 0.10) The study concluded that most of the females suffer from lower extremity
edema during pregnancy especially in 3rd trimester.27
A cross sectional study was conducted in Saudi Arabia to assess the knowledge and
practices of primigravida women regarding minor and common pregnancy discomfort at
Obstetrics & Gynecology Outpatient Department (antenatal clinic) of Maternity &
Children Hospital in Dammam city (MCH) from the beginning of March 2017 to the end
of April 2017. Total of 82 primigravida women have participated in this study, who met
the inclusion criteria. The main result suggests that most of the mothers (59%) had good
knowledge, 32% had excellent knowledge and only 2% of them had poor knowledge.
This study also shows that the overall level of measures practiced by the primigravida
women to relieve their discomforts during pregnancy were with good practice score
(47.0%). The study concluded that primigrvida women show good level of knowledge
scores and also good level of measures practiced by them to relieve their discomforts
during their pregnancy. However, the current study recommends further research to
28
investigate the unsafe practices related to minor discomforts during pregnancy and its
effect on the mother and fetus.28
Literature related to various complementary therapies used in the
reduction of edema
A retrospective study was conducted in Poland to assess the risk factors and to analyze
methods applied in the prevention and treatment of lower limb edema in pregnant women
with a particular focus on compression therapy and exercise. Fifty-four women during the
early 24-hour period following delivery were assigned to two groups—either to a group
with swellings of lower limbs during pregnancy, located mostly in the region of feet and
lower legs (Group A, n = 42), or to a group without edema (Group B, n = 12). Two
subgroups, namely A1 and A2, were additionally distinguished in Group A. Compression
therapy that consisted in wearing circular-knit compression garments, usually at
compression level 1 (ccl1), with three cases of compression level 2 (ccl2) was applied
only in Group A1 (n = 18 women). The study reveals that there is a link between the
occurrence of edema during pregnancy on the one hand and the pre gravidity episodes of
venous conditions (vascular insufficiency and thrombosis, p < 0.05) and the lack of
physical exercise during pregnancy (p = 0.01) on the other hand. However,
interdependence between the occurrence of edema and the number of times a female had
been pregnant, physical activity before gravidity, or body mass index before gravidity has
not been identified. Only 33% of the analyzed women applied compression therapy
during pregnancy; a half of them continued to apply compression during the postpartum
29
period. The study concluded that Compression therapy in combination with proper
physical exercises appears to be an effective means to prevent and treat venous
thrombosis and lower limb edema in pregnant women, yet further research in line with
the principles of evidence-based medicine is required.29
A study was conducted to assess the Response of Pregnancy Leg Edema to a Single
Immersion Exercise Session. Dependent leg edema is not uncommon in pregnant women
and may cause pain with each step. In addition to compression stockings and leg
elevation, immersing the extremities in water is beneficial. This prospective trial
evaluated a single session of immersion exercise in 9 women (32 to 36 years of age) who
had marked edema but otherwise uncomplicated pregnancies at 25 to 39 weeks gestation.
Only one of the women was parous. A few hours after the midday meal, the women had a
45-minute session of upright water immersion exercise. A vest, worn like a backpack,
kept the wearer afloat and immersed to the axillae without the need for extremity
movements. After warming up for 5 minutes, the women performed coordination
exercises for 10 minutes and a range of running sequences for 30 minutes. Lower leg
volume was measured in triplicate by the displacement method using a polyurethane
vessel with an overflow device. Supine lower leg circumference also was measured
before and after immersion exercise. A single session decreased the volume of both legs
by an average of 6.3% on the left and 4.9% on the right. Lower leg circumference
decreased significantly on both sides. Maternal heart rate did not change significantly
after immersion exercise, but during the session, the rate increased by 15 beats per minute
on average. Systolic blood pressure increased significantly 1 minute after exercise, from
124 to 130 mm Hg, and nearly significantly after 5 minutes. Diastolic blood pressure,
30
however, remained unchanged. The women felt very positive about the beneficial effects
of immersion exercise on leg edema. A single 45-minutes session of immersion exercise
effectively and safely improved marked lower leg edema in these women. This form of
exercise could complement or supplant the use of compression stockings as a means of
reducing dependent edema in pregnant women.30
A study was conducted in North America to determine the effectiveness of water
immersion as a means of reducing peripheral edema during the last 6 weeks of
pregnancy. Thirty-two pregnant women in their 34th weeks of a normally progressing
pregnancy were assigned randomly to either standing water immersion (16) or to sitting
upright in a chair with legs elevated at poolside (16). Subjects in the water group (W)
were immersed up to the Xiphoid process for 20 minutes in a swimming pool (85–90°F).
Subjects in the land group (L) sat in a chair with both feet elevated for 20 minutes.
Changes in right foot volume were quantified by foot volumetric immediately pre and
post intervention. The study results reveals that Right foot volume decreased 38 ± 18
ml (mean ± SD) for W and increased 2 ± 14 ml for L (P < .001 for between groups).The
present study concluded that Water immersion for 20 minutes is an effective means of
decreasing pedal edema during pregnancy.31
A quasi experimental, comparative study was conducted on Mansoura university Hospital
to assess the effectiveness of Leg Elevation versus Water Immersion on Leg Edema in
Third Trimester of Pregnancy. Lower extremities edema is a common complaint during
pregnancy and associated with daily activity limitations. Common intervention to reduce
31
edema includes leg elevation and immersion in water which represents potential
interventions to eliminate or minimize some of the functional limitations associated with
legs edema during pregnancy. This study aimed to evaluate effect of leg elevation versus
water immersion on leg edema in third trimester of pregnancy. The study was conducted
in Antenatal Clinics of the Obstetrics and Gynecology Department in Mansoura
University Hospital. The samples are selected through purposive sampling technique
sample of the study consist of 80 pregnant women who were randomly chosen and
divided into two equal groups for sitting upright in a chair with legs elevated or immersed
their legs in water for 20 minutes, Changes in leg volume of edema were assessed by
pitting edema techniques immediately pre and post intervention, immediately and after
two weeks. This study revealed that highly significant variations between pre- and post-
interventions for both groups and equal, non significant differences between both
interventions (leg elevation and water immersion). The study concluded that leg elevation
and water immersion are necessary to alleviate edema in lower extremities during
pregnancy. 32
A study was conducted in Masaryk University Brno Czech Republic on Changes in lower
extremity blood flow during advancing phases of pregnancy and the effects of special
footwear. During pregnancy, a number of changes affecting venous blood flow occur in
the circulatory system, such as reduced vein wall tension or increased exposure to
collagen fibers. These factors may cause blood stagnation, swelling of the legs, or
endothelial damage and consequently lead to development of venous disease. The aim of
this study is to evaluate the effect of special footwear designed to improve blood
circulation in the feet on venous blood flow changes observed during advancing phases
32
of pregnancy. The study consist of Thirty healthy pregnant women participated in this
study at 25, 30, and 35 weeks of gestation. Participants were allocated at random to an
experimental group (n = 15) which was provided with the special footwear, or a control
group (n = 15). At each data collection session, Doppler measurements of peak systolic
blood flow velocity and cross-sectional area of the right popliteal vein were performed
using a MySonoU6 ultrasound machine with a linear transducer (Samsung Medison). The
differences were compared using Cohen’s d test to calculate effect size.The study
revealed that with advancing phases of pregnancy, peak systolic velocity in the popliteal
vein decreased significantly in the control group, whereas it increased significantly in the
experimental group. No significant change in cross-sectional area was observed in any of
the groups. The study findings concluded that the experimental group demonstrated that
wearing the footwear tested may prevent venous blood velocity from reducing during
advanced phases of pregnancy. Nevertheless, there is a need for further investigation of
the beneficial effect on venous flow of the footwear tested and its application.33
Literature related to effectiveness lower limb massage in reduction of
physiological leg edema
A single – blinded randomized controlled trial was conducted to explore the differential
effects of “Two different foot reflexology techniques with a period of rest on edema –
relieving effects and symptoms relief in healthy pregnant women with foot edema”. A
sample of fifty- five women in the third trimester were randomly assigned to one of the
three groups: a period of rest, ‘relaxing’ reflexology techniques or a specific ‘lymphatic’
33
reflexology technique for 15 minutes with pre-and post- therapy ankle and foot
circumference measurements and participant questionnaire. The result of the study
showed that, there was no statistically significant difference in the circumference
measurements between the three groups; however, the lymphatic technique reflexology
groups’ mean circumference measurements were all decreased. A significant reduction in
the women’s symptom mean measurements in all groups (p<0.0001) was apparent. A
‘perceived wellbeing’ score revealed that the lymphatic technique group (p<0.0001)
significantly increased their wellbeing the most, followed closely by relaxing techniques
(p<0.0001) and then the control rest group (p<0.03). Lymphatic reflexology techniques
and a period of rest had a non – significant oedema- relieving effect. From the women’s
viewpoint’ lymphatic reflexology was the preferred therapy with significant increase in
symptom relief.34
A non- randomized clinical trial was performed in 2012, among 120 pregnant women
aged 20 to 35 years who were assigned to treatment and control groups. Treatment group,
received 20 minutes daily foot massage during 5 days. Data were analyzed using SPSS
statistical software, independent t-test and Mann- Whitney U test. Foot edema was
measured by using a measuring non- elastic tape on the leg.10 The results indicates a
statistically significant difference between the average of the feet environments (around
the ankle, heel and metatarsal joints between the bones) in both treatment and control
groups (p<0.001).The results of the study showed that massage therapy was effective in
reducing physiological edema during pregnancy. Therefore the lower limb massage can
be performed by trained midwives and as a useful, low risk and low cost method in
prenatal clinics or pregnant women homes35.
34
A study was conducted to evaluate the effectiveness of foot massage on reduction of
physiological lower leg edema among Primigravid mothers during third trimester in
Elariyampannai, Primary Health Center, Virudhunagar district Tamilnadu. The study
comprised of 60 samples selected by purposive sampling method. Demographic data was
collected through interview method, and pre-test was assessed using Erin Oedema Scale.
Foot massage was given over 20 min for each leg .The results concluded that the mean
value of post test level of physiological lower leg oedema after receiving foot massage
was 2.38 and it was more than the pretest mean value 0.58. The calculated t test value
7.51 showed that there was a significant difference in the effectiveness of foot massage
at p<0.05 level.36
A study titled ”The natural state of pregnancy also has its disorderly side” was conducted
in Australia Hospital midwives in Australia recruited fifty five women in their third
trimester of pregnancy to test the effect of foot massage for the foot and the ankle edema
(2003). The women were assigned to three groups: foot massage focused on relaxation
zones; foot massage focused on reflex on zones to the lymphatic system; and a rest
period. Ankle and foot circumference measure were taken before and after a fifteen –
minutes intervention or rest period and participants completed a symptamatology
questionnaire. The result of the study shows that edema measurements showed a
significant reduction for all groups, but what was more interesting is the step increase in
sense of well-being across groups, with the most significant increase documented for the
35
lymphatic reflexology group. A majority of those receiving the foot massage intervention
reported feeling of profound relaxation.37
A study was conducted in Australia to evaluate the effect of foot massage for decreasing
physiological lower leg edema in late pregnancy, Eighty pregnant women were
randomly divided into two groups; study group had a twenty minute foot massage daily
for five days whereas the control group did not receive any intervention beyond standard
prenatal care. The result obtained from the research, showed that foot massage was found
to have a positive effect on decreasing normal physiological lower leg edema in late
pregnancy.38
A Single- blind trial addressing the differential effect of two reflexology techniques
versus rest, on ankle and foot edema in late pregnancy was conducted to assess if the foot
massage had a positive effect on decreasing the normal physiological ede ma of late
pregnancy. The study group had a 20 minute foot massage daily for five days whereas the
control group did not receive any interventions beyond standard prenatal care. Compared
with the control group, women in the experimental group had a significantly smaller
lower leg circumference (right and left ankle instep and metatarsal- phalanges joint) after
5 days of massage; the control group tended toward increased circumferences. The study
conclude that foot massage is more effective in reduction of physiological foot edema39
A study conducted to assess the effectiveness of self massage on reduction of edema and
pain in lower extremity after completing a nurse’s daily shift was conducted in Korea.
36
Non equivalent control group pretest- post test design was used for the same. There were
81 nurses who took part in self leg massage program developed by the researcher. There
was a statistically significant difference in lower extremity edema and pain in nurses after
the shift and self leg massage.40
A study was conducted in Malta, to evaluate the impact of pregnancy on foot
health. A prospective non-experimental study was conducted. The authors interviewed 40
expectant Maltese mothers using the Bristol Foot Score (BFS). Results showed a
significant difference (p < 0.001) in foot health in the recruited subjects from Time 0 (15
weeks pregnancy) to Time 1 (37 weeks pregnancy), implying that pregnancy imposes a
negative impact on foot health. This finding is of key importance and needs to be taken
into consideration by all health stakeholders if better health care is to be offered to all
expectant mothers. Both locally and internationally, antenatal care aims to monitor
pregnant women’s general health and foetal development. However, very little attention
is given to foot health. The authors highlight the importance of providing all expectant
mothers with foot care education and podiatry services in the Antenatal Clinic.41
A study was conducted in USA to assess any form of intervention used to relieve
the symptoms associated with varicose veins and leg oedema in pregnancy. The study
consists of 356 women who were selected by randomized trial .Two studies were
placebo-controlled trials. The first one compared a phlebotonic (rutoside) with placebo
for the reduction in symptoms of varicose veins; the second study evaluated the efficacy
of troxerutin in comparison to placebo among 30 pregnant women in their second
37
trimester with symptomatic vulvar varicosities and venous insufficiency in their lower
extremities. Two trials compared either compression stockings with resting in left lateral
position or reflexology with rest for 15 minutes for the reduction of leg oedema. One trial
compared standing water immersion for 20 minutes with sitting upright in a chair with
legs elevated for 20 minutes. Foot massage versus routine care One trial, involving 80
women reported a significant difference in lower leg circumference when foot massage
was compared against routine care (MD -0.11, 95% CI -1.02 to 0.80).Women standing in
water were allowed to stand or walk in place. One trial compared 20 minutes of daily foot
massage for five consecutive days and usual prenatal care. The final trial compared three
treatment groups for treating leg oedema in pregnancy. The first group was assigned to
lateral supine bed rest at room temperature, women in the second group were asked to sit
in a bathtub of waist-deep water at 32 ± 0.5 C with their legs horizontal and the third
group included the women who were randomized to sitting immersed in shoulder-deep
water at 32 ± 0.5 C with legs extended downward. One trial, involving 80 women
reported that significant difference in lower leg circumference when foot massage was
compared against routine care (MD -0.11, 95% CI -1.02 to 0.80). so the study conclude
that Foot massage more effective than routine care for treating leg edema in
pregnancy.42
38
CHAPTER IV
METHODOLOGY
Methodology is the most important part of the research study, which enables the research
to achieve the highest possible precision and it should be able to establish trust worthy
relationship between variables.15
Research methodology is a design or a plan or a strategy of a research study that gives
guidelines, which direct the research steps, the research study process and enables in
systematic data collection, accurate data analysis and data interpretation.15
This chapter deals with methodology of the present study which includes research
approach, research design, variables, setting of the study, population, sample and
sampling technique, criteria for sample selection: inclusion and exclusion criteria,
development and description of the tool, pilot study, data collection procedure and data
analysis.
RESEARCH APPROACH:
The main aim of the present study is to assess the effectiveness of lower limb massage on
physiological lower leg/s edema and comfort during third trimester among gravid
mothers. Hence it involves the finding out of how well the intervention of lower limb
massage works among antenatal mothers with physiological lower leg/s edema. A
Quantitative evaluative research approach was adopted to attain the objectives.
39
RESEARCH DESIGN
Research design is also known as a blueprint that researchers select to carry out their
research study.15 A research design is the framework or guide used for the planning,
implementation and analysis of a study, it is a systematic plan of what is to be done, how
it will be done, and how the data will be analyzed
This study is carried out to assess the effectiveness of lower limb massage on
physiological lower leg/s edema and comfort among gravid mothers. The research design
used for the present study is pre experimental one group pre-test post-test design.
• Pre test- Assessment of edema using Erin edema scale and comfort using comfort
scale.
• Intervention- lower limb massage for 5 continuous days
• Post-test – Assessment of edema using Erin edema scale and comfort using comfort
scale on the fifth day after the intervention.
VARIABLES: Characteristics, attributes or phenomena under study are called
variables.15 Three types of variables are identified in the study. These are
Independent variable: Lower limb massage
Dependent variables: Physiological lower leg/s edema and comfort.
PRE TEST INTERVENTION POST TEST
40
Extraneous variables: Age, religion, education status, occupation, type of family,
weeks of gestation, maternal weight gain during pregnancy, family income/ month (in
rupees), number of previous delivery and previous information about lower limb
massage.
RESEARCH SETTING:
The setting is the physical location and condition in which data collection takes place for
the study.14 This study was conducted in Koramangala community. The community
covers a population of 70,000-1, 00,000 consisting of 19000 houses and one Primary
Health Centre (PHC). The PHC records an average of 124 antenatal cases per month.
POPULATION
The accessible population of this study comprised of gravid mothers having physiological
lower leg/s edema during third trimester in a Koramangala community.
SAMPLE
The sample consisted of 30 gravid mothers with physiological lower leg/s edema during
third trimester
SAMPLE SIZE
30 Sample who met the inclusion criteria
SAMPLING TECHNIQUE:
The subjects were selected through purposive sampling technique.
41
SAMPLING CRITERIA:
Inclusion Criteria
Gravid mothers
Between 28-40 weeks of gestation
– with mild to severe physiological lower leg/s edema as per ERIN edema
scale
– Who can understand Kannada/English
Exclusion
Gravid mothers who
– had pathological edema
– were at high risk.
DEVELOPMENT OF THE TOOL
The tool was prepared based on the objectives of the study. The following steps were
carried out before the selection and development of the tool
• Review of literature from electronic media and non electronic media
• Consultation with experts
• Pretesting of instruments by trial run
• Content validity
42
• Reliability
DESCRIPTION OF THE TOOL:
The tool consists of three sections
Section A :Sample Characteristics
Age, religion, education status, occupation, type of family, weeks of gestation, maternal
weight gain during pregnancy, family income/ month (in rupees), number of previous
delivery and previous information about lower limb massage.
Section B: Erin edema scale
Scoring pattern:
Trace 1-3
Mild 4-6
Moderate 7-9
Severe 10-12
Section C: Comfort scale
Scoring pattern:
Very comfortable 0-1
Less comfortable 2-3
Discomfort 4
Moderate discomfort 5-6
Serious discomfort 7-8
43
Extreme discomfort 9-10
CONTENT VALIDITY OF THE TOOL
Content validity of the tool was established by 14 experts.
The validators comprised of
Obstetric and gynecological Nursing faculty 12
Obstetricians 2
The items suggested irrelevant by the validators were removed and final tool was
devised.
RELIABILITY OF THE TOOL
The final tool was tested for reliability among 4 gravid mothers. The reliability of the tool
was established by using Karl Pearson’s Correlation Coefficient.
The reliability score for the Erin edema scale is r= 0.96 and thus the tool was found to be
reliable.
SCORING METHOD
The gravid mothers were examined for their physiological lower leg/s edema, by using
the Erin edema scale. The maximum score is 12 and the minimum score is 0. Higher the
score, severe edema.
44
ETHICAL CLEARANCE
The ethical clearance was obtained from the Institutional Ethical Review Board of St.
Philomena’s hospital, Bengaluru. Permission to conduct the study in Koramangala
community was obtained from, medical officer of the PHC. Written informed consent
was obtained from the gravid mothers with physiological lower leg/s edema who
participated in the study. Assurance was given to them that the anonymity of each
individual would be maintained as well as the confidentiality of the information obtained.
PILOT STUDY
Pilot study was conducted on Koramangala community from 16-11-2017 to 24-11-2017.
The researcher obtained written permission from the concerned authority prior to the
study.
Pilot study helped the researcher to understand the practical utility of the lower limb
massage among gravid mothers with physiological lower leg/s edema. Three subjects
were selected by using purposive sampling technique. Lower limb massage was given to
gravid mothers with physiological lower leg/s edema two times a day for five consecutive
days (total 6 sessions) and each session lasted for 15 minutes. Physiological leg/s edema
was assessed by using Erin edema scale and comfort was measured by using comfort
scale after the last sessions of lower limb massage. The findings of the pilot study
revealed that there was significant change in physiological leg/s edema.
45
PROBLEM FACED
• Getting sample was difficult.
• Less cooperation from the sample
These problems were corrected by following ways
Encouraged them for lower limb massage with explaining the benefit of the lower
limb massage.
Co-operation from the health team of the PHC was sought.
Corrected by visiting the family according to their convenient time.
DATA COLLECTION PROCEDURE
Preparatory phase
The researcher underwent a certified course on lower limb massage in Kottayam, Kerala.
An official written permission was obtained from the Institutional Ethical Review Board
and the medical officer of the PHC, Koramangala. The need and purpose of the study
were explained and a written informed consent was obtained from the gravid mothers
with physiological lower leg/s edema.
DATA COLLECTION PHASE
The data was collected from 30/11/2017 to 22/12 2017
Formal permission was obtained from the PHC
Physiological lower leg(s) edema was assessed by using Erin edema scale and
comfort was assessed by Comfort scale as a pre test.
46
Gravid Mothers were selected based on inclusion and exclusion criteria through
purposive sampling technique.
Sample characteristics were collected through an interview schedule.
Purpose and need for the study were explained to the gravid mothers with
physiological lower leg/s edema
Written informed consent was obtained from the gravid mothers
Intervention in the form of lower limb massage was administered for 30 minutes
(15 minutes/ leg) twice daily for five consecutive days
Assessed the physiological lower leg /s edema by using Erin edema scale and
comfort was measured using comfort scale on the fifth day after the intervention
as a post test.
TERMINATION PHASE:
The physiological lower leg/s edema and comfort among gravid mothers were assessed
by using Erin edema scale and comfort scale on the fifth day after the intervention.
DATA ANALYSIS
The data obtained was analysed in terms of the objectives and hypotheses of the study
using descriptive and inferential statistics.
The steps include
Organisation of the data
Description of sample characteristics
47
Determination of mean and the standard deviation
Determination of effectiveness of lower limb massage in reduction of edema
among gravid mothers with physiological lower leg/s edema.
Determination of effectiveness of lower limb massage in comfort among gravid
mothers with lower leg/s edema.
Determination of association between the sample characteristics and edema scores
using chi-square test.
Determination of association between the sample characteristics and comfort
scores using chi-square test with Yates correction.
48
TARGET POPULATION
Gravid mothers with
physiological lower leg/s
edema
ACCESSIBLE
POPULATION
Gravid mothers with
physiological lower leg/s
edema during third trimester in
Koramangala community
SETTING
KORMANGALA
community at
Bengaluru
SAMPLE
Gravid mothers with physiological
lower leg/s edema from
Koramangala community
SAMPLING
TECHNIQUE
Purposive sampling
technique
SAMPLE SIZE
n= 30
TOOLS
SECTION A Sample
characteristics
SECTION B Erin edema
scale
SECTION C Comfort
scale
VARIABLES
Independent variable: lower limb massage
Dependent variables: physiological lower
leg/s edema and comfort.
Extraneous variables: age, religion, education
status occupation, type of family, weeks of
gestation, maternal weight gain during
pregnancy, family income/ month, number of
previous delivery. Previous information about
lower limb massage
PILOT STUDY
DATE: 16/11/2017-
24/11/2017
MAIN STUDY:
30/11/2017- 22/12/2017
DATA COLLECTION PROCEDURE
Ethical clearance was obtained
Researcher underwent training on lower limb
massage
Subjects where selected based on inclusion and
exclusion criteria.
Assessed the edema and comfort by using Erin
edema and comfort scale. (pre test)
Written informed consent obtained
Interview schedule for sample characteristics
Performed lower limb massage twice a day for 5
consecutive days.
Assessed the physiological lower leg /s edema and
Comfort level as post test on fifth day .
DESCRIPTIVE STATISTICS
Frequency, Percentage, Mean, Standard deviation
INFERENTIAL STATISTICS
Paired t test, Chi square with Yates correction, Fisher’s
Exact test
pair
INTERPRETATION AND PLAN FOR
DISSEMINATION OF RESEARCH FINDING
Seminars, Exhibitions, Poster presentations,
publishing in journal
FIGURE 2: SCHEMATIC REPRESENTATION OF RESEARCH METHODOLOGY
49
49
SAMPLE SIZE ESTIMATION
The sample size was calculated based on comparison of proportions of the pilot study findings
with 80% power at 0.05 level of significance.
n = 1.96( √2*0.93*0.07 + 0.84 √.78*.22 – 0.31*0.69)2
(0.78+ 0.31)2
Though the recommended sample size based on comparison of proportions is 14 the study was
arbitrarily conducted among 30 samples after discussion with experts.
2
1-β 1 1 2 21-α/2
2
1 2
Z 2PQ +Z PQ +PQn =
P -P
1 2
1 1 2 2
P +Pwhere P = , Q =1-P
2
Q =1-P & Q =1-P
=14
50
CHAPTER V
RESULTS
The description of results is the eternity of a research project which enables the
researcher to reduce, summarize, organize, evaluate, interpret and communicate
numerical information. The term analysis refers to the computation of certain measures of
organizing and synthesizing data so as to answer the research question and to test the
hypothesis.15
The study was done to identify the effectiveness of lower limb massage on
physiological lower leg/s oedema and comfort during third trimester among gravid
mothers in a selected community, Bengaluru. In order to interpret a meaningful answer to
the research problem under study, the data was processed and analyzed in a systemic
orderly coherent fashion, so that patterns and relationships that exist between the data
groups can be discerned.
This chapter deals with analysis and interpretation of data obtained from 30
subjects selected from koramangala community, to evaluate the effectiveness of lower
limb massage on physiological lower leg/s and comfort during third trimester among
gravid mothers. The data collected were organized, tabulated, analyzed and interpreted
using descriptive and inferential statistics. MS Excel was used to analyze the data in
addition to manual calculations.
51
OBJECTIVES
To assess the level of physiological lower leg/s oedema and comfort during third
trimester among gravid mothers.
To evaluate the effectiveness of lower limb massage on physiological lower leg/s
edema and comfort during third trimester among gravid mothers.
To find out the association between the pre interventional physiological lower
leg/s oedema scores and selected sample characteristics.
To find out the association between the pre interventional comfort scores and
selected sample characteristics
HYPOTHESES
At 0.05 level of significance:
H1: There will be a statistically significant difference in the physiological lower leg/s
oedema scores before and after the lower limb massage among gravid mothers during
third trimester as measured by using Erin Edema scale
H2: There will be a statistically significant difference in the comfort scores before and
after lower limb massage among gravid mothers during third trimester as measured
by using comfort scale
52
H3: There will be a statistically significant association between pre interventional
physiological lower leg/s edema scores among gravid mothers during third trimester
and selected sample characteristics
H4: There will be a statistically significant association between pre interventional
comfort scores among gravid mothers during third trimester and selected sample
characteristics
ORGANIZATION OF FINDINGS.
The data collected were edited, tabulated, analyzed, interpreted and findings were
presented in the form of tables and graph.
53
Section: I – Description of percentage distribution of sample
characteristics.
Figure 3: Bar diagram showing percentage distribution of the gravid
mothers according to their age.
Data presented in figure 3 shows the percentage distribution of gravid mothers
according to their age in years. Among the gravid mothers, half (50%) of them
belonged to the age group between 23-27 years, 40% of them were between 18-22 years,
6.7% of them belonged to 28-32 years, and 3.3% of them belonged to 33-37 years.
40
50
6.73.3
0
10
20
30
40
50
60
70
80
90
100
18-22 yrs 23-27 yrs 28-32 yrs 33-37 yrs
Perc
enta
ge o
f m
oth
ers
Age in years
18-22 yrs
23-27 yrs
28-32 yrs
33-37 yrs
n=30
54
Figure 4: Cylindrical diagram showing percentage distribution of the
gravid mothers according to their Religion.
Data presented in figure 4 shows the percentage distribution of gravid mothers
according to their religion, where half (50%) of the gravid mothers were Christians, 30%
were Hindus and 20% were Muslims.
0
10
20
30
40
50
60
70
80
90
100
Hindu Christian Muslim
30
50
20
Perc
enta
ge o
f m
oth
ers
Religion
Hindu
Christian
Muslim
n=30
55
Figure 5: Bar diagram showing percentage distribution of the gravid
mothers according to their educational status.
Data presented in Figure 5 shows the percentage distribution of gravid mothers
according to their educational status, where less than half (46.7%) of them completed
their Pre-University, 30% were diploma/ degree holders, 16.6% had completed their
high school education and 6.7% had finished their primary education.
6.716.6
46.7
30
0102030405060708090
100
Primary High school Pre-university Diploma/
graduates and
above
Perc
enta
ge o
f m
oth
ers
Educational status
Primary
High school
Pre-university
Diploma/ graduates
and above
n=30
56
Figure 6: Bar diagram showing percentage distribution of gravid
mothers according to their occupational status.
Data presented in Figure 6 shows the percentage distribution of gravid mothers
according to their occupational status. A little more than half (53.3%) were homemakers,
36.7% were privately employed and 10% were self employed.
10
36.7
53.3
0
10
20
30
40
50
60
70
80
90
100
Self employee Private employee Home maker
Perc
enta
ge o
f m
oth
ers
Occupation
Self employee
Private employee
Home maker
n=30
57
Figure 7: Bar diagram showing percentage distribution of the gravid
mothers according to their type of family
Data presented in figure 7 shows the percentage distribution of gravid mothers
according to their type of family. Most (70%) of the gravid mothers belonged to nuclear
family, and 30% of them belonged to joint family.
70
30
0
10
20
30
40
50
60
70
80
90
100
Nuclear Joint
Perc
enta
ge o
f m
oth
ers
Type of family
Nuclear
Joint
n=30
58
Figure 8: Bar diagram showing percentage distribution of the gravid
mothers according to their weeks of gestation
Data presented in figure 8 shows the percentage distribution of gravid mothers
according to their weeks of gestation. Less than half (43.3%) of the gravid mothers were
in their 28-32 weeks of gestation,33.3% were in 33-36 weeks of gestation and 23.4 %
were in 37-40 weeks of gestation.
43.3
33.3
23.4
0
10
20
30
40
50
60
70
80
90
100
28- 32 weeks 33-36 Weeks 37-40 Weeks
Pe
rce
nta
ge
of
moth
ers
Weeks of gestation
28- 32 weeks
33-36 Weeks
37-40 Weeks
n=30
59
Figure 9: Bar diagram showing percentage distribution of the gravid
mothers according to maternal weight gain during pregnancy.
Data presented in figure 7 shows the percentage distribution of gravid mothers
according to their maternal weight gain during pregnancy. More than half (66.6%) of
gravid mothers gained 7- 9 kg weight, 30% gained 10-12 kg weight, and 3.4% gained
13-15 kg of weight.
66.6
30
3.4
0
10
20
30
40
50
60
70
80
90
100
7-9 Kg 10-12 Kg 13-15 kg
Perc
enta
ge o
f m
oth
ers
Maternal weight gain (kg)
7-9 Kg
10-12 Kg
13-15 kg
n=30
60
Figure 10: Bar diagram showing percentage distribution of the gravid
mothers according to their previous number of deliveries.
Data presented in Figure 10 shows the percentage distribution of gravid mothers
according to their number of previous delivery. More than half (53.4%) of them were
nulliparas, 26.6% of gravid mothers were primiparas, and 20% of them were multiparas.
53.4
26.620
0
10
20
30
40
50
60
70
80
90
100
Nil One Two
Perc
enta
ge o
f m
oth
ers
Numbers of previous delivery
Nil
One
Two
n=30
61
Figure 11: Bar diagram showing percentage distribution of of gravid
mothers according to their monthly income.
Data presented in figure 11 shows the percentage distribution of gravid mothers
according to their monthly income. More than half ( 56.6%)of gravid mothers had their
family income of Rs 10001-15000 per month, 36.7% of them had family income of Rs
5000-10000 per month, and 6.7% had family income of Rs 15001-20000 per month.
36.7
56.6
6.7
0
10
20
30
40
50
60
70
80
90
100
5000-10000 10001-15000 15001-20000
Perc
enta
ge o
f m
oth
ers
Monthly income (in rupees)
5000-10000
10001-15000
15001-20000
n=30
62
Figure 12: Bar diagram showing percentage distribution of the gravid
mothers according to their previous knowledge about lower limb
massage.
Data presented in Figure 12 shows the percentage distribution of gravid mothers
according to their previous information about lower limb massage. Most (73.3%) of them
had previously obtained information about lower limb massage, and 26.7% did not obtain
any previous information about lower limb massage.
73.3
26.7
0
10
20
30
40
50
60
70
80
90
100
Yes No
Perc
enta
ge o
f m
oth
ers
Have you obtained previous information regarding lower limb massage
Previous information obtained regarding lower limb
massage
Yes
No
n=30
63
Section II: Effectiveness of lower limb massage on physiological lower
leg/s edema
Figure 13: Bar diagram showing percentage distribution of pre and post
intervention lower leg/s edema scores among gravid mothers during
third trimester.
Figure 13 depicts the percentage distribution of pre and post interventional lower
leg/s edema scores among gravid mothers during third trimester. In pretest most (76.6%)
of them had severe edema, 20% of them had moderate edema and 3.4% of them had mild
edema. In post test after the intervention of lower limb massage majority (90%) of them
had mild edema and 10% of them had trace edema.
0
10
20
30
40
50
60
70
80
90
100
pre test post test
0
103.4
90
20
0
76.6
0
Perc
enta
ge o
f m
oth
ers
ERIN EDEMA SCORE
Trace
Mild
Moderate
Severe
n=30
64
Table 1: Comparison of mean pre and post intervention lower leg/s
edema scores among gravid mothers during third trimester.
Pretest/ Post test edema scores
Mean SD Mean difference df Paired
t-test p value Inference
Pretest 10.8 0.96 6.6 29 32.49 p<0.05 S*
Post test 4.23 0.67
* Significant at p< 0.05 t
29 =2.05
Data presented in Table 1: reveals the mean, mean difference, standard deviation,
degree of freedom and paired‘t’ test values of pre and post interventional lower leg
edema scores. The mean pre-test score is 10.8 with a standard deviation of 0.96 and the
post test score is 4.23 with a standard deviation of 0.67
The calculated paired‘t’ value is 32.49 which is greater than the table value (2.05). Hence
H1 is accepted stating that there is a statistically significant difference in the physiological
lower leg/s oedema before and after the lower limb massage among gravid mothers
during third trimester as measured using Erin Edema scale
n=30
65
Section III : Effectiveness of lower limb massage on Comfort among
gravid mothers during third trimester.
Figure 14: Bar diagram showing percentage distribution of pre and post
intervention comfort scores among gravid mothers during third
trimester.
The data in figure 14 shows the percentage distribution of pre and post
intervention comfort scores of gravid mothers. In pre test more than half (56.6%) of them
had serious discomfort, 30% of them had extreme discomfort, and 13.4% of them had
moderate discomfort. In post test after the intervention of lower limb massage 63.4 % of
them were less comfortable, 26.6% of them had discomfort and 10% of them felt very
comfortable.
0
10
0
63.4
0
26.6
13.4
0
56.6
0
30
0
10
20
30
40
50
60
70
80
90
100
pre test post test
Pe
rce
nta
ge
of
moth
ers
Percentage of pre and post test comfort scores
Very comfortable
Less comfortable
Discomfort
Moderate discomfort
Serious discomfort
Extreme discomfort
n=30
66
Table 2: Comparison of mean pre and post intervention comfort scores
among gravid mothers during third trimester.
Pretest/ Post test
comfort score
Mean SD Mean difference
df Paired t-test
p value Inference
Pretest 8 1.26 3.9 29 8.9 p<0.05 S*
Post test 4.1 1.6
* Significant at p< 0.05 t
29 =2.05
The data presented in table 2 reveals the mean, mean difference, standard deviation,
degree of freedom and paired‘t’ test values of pre and post interventional comforts
scores. The mean pre-test score is 8 with a standard deviation of 1.26 and the post test
score is 4.1 with a standard deviation of 1.6.
The calculated paired‘t’ value is 8.9 which is greater than the table value (2.05). Hence
H2 is accepted stating that there is a statistically significant difference in the comfort
before and after lower limb massage among gravid mothers during third trimester as
measured using comfort scale.
n=30
67
Section IV: Association between sample characteristics and pretest
intervention scores among gravid mothers with physiological lower leg
Edema during third trimester.
Table 3: Association between sample characteristics and pretest
intervention edema scores among gravid mothers with physiological
lower leg/s Edema during third trimester.
Sample characteristics Mild/Modera
te Severe Chi square/
Fisher exact p value
Age (in years)
≤ 27 5 22 3.035 Yates
0.081 (NS)
> 27 2 1
Type of family
Nuclear 7 13 0.34 Fisher exact
0.34 (NS)
Joint 0 10
Religion
Hindu 1 8
0.531 Fishers exact
0.766 (NS)
Christian 5 10
Muslim 1 5
Occupation
0.041 Yates
0.42 (NS) Employed 4 10
Unemployed 3 13
Education status
High school 1 6 0.24
Fisher exact Table value
5.99
0.883 (NS)
PUC 2 12
Diploma and above 4 5
n=30
68
Weeks of gestation (in
weeks)
28-32 5 8 0.302
Fisher exact
0.85 (NS)
33-36 1 9
37-40 1 6
Maternal weight gain
(kg)
7-9 3 17 0.129
Fisher exact
0.71 (NS)
10-12 3 6
13-15 1 0
Family income/ month
(in rupees)
5000-10000 3 8
0.825
Fisher exact
0.66
(NS)
10001-15000 4 13
150001-20000 0 2
Number of previous
delivery
0 4 12
0.44 Fisher exact
0.97 (NS)
1 0 8
2 3 3
Previous information
obtained about lower
limb massage
Yes 6 16 1.13 Yates
0.35 (NS)
No 1 7
69
The computed chi-square values between the pre intervention oedema scores and the
sample characteristics like age, religion, occupation, type of family, educational status,
weeks of gestation, , maternal weight gain during pregnancy, family income/ month,
number of previous deliveries and previous information obtained about lower limb
massage were less than the corresponding table values at p< 0.05 level. Hence the
research hypothesis H3 is rejected stating that there is no significant association found
between pre interventional edema scores and selected sample characteristics.
70
Table 3.b) Association between sample characteristics and pretest
Comfort scores among gravid mothers with physiological lower leg
Edema during third trimester.
Sample characteristics Moderate Serious Extreme Chi square/ Fisher exact
p
value
Age (in years)
≤ 27 4 16 7 0.63
Yates
0.21
(NS) > 27 0 1 2
Occupation
Employed 2 5 7 0.05
Fisher exact
0.97
(NS) Unemployed 2 12 2
Type of family
Nuclear 3 13 5 0.48
Yates
0.24
(NS) Joint 1 4 4
Education status
High school 0 6 2
0.40
Yates
0.85
(NS) PUC 1 8 5
Diploma and above 3 3 2
Weeks of gestation (in
weeks)
28-32
3 7 3
0.41 Yates
0.85 (NS)
33-36
1 7 2
37-40
0 3 4
n=30
71
Maternal weight gain
(Kg)
7-9 3 14 3
0.60 Yates
0.96 (NS)
10-12 1 3 5
13-15 0 0 1
Family income/ month
(in rupees)
5000-10000 1 7 3
0.67 Yates
0.94 (NS)
10001-15000 3 8 6
15001-20000 0 2 0
Number of previous
delivery
0 4 9 3
3.15
Yates
0.94
(NS) 1 0 4 4
2 0 4 2
Pervious information
obtained about lower
limb massage
Yes 2 13 7 0.13 Yates
0.35 (NS) No 2 4 2
The computed chi-square values between the pre intervention comfort scores and
the sample characteristics like age, religion, occupation, type of family, educational
status, weeks of gestation, maternal weight gain during pregnancy, family income/
month, number of previous deliveries and previous information obtained about lower
limb massage were less than the corresponding table values at p< 0.05 level. Hence the
research hypothesis H4 is rejected stating that there is no association found between the
pre- interventional comfort scores among gravid mothers during third trimester and
selected sample characteristics.
72
SUMMARY
This chapter dealt with the analysis and interpretation of data using descriptive
and inferential statistics. The effectiveness of lower limb massage was identified by
paired‘t’ test. The finding showed that there is a significant difference in the level of
physiological lower leg/s edema scores and comfort scores among pre and post
interventional scores. Hence the study reveals that lower limb massage is effective in the
reduction of physiological lower leg/s edema and promotion of comfort among gravid
mothers during third trimester.
73
CHAPTER VI
DISCUSSION
This chapter deals with the discussion of study findings in accordance with the
objectives of the study and discusses them in relation to similar studies. The study intends
to evaluate the effectiveness of lower limb massage on physiological lower leg/s edema
among gravid mothers during third trimester in a selected community Koramangala,
Bengaluru.
In order to achieve the objectives of the study, a pre experimental one group
pretest post test design was adopted. Purposive sampling technique was used to select the
sample. The data was collected from 30 gravid mothers with physiological lower leg/s
edema. The data was collected using Erin edema scale and Comfort scale; the findings of
the study have been discussed with specific reference to objectives, hypotheses and
related findings of available studies. The data were organized, analysed and presented in
five sections.
74
Section I: Description of sample characteristics
Section II : Description of Pre and post test edema scores after the lower limb massage
Section III: Description of Pre and post test comfort scores after lower limb massage.
Section IV: Association between pre interventional scores and selected sample
characteristics.
MAJOR FINDINGS
SECTION I: Description of gravid mothers with physiological lower leg/s edema
according to their sample characteristics.
Age: Half (50%) of them belonged to the age group between 23-27 years, 40% of them
were between 18-22 years, 6.7% of them belonged to 28-32 years, and 3.3% of them
belonged to 32-37 years.
Religion: Half (50%) of the subjects were Christians, 30% were Hindus and 20% were
Muslims.
Educational status: Less than half (46.7%) of them completed their Pre-University, 30%
of were diploma/ degree holders, 16.6% had completed high school education and 6.7%
had finished their primary education.
Occupational status: A little more than half (53.3%) were homemakers, 36.7% were
privately employed and 10% were self employed.
Type of family: Most (70%) of the gravid mothers belonged to nuclear family, and 30%
of them belonged to joint family.
75
Weeks of gestation: Less than half (43.3%) of the gravid mothers were in their 28-32
weeks of gestation,33.3% were in 33-36 weeks of gestation and 23.4 % were in 37-40
weeks of gestation.
Maternal weight gain during pregnancy: More than half (66.6%) of gravid mothers
gained 7- 9 kg weight, 30% gained 10-12 kg weight, and 3.4% gained 13-15 kg of
weight.
Previous number of deliveries: More than half (53.4%) of them were nulliparas, 26.6%
of gravid mothers were primiparas, and 20% of them were multiparas.
Monthly income of the gravid mothers: More than half (56.6%)of gravid mothers had
their family income of Rs 10001-15000 per month, 36.7% of them had family income of
Rs 5000-10000 per month, and 6.7% had family income of Rs 15001-20000 per month.
Previous knowledge about lower limb massage: Most (73.3%) of them had previously
obtained information about lower limb massage, and 26.7% of d id not obtain any
previous information about lower limb massage.
Section II: Description of Pre and post –test Erin edema scores after the lower limb
massage
a) Percentage distribution of pre and post intervention lower leg/s edema scores
among gravid mothers during third trimester.
In pretest most (76.6%) of them had severe edema, 20% of them had moderate
edema, 3.4% of them had mild edema. In post test after the intervention of lower
76
limb massage majority (90%) of them had mild edema and 10% of them had trace
edema.
b) Comparison of pre and post intervention lower leg/s edema scores among gravid
mothers during third trimester.
The mean pre-test edema score is 10.8 with a standard deviation of 0.96 and the post
test edema score is 4.23 with a standard deviation of 0.67.The calculated paired‘t’
value is 32.49 which is greater than the table value (2.05). Hence H1 is accepted
stating that there is a statistically significant difference in the physiological lower
leg/s oedema before and after the lower limb massage among gravid mothers during
third trimester as measured using Erin Edema scale.
These findings was supported with a study conducted to evaluate the effectiveness of
foot massage on reduction of physiological lower leg edema among Primigravid
mothers during third trimester in Elariyampannai, Primary Health Center,
Virudhunagar district Tamilnadu. The study comprised of 60 samples selected by
purposive sampling method. Demographic data was collected through interview
method, and pre-test was assessed using Erin edema Scale. Foot massage was given
over 20 min for each leg. The mean value of post test level of physiological lower leg
edema after receiving foot massage was 2.38 and it was more than the pretest mean
value 0.58. The calculated t test value showed that there was a significant difference
supporting the effectiveness of foot massage at p<0.05 level.
77
Section III : Effectiveness of lower limb massage on Comfort among gravid mothers
during third trimester
Percentage distribution of pre and post intervention comfort scores among gravid
mothers during third trimester
In pre test more than half (56.6%) of them had serious discomfort, 30% of them had
extreme discomfort, and 13.4% of them had moderate discomfort. In post test after the
intervention of lower limb massage 63.4 % of them were less comfortable, 26.6% of
them had discomfort and 10% of them felt very comfortable.
These findings were supported by a study was conducted in Japan on “comfort over pain
in pregnancy”. The sample comprised of 114 primipara and 102 multipara mothers.
Holistic/ alternative techniques (positioning and massage) individualized over three
sessions were administered to the participants. Levels of pain and comfort were measured
before and after the treatment, using the validated general comfort questionnaire and
pain outcomes profile. Result of the study showed that pain scores decreased from an
average of 5.8/10 to 5/10 (p=.00). Comfort scores increased from an average of 17.5 to
30 (p=.00).
Comparison of mean pre and post intervention comfort scores among gravid
mothers during third trimester.
The mean pre-test comfort score is 8 with a standard deviation of 1.26 and the post test
score is 4.1 with a standard deviation of 1.6. The calculated paired‘t’ value is 8.9 which is
greater than the table value (2.05). Hence H2 is accepted stating that there is a
78
statistically significant difference in the comfort scores before and after lower limb
massage among gravid mothers during third trimester as measured using comfort scale.
Section IV: Association between pre interventional scores and selected sample
characteristics
a) Association between sample characteristics and pretest edema scores among
gravid mothers with physiological lower leg/s edema during third trimester.
The computed chi-square values between the pre intervention oedema
scores and the sample characteristics like age, religion, occupation, type of family,
educational status, weeks of gestation, , maternal weight gain during pregnancy, family
income/ month, number of previous deliveries and previous information obtained about
lower limb massage were less than the corresponding table values at p> 0.05 level. Hence
the research hypothesis H3 is rejected stating that there is no significant association found
between pre interventional edema scores and selected sample characteristics.
b) Association between sample characteristics and pretest Comfort scores among
gravid mothers with physiological lower leg edema during third trimester.
The computed chi-square values between the pre intervention comfort scores and
the sample characteristics like age, religion, occupation, type of family, educational
status, weeks of gestation, maternal weight gain during pregnancy, family income/
month, number of previous deliveries and previous information obtained about lower
limb massage were less than the corresponding table values at p> 0.05 level. Hence the
research hypothesis H4 is rejected stating that there is no association found between the
79
pre- interventional comfort scores among gravid mothers during third trimester and
selected sample characteristics.
80
CHAPTER VII
CONCLUSION
This chapter deals with conclusion, implication, limitation, suggestions and
recommendation. The purpose of the study was to evaluate the effectiveness of lower
limb massage on physiological lower leg edema among gravid mothers during third
trimester in a selected community Koramangala.
The conceptual frame work of the study was based on Kolcaba’s Comfort theory. The
sample size selected was 30. The study design used was one group pretest posttest design.
The conclusions drawn from the study are:
Lower limb massage is effective in reduction of physiological lower leg/s edema during
third trimester of pregnancy
There is no significant association found between the pre interventional edema scores and
comfort scores with sample characteristics.
NURSING IMPLICATIONS
The present study was conducted to assess the effectiveness of lower limb massage on
physiological lower leg/s edema and comfort during third trimester among gravid
mothers. The study findings have several implications on Nursing education, Nursing
practice, Nursing administration, Nursing research and community.
81
NURSING PRACTICE
• To provide a comprehensive maternity care, even the mild discomfort caused by
physiological edema should not be neglected.
• Nurses can use suitable assessment tools to identify edema and take appropriate
measures to ease the discomfort caused.
• Nurses in practice can make time to teach the pregnant women about minor
ailments in pregnancy with simple remedial measures.
• Massage involving therapeutic touch can improve interpersonal relationship and
promote comfort.
NURSING EDUCATION
• Lower limb massage as a complementary therapy is easy to learn as it is neither
machine oriented nor technology dependent.
• The staff nurses and student nurses, may be oriented to the use of objective tools
to assess various minor ailments and provide appropriate nursing intervention.
• The student nurses should be taught and encouraged to practice simple cost
effective therapeutic procedures to relieve discomfort during pregnancy.
NURSING RESEARCH
• Evidence based research is needed to improve quality of health services and to
improve client satisfaction towards nursing care.
82
• The study findings serve as an evidence to practice lower limb massage in
reducing physiological lower leg edema and discomfort during pregnancy.
• The study findings can be disseminated through mass media, journal clubs,
presentations and conferences.
• The nurse researchers can work to develop suitable interventions for physiological
lower leg edema during third trimester, test them through research and implement
them effectively to reduce the edema related discomfort.
NURSING ADMINISTRATION
• The nurse administrators can encourage the nursing staff to utilize effective
interventions tested through research which can increase the client satisfaction.
• Information regarding minor ailments and discomfort during pregnancy with
appropriate intervention such as lower limb massage in reducing edema and
discomfort, can be made known to the general public through pamphlets, running
screens at the waiting areas and out patient departments.
LIMITATIONS
The limitations of the study are
The findings of the study cannot be generalized as the sample size is 30
The study was limited only to antenatal mothers in Koramangala community
RECOMMENDATIONS
83
Based on the findings of the present study, recommendations offered for future research
are
A similar study can be replicated on large samples and for a long duration for the
generalization.
A comparative study can be conducted to assess the effect of lower limb massage
with other interventions like salt water soaking, position during sleep, life style
modification, and elevation of leg during resting period.
A true experimental study can be done with randomization and control for
generalization.
A comparative study can be conducted on the same between primiparous and
multiparous mothers in different settings.
84
CHAPTER VIII
SUMMARY
Physiological lower leg edema is one of the cutaneous manifestations of pregnancy. The
weight gain during pregnancy and gravity slow the circulation of blood and body fluids
particularly in lower limbs.1 The swelling or edema is a common discomfort of
pregnancy. It is estimated that about 75% of women experience this excessive
accumulation of fluid around the leg and ankles during pregnancy.2 Physiological edema
results from hormones induced sodium retention. Leg edema in lower extremities
unilateral or bilateral.4 Edema may also be present when the enlarged uterus
intermittently compresses the inferior vena during recumbency, obstructing outflow from
both femoral veins.10 Dorsum of the foot, medial malleolus, and anterior 2/3rd of tibia are
the common sites of physiological edema.2
STATEMENT OF THE PROBLEM
A study to assess the effectiveness of lower limb massage on physiological lower leg/s
oedema and comfort during third trimester among gravid mothers in a selected
Community, Bengaluru.
85
OBJECTIVES
To assess the level of physiological lower leg/s oedema and comfort during third
trimester among gravid mothers.
To evaluate the effectiveness of lower limb massage on physiological lower leg/s
edema and comfort during third trimester among gravid mothers.
To find out the association between the pre interventional physiological lower
leg/s oedema scores and selected sample characteristics.
To find out the association between the pre interventional comfort scores and
selected sample characteristics
ASSUMPTIONS:
Gravid mothers may experience physiological leg/s edema during third trimester.
Edema may cause discomfort to gravid mothers during third trimester.
Foot massage may have an effect on physiological leg edema.
HYPOTHESES
At 0.05 level of significance:
H1: There will be a statistically significant difference in the physiological lower leg/s
oedema scores before and after the lower limb massage among gravid mothers during
third trimester as measured by using Erin Edema scale
86
H2: There will be a statistically significant difference in the comfort scores before and
after lower limb massage among gravid mothers during third trimester as measured
by using comfort scale
H3: There will be a statistically significant association between pre interventional
physiological lower leg/s edema scores among gravid mothers during third trimester
and selected sample characteristics
H4: There will be a statistically significant association between pre interventional
comfort scores among gravid mothers during third trimester and selected sample
characteristics
CONCEPTUAL FRAMEWORK
The conceptual frame work used for the study was Katharine Kolcaba’s Theory of
Comfort.
RESEARCH METHODOLOGY
The final tool consisted of three sections including the Sample Characteristics, Erin
edema scale, and Comfort scale.
SECTION A: Sample characteristics
SECTION B: Erin edema scale
SECTION C: Comfort scale
87
Content validity of the tool was established by 14 experts. The tool was found feasible for
the study. The reliability of the tool was established through Karl Pearson’s Correlation
Coefficient prior to the study (r=0.96). The research approach used was quantitative
approach. The research design was pre experimental one group pretest post test design.
The study sample comprised of 30 gravid mothers. Data were collected from subjects
through an interview method using Erin edema scale and comfort scale. The data was
further analyzed by descriptive and inferential statistics.
MAJOR FINDING OF THE STUDY
Section:I – Description of percentage distribution of sample
characteristics.
Among the antenatal mothers, half (50%) of them belonged to the age group of 23-27
years, 50% were Christians, 46.7% of them completed their PUC, 53.3% were home
makers,70% of them belonged to nuclear family, 43.3% of them were in their 28-32
weeks of gestation, 66.6 % of them gained 7-9kg weight during their pregnancy,56.6% of
them had an family income of Rs 10001-15000/ month,53.4% of them were nulliparas
and 73.3% of them had obtained previous information about lower limb massage .
88
Section II Effectiveness of lower limb massage on physiological lower
leg edema among gravid mothers during third trimester
a) Percentage distribution of pre and post intervention lower leg edema scores
among gravid mothers during third trimester.
In pretest most (76.6%) of them had severe edema, 20% of them had moderate edema,
3.4% of them had mild edema. In post test after the intervention of lower limb massage
majority (90%) of them had mild edema and 10% of them had trace edema.
a) Comparison of mean pre and post intervention lower leg edema scores among
gravid mothers during third trimester.
The mean pre-test edema score is 10.8 with a standard deviation of 0.96 and the post test
edema score is 4.23 with a standard deviation of 0.67.The calculated paired ‘t’ value is
32.49 which is greater than the table value (2.05). Hence H1 is accepted stating that there
is a statistically significant difference in the physiological lower leg/s oedema scores
before and after the lower limb massage among gravid mothers during third trimester as
measured using Erin Edema scale
89
Section III : Effectiveness of lower limb massage on Comfort scores
among gravid mothers during third trimester.
a) Percentage distribution of pre and post intervention comfort scores among
gravid mothers during third trimester
In pre test more than half (56.6%) of them had serious discomfort, 30% of them had
extreme discomfort, and 13.4% of them had moderate discomfort. In post test after the
intervention of lower limb massage 63.4 % of them were less comfortable, 26.6% of
them had discomfort and 10% of them felt very comfortable.
b) Comparison of pre and post intervention comfort scores among gravid mothers
during third trimester.
The mean pre-test comfort score is 8 with a standard deviation of 1.26 and the post test
score is 4.1 with a standard deviation of 1.6. The calculated paired‘t’ value is 8.9 which is
greater than the table value (2.05). Hence H2 is accepted stating that there is a
statistically significant difference in the comfort scores before and after lower limb
massage among gravid mothers during third trimester as measured using comfort scale.
Section IV: Association between sample characteristics and pretest Erin edema
scores and comfort scores among gravid mothers with physiological lower leg edema
during third trimester.
90
a ) Association between sample characteristics and pretest Erin edema scores among
gravid mothers with physiological lower leg edema during third trimester.
The computed chi-square values between the pre intervention oedema scores and the
sample characteristics like age, religion, occupation, type of family, educational status,
weeks of gestation, maternal weight gain during pregnancy, family income/ month,
number of previous deliveries, previous information obtained about lower limb massage,
source of information were less than the corresponding table values at p< 0.05 level of
significance.. Hence the research hypothesis H3 is rejected stating that their no significant
association found pre interventional edema scores and selected sample characteristics.
b) Association between sample characteristics and pretest Comfort scores among
gravid mothers with physiological lower leg edema during third trimester.
The computed chi-square values between the pre intervention comfort scores and the
sample characteristics like age, religion, occupation, type of family, educational status,
weeks of gestation, maternal weight gain, family income/ month, number of previous
deliveries and previous information obtained about lower limb massage were less than
the corresponding table values at p< 0.05 level. Hence the research hypothesis H4 is
rejected stating that there is no association found between the pre interventional comfort
scores among gravid mothers during third trimester and selected sample characteristics.
91
SUMMARY
On the whole, carrying out the present study was really an enriching experience of the
researcher. It helped the researcher to improve the skill of lower limb massage. Lower
limb massage helped in the reduction of physiological lower leg/s edema and discomfort
during third trimester in gravid mothers. Timely guidance and assistance from the experts
helped the researcher to complete the study successfully.
92
CHAPTER IX
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FORMAT OF CONSENT FORM
Letter to the subject requesting to participate in this study
Dear participant,
I am a post graduate student of St.Philomena’s College of Nursing. I am conducting a research
on the following topic
“A study to assess the effectiveness of lower limb massage on physiological lower leg/s oedema
and comfort during third trimester among gravid mothers in a selected community, Bengaluru.”
As a part of the study, I will be giving foot massage for 5 days. On the beginning and end of the
foot massage I will be assessing lower limb edema by using Erin edema scale and comfort
assessed by Comfort scale. Please read the instructions care fully and place a tick mark[√against
the answer of your choice. Any information obtained in connection with the study remain
confidential. Please be free to clarify the same at any point of time.
The decision to participate in the study is entirely voluntary. Further after having given the
consent, you will have the right to withdraw the same at any time during the study.
Thanking you. Yours faithfully,
Ms. Elizabeth Joseph
101
DECLARATION OF CONSENT
I Ms/Mrs …………………………………….. have understood the need for participation
in the study and willingly giving the consent for the same
Name of the participants Signature of the participant/ care giver
Signature of the investigator
Date:
Place : Bengaluru
102
CONSENT FORM-KANNADA
103
104
ETHICAL COMMITTEE CLEARANCE CERTIFICATE
105
PROFORMA PROTOTYPE
LETTER SEEKING EXPERTS OPINION AND SUGGESTIONS FOR CONSENT
VALIDITY OF THE TOOLS
From,
Ms. Elizabeth Joseph
2nd year M.Sc. Nursing
St.Philomena’s College of Nursing
Bengaluru-47
To,
Forwarded Through,
Rev. Sr. Martha Thirumal Reddy
Principal
St. Philomena’s College of Nursing
Bengaluru- 47
Subject: Seeking expert opinion and suggestions on content validity of the tool
Respected Madam/ Sir,
106
I am a post graduate student of St. Philomena’s College of Nursing. I have selected the
topic mentioned below for the research project to be submitted to Rajiv Gandhi University of
Health Sciences, as a partial fulfillment of Masters Nursing Degree.
Title of the study
“A study to assess the effectiveness of lower limb massage on physiological lower
leg/s oedema and comfort during third trimester among gravid mothers in a selected
community, Bengaluru.”
OBJECTIVES OF THE STUDY ARE
To assess the level of physiological lower leg/s oedema and comfort during third
trimester among gravid mothers.
To evaluate the effectiveness of lower limb massage on physiological lower leg/s edema
and comfort during third trimester among gravid mothers.
To find out the association between the pre interventional physiological lower leg/s
oedema scores and selected sample characteristics.
To find out the association between the pre interventional comfort scores and selected
sample characteristics
ENCLOSURES
SECTION A: Sample characteristics
SECTION B: Erin edema scale
107
SECTION C: Comfort scale
I would be highly obliged and remain thankful for your great help if you could validate and give
it as early as possible. I also request you to kindly sign the certificate that tool and video has been
validated. Your kind co-operation and expert judgment will be highly appreciated.
Thanking you,
Place: Bengaluru
Date: Yours Sincerely,
Elizabeth Joseph
II Year M.Sc Nursing,
St Philomena’s college of nursing
Bangalore- 47
Ph no: 9496399278
108
ACCEPTANCE FORM FOR TOOL VALIDATION
Name: -------------------------------------------------------------------------------------------
Designation: ------------------------------------------------------------------------------------
Name of the college/Hospital: ------------------------------------------------------------------
Statement of acceptance/non acceptance
I give my acceptance/ non acceptance to validate the tool,
TOPIC:
“A study to assess the effectiveness of lower limb massage on physiological lower leg/s
oedema and comfort during third trimester among gravid mothers in a selected community,
Bengaluru.”
Place:
Date: Signature of Expert:
109
CONTENT VALIDITY CERTIFICATE
I hereby certify that I have validated the tool of Ms. Elizabeth Joseph, IInd Year Msc Nursing
student of St.Philomena’s College of Nursing, who is undertaking following study.
“A study to assess the effectiveness of lower limb massage on physiological lower leg/s
oedema and comfort during third trimester among gravid mothers in a selected
community, Bengaluru.”
Place: Signature of expert
Date: Name and Designation
110
TOOL FOR THE STUDY
SECTION A:
SOCIO DEMOGRAPHIC DATA PROFILE
Sample No: Date of data collection:
Instructions: Dear respondent, you are requested to answer the following which are appropriate
to you. Information given by you will be kept confidential.
1) Age ( in years)--------------------------------------
2) Religion
a. Hindu
b. Christian
c. Muslim
d. Others
3) Educational status
a. No formal education
b. Primary school education
c. High school education
d. Pre-university
e. Diploma/ Graduate and above
4) Occupation
a. Self employee
b. Private employee
c. Government employee
d. Homemaker
5) Type of family
a. Nuclear
111
b. Joint
6) Weeks of gestation-------------------------------------
7) The maternal weight during first antenatal visit: …………………………………
8) Maternal weight at present: …………………………………………………………
9) Family income / month: …………………………………………………………..
10) Number of previous deliveries
a. 0
b. 1
c. 2
d. 3 or above
11) Have you obtained any information regarding lower limb massage
a. Yes
b. No
112
SECTION: B ERIN EDEMA SCALE
Instructions
Dear participant,
Kindly cooperate with the researcher as she examines you. The data collected will be kept
confidential.
SCORE
NATURE OF EDEMA
OEDEMA
ASSESSMENT
0
NONE
NO- OEDEMA
+1
TRACE
RAPID RETURN TO NORMAL
+2
MILD
REBOUND IN FEW SECOND
+3
MODERATE
10-20 SECONDS TO RETURN TO NORMAL
+4
SEVERE
>30 SECOND TO RETURN TO NORMAL
Site wise edema assessment:
Site of assessment Right leg Left leg
Lower 2/3rd of tibia
Medial malleolus
Dorsum of the foot
113
INTERPRETATION OF SCORES
1 to 3 = Trace
4 to 6 =Mild
7 to 9 = Moderate
10 to 12= Severe
SECTION C: COMFORT SCALE
114
TOOL FOR THE STUDY-KANNADA
Sample Characteristics
115
116
Erin Edema Scale
117
Comfort Scale
118
119
120
ANNEXURE 1
PERMISSION LETTER FOR RESEARCH PILOT STUDY
121
ANNEXURE 2
PERMISSION LETTER FOR RESEARCH ( MAIN ) STUDY
122
ANNEXURE 3
CERTIFICATE OF FOOT MASSAGE
123
ANNEXURE 4
4 (a) Manuscript of Lower limb massage-English
Lower limb massage is a simple, cheap and effective method to relax the body and mind. It is
based on the tenets. This technique has been practiced for many centuries for its various benefits.
Our feet contain greater than 7,000 nerves. By stimulating them gently you can get pleasurable
and relaxing sensations.
Peaceful, Easy Feeling: lower limb massage can help to relieve anxiety and induce deep
relaxation. This is because stress is normally stored in a point called the solar plexus reflex in the
feet. By pressing and massaging this point, you can release stress and induce relaxation.
Improves Cleansing and Circulation: Stress inhibits proper blood flow which is important for
transporting nutrition and oxygen to body cells. Blood circulation also removes toxins and
wastes out of the body. Lower limb massage reduces stress and facilitates unimpeded blood flow
throughout the body.
Facilitates Homeostasis: It occurs when our body systems work harmoniously to produce
balance and good health. A relaxing lower limb massage can facilitate homeostasis and optimum
functioning of the body systems.
Lower limb massage removes blockages: to enable proper energy flow throughout the body.
This can give you more energy and vitality to perform daily tasks.
124
Enhances Immunity: Another ill-effect of stress is that it reduces immunity by taking a heavy
toll on body and mind. Lower limb massage heals and relaxes our body and mind, and protects
against stress-related ailments.
Feel Sensual Bliss: A sensual lower limb massage can be the soothing. Rubbing feet in a,
relaxing and sensual manner will improve comfort.
Lower limb Massage is used in sports to break down adhesions (deep friction) reduces swelling
and oedema in muscles. Massage will aid relaxation and reduce swelling and oedema. Lower
limb massage helps to induce deep relaxation, avoid foot pain and reduces physiological leg
edema.
When is lower limb massage done?
It can be done at any time of the day
It is more effective when it is done in the evening or at night before retiring to bed.
Massage technique
Joints of hands and legs: Rotation movement
Hands and legs: From up, downward, with the flow of muscles.
Use long strokes on the limbs (arms and legs) and circular strokes on the joints
Finger walking: dorsum of the foot.
Thumb walking sole of the foot
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Instructions:
Dear participants
You are requested to clean the legs with soap and water and dry it with clean towel and
be in a comfortable position either in sitting or lying down.
Take two comfortable deep breaths.
Take light food half an hour before the foot massage.
Researcher will massage your foot for 30 minutes.
Researcher uses soft, gentle strokes while giving foot massage.
Avoid emotions like frustration, anger, and irritation during the foot massage and keep
yourself calm and free from mental stress.
If you feel any discomfort during the massage you are free to communicate with the
researcher about it.
Do not bath immediately following the foot massage.
After completion of foot massage rest for at least 15 mintues.
Step 1:
The researcher starts by massaging the pressure points on the soles of the foot. Then applies
pressure lightly on the middle of the sole for 2 mintues to relax the whole body.
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Step 2: Lower 2/3rd of the tibia
Massage from the lower 2/3rd of the tibia to dorsum of the foot and toes for five times and stretch
and pull the great toe gently and rub each side of the nail.
Step 3: Medial malleolus
The researcher applies gentle pressure on both sides of the heel below the ankle joint, followed
by circling around the ankle joint with both tip of thumb in a clockwise and anti clockwise
direction. This improves circulation and the energy level of the body.
Step 4: Dorsum of the foot
The researcher uses fingers walking forward in a crawling movement similar to a worm
from the dorsum of the foot till the ankle for five times and then the thumb running
backward movement starts from the ankle towards the toes for five times. This
promotes circulation and improves venous return.
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Step 5 : Lower 2/3rd of the tibia and dorsum of the foot
The researcher uses small circular motion to massage the lower the 2/3 rd of the tibia till
the dorsum of the foot for five times.
Total duration of lower limb massage is 15 minutes in each leg for 30 minutes. The researcher
administer this foot massage twice (morning and evening) a day for the five consecutive days.
Conclusion
Lower limb massage is an alternative therapy. Slow and light massage should be preferable for
pregnant mothers. Man is considered as an inverted tree. Foot massage help in the locomotion or
easy movement, feasibility of body, reduce stress and depression, helpful in the activation of
immunity, promotes sleep and prevents insomnia, and reducing edema.
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4(b) Manuscript in Kannada
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ANNEXURE 5
5(A) Certificate Of English Editing
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5(B) Certificate Of Kannada Editing
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ANNEXURE 6
LIST OF EXPERTS WHO VALIDATED THE TOOL
1) Dr.Swetha Reddy
Obstetric and Gynaecological Department(MBBS, MD,DNB)
St.Philomena’s Hospital, Bengaluru
2) Dr.Anitha David
Obstetric and Gynaecological Department(MBBS, MD,DNB)
St.Philomena’s Hospital, Bengaluru
3) Dr. Shylaja
Obstetric and Gynaecological Department(MBBS, MD,DNB)
St.Philomena’s Hospital, Bengaluru
4) Mrs. Gayathri
Assistant professor
St. John’s college of Nursing
5) Mrs. Mary Ann Washington
Nurse Researcher
St. John’s Researcher Institute, Bengaluru
6) Mrs. Sonam Maclay
Nurse Researcher
St. John’s Researcher Institute, Bengaluru
7) Mrs.Vrigin Mary
Nurse Researcher
St. John’s Researcher Institute, Bengaluru
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8) Mrs. Kamala
Assistant professor
KIMS
9) Mrs.Alma Juliet
Assistant Professor
St. Martha College of Nursing
10) Mrs. Balakshimi
Professor
Oxford college of nursing
11) Mrs. Sangeetha
HOD of Obg
Ramiaya College of Nursing
12) Mrs.Teena
Assistant professor
Ramiah College of Nursing
13) Mrs. Swathy
Assistant professor
T. John College of nursing
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ANNEXURE 7
FORMULAE FOR STATISTICAL ANALYSIS
1 . Mean : ∑ X
N
2) Standard Deviation : SD
S= ∑ (x – x)2
n-1
3. Karl Person’s correlation co-efficient Formula:
4. Paired t-test :t = ∑d
n(∑d 2) - (∑d)2
n-1
5. Degree of freedom df = ( n -1)
2r
1+r
r 1 =
∑ ( x - x ) ( y - y )
r =
∑ (x - x )2 ∑ (y – y )2
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6 . Chi square test :
ꭓ2 = ∑ ( O- E )2
E
ꭓ2 = ∑ ( | O- E| -0.5)2
E
Where , O = Observed frequency, E = Expected frequency