RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCESBANGALORE, KARNATAKA.
A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED
TEACHING PROGRAMME REGARDING SELECTED
ASPECTS OF PUERPERAL COMPLICATIONS AND
ITS PREVENTION AMONG PRIMIGRAVIDA
MOTHERS ATTENDING ANTENATAL
OPD IN A SELECTED HOSPITAL
AT KOLAR DISTRICT.
PROFORMA FOR REGISTRATION OF SUBJECTFOR DISSERTATION
Ms. S. SAGILA RANIA.E. & C.S. PAVAN COLLEGE OF NURSING,
KOLAR, KARNATAKA.
1
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCESBANGALORE KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FORDISSERTATION
1. NAME AND ADDRESS OF THE CANDIDATE
Ms. S.SAGILA RANI 1st YEAR M.Sc NURSINGA.E. & C.S PAVAN COLLEGE OF NURSING, KOLAR.
2. NAME OF THE INSTITUTE A.E. & C.S PAVAN COLLEGE OF NURSING, KOLAR
3. COURSE OF STUDY AND SUBJECT
1ST YEAR M.Sc. NURSINGOBSTETRICS ANDGYNAECOLOGICAL NURSING
4. DATE OF ADMISSION OF COURSE
02-06-2008
5. TITLE AND TOPIC:- A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME REGARDING SELECTED ASPECTS OF PUERPERAL COMPLICATIONS AND ITS PREVENTION AMONG PRIMIGRAVIDA MOTHERS ATTENDING ANTENATAL OPD IN A SELECTED HOSPITAL AT KOLAR DISTRICT.
2
6. BRIEF RESUME OF INTENDED WORK
INTRODUCTION:
“Healthy Mothers, Healthy babies, Healthy Nations” (Confederation mission statement)
The postpartal period (or) puerperium ( from the latin word puer, ‘child’
and parere, “ to bring forth”) refers to the 6 week period after child birth, when the
women is readjusting physiologically and psychosocially to motherhood. This is a
time of maternal changes that are retrogressive (involution of the uterus and vagina)
and progressive (Production of milk for lactation, restoration of normal menstrual
cycle and beginning of a parenting role). Protecting a woman’s health as these
changes occur is important for preserving her future child bearing function and for
3
ensuring that, she is physically well enough to incorporate her new child into the
family. This period is popularly termed the fourth trimester of pregnancy .1
Maternal mortality is currently estimated at 5,29,000 deaths per year, a global
ratio of 400 maternal deaths per 1,00,000 live births. A tiny 1 % of maternal deaths
occur in the developed world. Maternal mortality ratios range from 830 per 1,00,000
births in African countries to 24 per 1,00,000 births in European countries. Of the
20 countries with the highest maternal mortality ratios, 19 are in sub – Saharan
Africa. Rural populations suffer higher mortality than urban dwellers, rates can vary
widely by ethnicity or by wealth status, and remote areas bear a heavy burden of
deaths .2
Maternal deaths are deaths from pregnancy related complications occurring
throughout pregnancy, labour, childbirth and in the postpartum period (up to the
42nd day after the birth). Such deaths often occur suddenly and unpredictably.
Between 11% and 17% of maternal deaths happen during childbirth itself and
between 50% and 71 % in the postpartum period. Within this period, the first week
is the most prone to risk. About 45% of postpartum maternal deaths occur during
the first 24 hours, and more than two thirds during the first week. 2
In India, 23% of women report health problems in the first months after
delivery. Some of these problems are temporary but others become chronic. They
include, urinary incontinence, uterine prolapse, pain following poor repair of
episiotomy and perineal tears, nutritional deficiencies, depression and puerperal
psychosis and mastitis. Maternal mortality is low in states like kerala and Punjab. In
contrast in as many as 10 of the 15 major states (Assam, Bihar, Gujarat, Haryana,
Karnataka, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh and west Bengal)
where Maternal Mortality Ratios (MMRs) exceed 400 per 1,00,000 live births,
and three states ( Assam, Madhya Pradesh and Uttar Pradesh) where MMRs are as
high as 700 or more. 2
Puerperal sepsis is an infection of the genital tract during the first 6 weeks
after delivery. Puerperal sepsis remains the most important cause of morbidity and
mortality following childbirth. Puerperal sepsis contributes directly (or) indirectly to
about one – third of all maternal deaths. Postpartum infection occurs in about 1-8 %
4
of vaginal deliveries and it is 5-10 times higher following caesarean section.3
Puerperal sepsis occurs after about 6% of birth in the united states.4
Sepsis is estimated to be the cause of maternal deaths in 0.5 - 15% of cases. It
is significantly more common in Africa, Asia, Latin America and the Caribbean
than in developed countries. Today in USA, puerperal infection is believed to occur
in between 1 and 8 % of all deliveries. About 3 die from puerperal sepsis for every
1, 00,000 deliveries. In the United Kingdom 1985 to 2005, the number of direct
deaths associated with genital tract sepsis per 1, 00,000 maternities was 0.40-0.85.
The incidence of maternal deaths in the United States is 13 in 1, 00,000. The
confidencial enquiry into maternal and child health (UK) reported that, in 2003 to
2005, genital tract sepsis accounted for 14% of direct causes of maternal death.5
The risk factors for puerperal sepsis are malnutrition and anemia, low socio
economic status, low host resistance, chronic debilitating illness, repeated vaginal
examinations, traumatic operative vaginal delivery, retained bits of placental tissues
and membranes, diabetes etc. 6
Untreated puerperal sepsis has risk of developing septicemia, endotoxic
shock, disseminated intravascular coagulation, septic embolization and chronic
pelvic inflammatory diseases. The preventive measures of puerperal sepsis during
antenatal period include, improvement of nutritional status and general condition,
treatment of anemia, eradication of any septic focus ( Skin, throat, etc), abstinence
from sexual intercourse in the last 2 months, daily bath and daily change of clean
cloths, avoiding contact with people with infections such as cold, boils etc, and
avoiding unnecessary vaginal examination and vaginal douches in the later
months. Preventive measures during postnatal period include, use of sterilized
sanitary pads, care of the perineal wounds and episiotomy, and avoiding contact
between patient and visitors with infection etc. 7
Mastitis is a true infection of the breast. It usually occurs about 1-3 weeks
after child birth.3 Mastitis (or) breast infection affects about 1 % of women soon
after child birth, most of whom are first time mothers who are breast feeding 4. It
occurs most frequently in women who do not nurse their infant frequently and do
not express out the breast adequately as a result of breast engorgement and stasis of
5
milk occurs. Fissures in the nipples, poor personal hygiene, milk stasis and poor
nursing technique predispose to its occurrence. The baby’s mouth, attending
personnel or the mother herself may provide the source for the infection.3
Untreated mastitis has approximately a 10% risk of developing an abscess.
The best treatment of mastitis is prevention. Prevention is accomplished through
meticulous attention to hand washing with antibacterial soap, prevention of
engorgement with early treatment and frequent feedings, proper positioning of
the baby on the breasts, good support of the breasts without constriction, cleansing
with water only and no drying agents, daily observation of the baby for skin or cord
infection, and avoiding close contact with people with a known staphylococcal
infection or lesion .8
Postpartum depression develops in the early postpartum period. The
frequency of postpartum depression varies from 5% to more than 25%. The
depressive episode may be minor or it may be major without psychotic features4.
The actual etiology is unclear, however the most powerful predictor appears to be a
previous history of depressive illness either postpartum (or) at other times.9
The most severe untreated depression is that of postpartum psychosis.
Prevention of postpartum depression through the identification of risks during the
prenatal period as well as early intervention, including telephone or office follow up
in the early postpartum phase based on indicators of risk, is key to shortening the
cycle of postpartum depression. Coaching women to plan for life changes that will
increase positive stimulation, open lines of good communication with family and
friends and care for themselves are helpful tools.4
It is important that the nurse has to determine how much the mother knows
and understands about her needs and prevention of puerperal complications. A
mother who is unfamiliar with prevention of puerperal complications during
puerperal period may be disappointed about her health status. Only a healthy mother
can bear a healthy baby. Taking advantage of such a phenomena the nurse can play
a vital role to encourage the mothers to be more active and take active participation
in her own care.
6
6.1. NEED FOR THE STUDY
About 150-200 million women deliver every year world over. Five million
die, but this is the tip of the iceberg. Some deaths remain unreported, especially
those occurring in the rural areas. The life risk of a woman dying as a result of a
complicated pregnancy or delivery is 1:20. Many are avoidable deaths. Of the total
maternal deaths, only 1% occurs in the developed countries and 99 % occur in the
developing countries, indicating that avoidable factors have been overcome and well
tackled in the developed countries through regular antenatal supervision and
hospital delivery by trained personnel.10
7
In Uk, maternal mortality is 1/1,00,000. Singapore, Japan, Europe report
maternal mortality less than 10 per 1,00,000 deliveries. Srilanka has reduced its
maternal mortality from 520 in 1955 to 80/1,00, 000.10
In India Maternal Mortality is 400-500/1,00,000 in the urban population but
as high as 800/1,00,000 in the rural areas. Three hundred women die every day.
India, Bangladesh, Pakistan together contributes to 28% of the total births all over
the world, but account for 46% of maternal deaths. In kerala, which is a small state
but with a literate population, maternal mortality has already reached a low of
200/1,00,000 deliveries. Similarly Bombay reports maternal mortality of
100/1,00,000 births.10
Even in the 21st century, approximately 6,00,000 women die of pregnancy –
related causes each year. The WHO reported that 98% of these deaths occur in
developing countries, where the leading cause of maternal mortality is perinatal
infection.11 Puerperal sepsis has been responsible for about 25% maternal mortality
in India 10. Puerperal infectious morbidity affects 2-10% of patients. It is 5-10 times
higher following caesareans delivery .3
World wide puerperal sepsis is a leading cause of maternal mortality and
that many of the predisposing factors are preventable (unhygienic conditions, low
socio economic status, poor nutrition, anaemia, prolonged lobour, prolonged
rupture of membranes, multiple vaginal examination etc). Both nosocomial
infections as well as exogenous infections are serious factors and relate that aseptic
techniques and antibiotics can play a major role in reducing the incidence of
puerperal infections. 12
The virulence of the organism, the resistance of the women, and her likely
response of treatment are the intangibles of prognosis. Prevention, supportive
therapy and prompt massive antibiotic administration have reduced the maternal
mortality in the united states of less than 0.4%. Regrettably in developing countries
the death rate may be more than 10 to 20 times this figure .4
A Study was conducted to determine the risk factors for puerperal sepsis. A
case control design was used. The study included 160 puerperal sepsis cases and
160 controls. A pre- designed interviewing questionnaire was used to collect data.
8
Findings reveals that very low socio- economic score (OR = 6.4), No ANC
(R = 4.5), delivery at a Govt. maternity hospital (OR = 203.4), frequent vaginal
examinations (OR = 5.1), anaemia during puerperium (OR=4.3), unsanitary vaginal
douching during puerperium (OR= 19.9), unhygienic preparation of diapers
(OR= 12.1) were related to occurrence of puerperal sepsis. Improving infection
control measures during delivery, limiting the frequency of vaginal examinations
and avoiding all unhygienic practices related to delivery are strongly
recommended.13
Mastitis is infection of the breast tissue .The incidence is highest in the first
few weeks postpartum, decreasing gradually after that. However, cases may occur
as long as the women is breast feeding.14 The incidence of mastitis is 2-5% in
lactating and less than 1% in non lactating women.15 It occurs when organisms from
the skin or the infant’s mouth enter small cracks in the nipples or areola. Breast
engorgement and inadequate emptying of milk are associated with mastitis.16
Almost all instances of acute mastitis can be avoided by proper breast
feeding technique to prevent cracked nipples. Missed feedings, waiting too long
between feedings and abrupt weaning may lead to clogged nipples and mastitis.
Cleanliness practiced by all who have contact with the newborn and new mother
also reduce the incidence of mastitis.4
A study was conducted on common problems associated with breastfeeding
and their management. The findings reveals that many common problems that may
arise during the breastfeeding period such as breast engorgement, plugged milk
duct, breast infection and insufficient milk supply, originate from conditions that
lead the mother to inadequate empty the breasts. Incorrect techniques, not frequent
breast feeding and breast feeding on scheduled times, pacifiers and food suppliers
are important risk factors that can predispose to lactation problems. There are
specific measures that should be taken to empty the breasts effectively. Besides, the
emotional support and actions that yield more comfort to the lactating mother can
not be neglected. Most common problems associated with breastfeeding can be
prevented if the mother empties her breasts effectively.17
9
The risk of women being referred to a psychiatrist in the year following pregnancy
and childbirth is five times greater than at other times in their lives.9 The postpartum
depression is observed in 10-20% of mothers. It is more gradual in onset over the
first 4-6 months following delivery. The risk of recurrence is high (50-100%) in
subsequent pregnancies. The women feels slighted easily and develops a suicidal
tendency.15
Predisposing factors may be hormone related, stress related or infant related.
Environmental and family stress issues may be linked to postpartum depression. It
can seriously disrupt her life and that of her family. It may persist for months before
it finally lifts. Isolation can be both a cause and result of depression. The new
mother is helped to identity sources of emotional support among her family and
friends.4 Ideally, care and management based primarily on preventive measures and
begin preconception or at least during the antenatal period, for women with a past
history and known risk factors.9
A study was conducted on postpartum depression (PPD) in a 68-bed
maternity hospital in lagos, Nigeria. The study was conducted in 252 women, by
using a questionnaire, the Edinburgh Postnatal Depression Scale (EPDS), and the
depressive module of International Classification of Diseases, 10th edition (ICD-10).
The cohort was predominantly young (mean age 28.5+/- 5.26 years). About one-
quarter (23%) scored >or =12, (the cut – off score) on EPDS assessment; with
majority of these depressed on further evaluation with ICD-10. The risk factors for
PPD were found to be mainly psychosocial, including unwanted pregnancy,
unemployment and marital conflict and which can be minimized by improving
both the citizens socioeconomic condition and providing cheaper and more efficient
health care services .18
The nurse can also ease the transition from pregnancy to motherhood.
Therefore it is the nurse’s responsibility to provide the women with adequate health
information to bridge the gap between the knowledge and the health practices of the
mothers. It important, therefore the information is to be given to primigravida
mothers about selected aspects of puerperal complications and its prevention.
Therefore, the investigator felt need to administer a structured teaching programme
10
to improve the knowledge regarding selected aspects of puerperal complications and
its prevention among primigravida mothers.
6.2. REVIEW OF LITERATURE
The typical purpose for analyzing or reviewing existing literature are to
generate research question to identify what is known and not known about a topic to
identify conceptual of theoretical tradition with in the bodies of literature and to
describe methods of enquiry used in earlier work including their success and short
campaigns.19
Review of literature was undertaken to gain in depth knowledge of the
various aspects of the problem under study.
The reviewed literature has been presented under the following headings.
11
1. Studies related to selected aspects of puerperal complications.
2. Studies related to structured teaching program regarding selected aspects of
puerperal complications.
1. Studies related to selected aspects of puerperal complications
The prospective community based study was conducted in the village of
chhainsa, Haryana, India, in order to discover the incidence and types of postpartum
morbidity and the factors associated with the morbidities. The study was conducted
in 211 women and they were followed up to 42 days of post partum, with a
minimum of 3 visits. About 74% reported at least one morbidity and there were
1.75% reported morbidities per women per postpartum period. Common problems
reported were; weakness, lower abdominal pain, perineal pain, abnormal vaginal
discharge, high fever, breast problems, excessive vaginal bleeding etc. There was
greater morbidity among women of lower socio- economic status, parity >4, birth
interval >36 months, delivery assisted by relatives/ neighbours. A Significant
positive association was found between age and non- maintenance of the “five
cleans” during delivery. 20
A study was conducted on reduction in maternal mortality due to sepsis.
During the study period of 20 years, a total of 37,155 women delivered, 192 deaths
occurred and 40 deaths (20.83%) were due to sepsis and its sequlae. It was revealed
that there is a definite decrease in the proportion of deaths due to sepsis, to 10% in
the last five years from 35% in earlier years. The change seems to be due to the
advocacy of clean deliveries and reduction in case fatality because of alterations in
medication and earlier surgical intervention.21
A Study was conducted on maternal morbidity during labour and the
puerperium. Study was conducted in 772 women, and the women followed up from
the seventh month in pregnancy to 28 days postpartum (up to 10 visits in total).
Findings reveal that the incidence of maternal morbidity was 52.6%, 17.7% during
labour and 42.9% during puerperium. The postpartum morbidities included breast
problems (18.4%), secondary postpartum haemorrhage (15.2%), puerperal genital
infection (10.2%) and insomnia (7.4%). Puerperal complications (infection, fits,
12
psychosis, breast problems) were significantly associated with adverse perinatal
outcomes. Frequent (43%) postpartum morbidity and its association with adverse
perinatal outcome, suggests the need for health teaching regarding the prevention of
puerperal complications and home based postpartum care in developing countries.22
A study was conducted on puerperal sepsis. The study was conducted in 146
patients with puerperal sepsis. Findings revealed that 1.7% out of 8428 deliveries
where diagnosed as puerperal sepsis. The incidence was higher among unbooked
patients (71.2%). Predisposing factors were anaemia in pregnancy 69.2%, prolonged
labour 65.7%, frequent vaginal examinations 50.7%, premature rupture of
membranes 31.5% and non adherence to asepsis during delivery. The case mortality
rate was 4.1%. Antenatal care and supervised hospital delivery should be
encouraged inorder to prevent or reduce this serious post- partum morbidity.23
A prospective cohort study was conducted to report the incidence of mastitis
in the first 6 months postpartum in a Scottish population, its impact on breast
feeding duration and to describe the type and appropriateness of the support and
management received by affected women from health professionals. For a
longitudinal study 420 breast feeding women was selected in Glasgow in 2004/05.
Cases of mastitis were reported either directly or were detected during regular
follow-up telephone interviews at weeks 3, 8, 18 and 26. Women experiencing
mastitis provided further information of their symptoms and the management and
advice they received from health professionals. Result shows that, 74 women (18%)
experienced at least one episode of mastitis. More than one half of initial episodes
(53%) occurred with in the first 4 weeks postpartum. One in 10 women (6 / 57) were
advised to either stop breast feeding from the affected breast or to discontinue breast
feeding all together. Approximately one in six women is likely to experience one or
more episodes of mastitis while breast feeding.24
A study was conducted to describe incidence and treatment of lactational
mastitis. The study conducted in 946 breast feeding women from Michigan and
Nebraska and they were followed for the first 3 months postpartum or until they
stopped breast feeding. Result shows that a total of 9.5% diagnosed lactational
mastitis at least once during the 12 week period, with 64% diagnosed via telephone.
13
After adjustment in a logistic regression model, history of mastitis with a previous
child (odds ratio (OR)= 4.0, 95 % (CI) confidence interval :2.64 , 6.11 ), cracks and
nipple sores in the same week as mastitis (OR=3.4,95%CI :2.04, 5.51), using an
antifungal nipple cream in the same 3weeks interval as mastitis (OR=3.4 , 95%
CI :1.37, 8.54) and (for women with no prior mastitis history) using a manual breast
pump (OR = 3.3 ,95% CI :1.92, 5.62) strongly predicted mastitis. Feeding fewer
than 10 times per day was protective regardless of whether or not feeding frequency
in the same week or the week before mastitis was included in the model (for the
same week :7-9 times; OR=0.6,95% CI:0.41,1.01;<6 times: OR=0.4, 95% CI:0.19,
0.82). Duration of feeding was not associated with mastitis risk.25
A study was conducted to assess the contributing factors in puerperal breast
abscess and to evaluate the treatment option. During the study period, 128 nursing
women with breast infection were followed. Of these, 102 had mastitis (80%) and
26 had breast abscess (20%). All mastitis patients were treated with antibiotics and
none developed an abscess. Ten abscesses were aspirated and 16 abscesses were
treated by incision and drainage. Recurrent mastitis developed in 13 Patients
(10.2%) with in a median of 24 weeks of follow up. Delayed treatment of mastitis
can lead to abscess formation and it can be prevented by early antibiotic therapy.26
The study was conducted in 664 south – west, Finland women, and they were
studied 5-12 weeks after delivery. The total frequency of mastitis was higher than
generally reported. The frequency of mastitis was similar among nulli and
multiparous women. In multiparous woman who has mastitis during previous
puerperium, the probability of mastitis during subsequent puerperium is threefold,
but the type of skin, its reaction to the sun, allergies, rasher, getting cold and
oxytocin medication during delivery did not affect the incidence of mastitis.
Mother under 21 and over 35 years of age had a decreased incidence (P=0.034) of
mastitis. If the women had sore nipples, the frequency increased (P =0.003) .27
A study was conducted on stripping out pus in lactational mastitis is effective
in preventing the formation of breast abscesses. Study was conducted in 475 women
with lactational mastitis. About 61 women were excluded because they already had
a breast abscess. Result shows that the duration of symptoms before treatment was
14
1 to 56 (mean 5.3 days). In 9% of the cases both breasts were affected and in 23%
atleast one episode of mastitis had previously occurred. By stripping technique pus
was removed in 210 women. The remaining women were considered to have
cellulitis. Only 4 patients (less than 1%) had breast abscesses. The mean length of
illness after treatment was 7.2 days. The rate of recurrence was 14%. In all 6% of
the mothers and 9% of the infants became ill in the 6 weeks after the mastitis. Most
(92%) of the patients continued to breast feed.28
A study was conducted to determine the incidence and associated factors for
postnatal depression in the Bucaramanga, Colombia, and Metropolitan area. The
study was conducted on 286 puerperal women from 11 health centers at different
levels, women were monitored for 6 weeks, Information was obtained by a semi
structured clinical interview, on social demographic and obstetric variables,
psychiatric history variables concerning the newborn, satisfaction with delivery,
and breast feeding. Result shows that the incidence rate of postnatal depression was
1 case per 1000 days/ person monitored (95% CI, 0.5 – 1.7) and factors were
associated with postnatal depression ; depression background , HR 3.87 ( 95% CI,
1.02 – 14.7), absence of prenatal monitoring , HR 3.87 (95 % CI, 1.1 – 13.2) and
back ground of dysphoria , HR 15.13 (95% CI, 1.9- 118.2). Postnatal depression is
as major public health problem, where an appropriate prenatal monitoring, follow –
up programme for mother and child would help its early diagnosis and
management.29
A study was conducted to assess the effect of psychosocial and psychological
interventions compared with usual antepartum, intrapartum or postpartum care on
the risk of postnatal depression. Fifteen trials with 7697 pregnant women or new
mothers less than six weeks postpartum were included in the study. The result
shows that there was no overall statistically significant effect on the prevention of
postnatal depression in the meta –analysis of all types of interventions (15 trials,
n=7697; relative risk 0.81, 95% CI: 0.65 to 1.02), these results suggest a potential
reduction in postnatal depression. The only intervention to have a clear preventive
effect was intensive postpartum support provided by a health professional (0.68,
0.55 to 0.84). Identifying women at risk assisted in the prevention of postnatal
15
depression (0.67, 0.51 to 0.89). Interventions with only a postnatal component were
more beneficial (0.76, 0.58 to 0.98) than interventions that incorporated an antenatal
component. In addition, individually based interventions were more effective (0.76,
0.59 to 1.00) than group based interventions (1.03, 0.65 to 1.63). The most
promising intervention is the provision of intensive, professionally based
postpartum support .30
A prospective study was conducted on emotional disorders in child bearing
women. A group of first time mothers (119) were interviewed repeatedly at fixed
intervals during their pregnancies and until their babies were a year old; they were
then followed up at 4 years. A similar investigation was carried out on 38 other
primiparae and 39 multiparae, but only postnatally. The incidence of depressive
neurosis rose significantly in early pregnancy and in the first 3 months after delivery
(10% & 14% of the main sample respectively). Subjects mainly suffered either from
antenatal or postnatal depression, not both. Marital conflict and severe doubts about
having the baby were associated with depression at either time. Bereavement and
preterm birth were the only life events to relate with the onset of depression and
bereavement had a greater impact during pregnancy.31
2. Studies related to structured teaching programme on selected aspects of
puerperal complications.
A study was conducted to determine the effectiveness of an intervention that
incorporated education about the “six cleans “with the use of a clean delivery kit in
preventing puerperal sepsis and cord infection. The study was conducted in 3262
pregnant women between the ages of 17 and 45 years. Results shows, women who
used the kit for delivery were 3.2 times less likely to develop puerperal sepsis than
women who did not use the kit. Women who bathed before delivery were 2.6 times
less likely to develop puerperal sepsis than women who did not bathe, and their
infants were 3.9 times less likely to develop cord infection. Single – use delivery
kits, when combined with education about clean delivery , can have a positive
impact on the health of women and their newborns by significantly decreasing the
likelihood of developing puerperal sepsis or cord infection. 32
16
A cross – sectional study was conducted to evaluate whether follow – up of
breast feeding mothers at maternity hospitals classified as “Baby – Friendly
hospitals” in Brazil, was a protective factor against mastitis. The study conducted in
2,543 mothers of infants (<1 year of age) were selected by simple stratification and
interviewed by 104 college students at immunization services. Findings reveals that
women who delivered in “Baby friendly Hospital” had a lower prevalence of
lactational mastitis (3.6% V S 5.3%; OR =0.68; 95% CI: 0.46 – 1.01). Additionally ,
delivery in Baby Friendly Hospitals, (OR = n0.71 ;95%CI : 0.48 – 1.06) , absence of
nipple fissure ( OR =0.27 ; 95% CI : 0.19 – 0.40 ) , and no maternal outdoor work
(OR = 0.64 ; 95% CI : 0.44 – 0.94) were also associated with a decreased prevalence
of lactational mastitis. Prevalence of lactational mastitis was observed to be lower
in women delivering in “Baby – Friendly Hospitals” with Breastfeeding Counseling
Programmes.33
A study was conducted to evaluate the effect of antenatal prevention of
postnatal depression. Twenty three women at risk for postpartum depression were
offered ten classes in pregnancy and postpartum, focusing on parenting and coping
strategies. Twenty one controls attended standard six antenatal classes. In
postpartum there were no differences in depression scores, however anxiety was less
at 6 weeks postpartum in the intervention group. Over time both groups had reduced
numbers and reduced satisfaction with supports, but this was greater in the control
group. With respect to the marital relationship, this was also less satisfactory
postpartum in the control group. The intervention group was well attended and
participants satisfied with the alternative antenatal class farmat.34
A prospective, randomized controlled study was conducted with the
objectives, to develop an education intervention about perinatal depression, to
deliver this intervention antenatally and to determine the effect of the antenatal
education intervention in the reduction of postnatal depression. The education
intervention (n = 206) was conducted at three sites in Australia. The changes in
mood state were measured by the profile of mood states questionnaire once
antenatally (12 – 28 weeks), and twice postnatally (8 – 12 and 16 – 24 wk); the
education package was administered to the intervention group at the antenatal
17
assessment of mood. Result shows a significant and steady reduction in scores was
observed over time for both groups that showed significant improvement in
symptoms of depression. Women in both the study and control groups were more
depressed antenatally than postnatally. The finding that the education intervention
made no difference challenges the two strongly held tenets of health education in
child bearing women – that depression can be reduced through education and that
antenatal education interventions can endure into the postnatal period.35
STATEMENT OF THE PROBLEM
A study to assess the effectiveness of structured teaching progremme
regarding selected aspects of puerperal complications and its prevention among
primigravida mothers attending antenatal OPD in a selected hospital at kolar district.
6.3. OBJECTIVES OF THE STUDY
1. To assess the existing level of knowledge of primigravida mothers
regarding selected aspects of puerperal complications and its prevention.
2. To determine the effectiveness of structured teaching programme
regarding selected aspects of puerperal complications and its prevention among
primigravida mothers.
3. To find the association between post test knowledge level with their
selected demographic variables.
6.4. OPERATIONAL DEFINITIONS:
Assess:
It refers to determine the level of knowledge regarding selected aspects of
puerperal complications and its prevention among primigravida mothers.
Effectiveness:
18
It refers to desired changes brought about by the structured teaching
programme on selected aspects of puerperal complications and its prevention.
Structured teaching programme:
It refers to system of planned instructional design used to impart
information in order to bring a change in knowledge regarding selected aspects of
puerperal complications and its prevention among primigravida mothers.
Selected aspects of puerperal complications:
It refers to puerperal complications like puerperal sepsis, mastitis and
postnatal depression.
Prevention:
It refers to prior precautionary steps followed before the occurrence of
puerperal sepsis, mastitis, postnatal depression.
Primigravida mothers:
It refers to mothers who are pregnant for the first time.
6.5. HYPOTHESIS:
Ho: There will be no relationship between pretest and post test scores
of primigravida mothers.
6.6. VARIABLES:
6.6.1. Dependent variable:
Knowledge of primigravida mothers regarding selected aspects of
puerperal complications and its prevention.
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6.6.2. Independent variables:
Structured teaching programme on selected aspects of puerperal
complications and its prevention.
6.6.3. Attributed variables:
Age, education, occupation, income, religion, source of information.
7. MATERIAL AND METHOD
7.1. Source of data:
Primigravida mothers attending antenatal OPD in selected hospital.
7.2. Method of data collection:
7.2.1. Research design:
Pre -experimental design [one group pre test - post test design]
7.2.2. Setting of the study:
The study will be conducted in SNR hospital, kolar, which is 2kms away
from the pavan college of nursing, having 500, bed strength.
7.2.3. Population:
The population for the present study comprises of primigravida mothers
attending antenatal OPD in SNR hospital.
7.2.4. Sample:
Primigravida mothers attending antenatal OPD, with age group
between 20 to 35 years.
7.2.5. Sample size:
60 primigravida mothers will be selected as a sample for the study.
7.2.6. Sampling technique:
Convenience sampling technique will be used to select the sample for
the study.
7.2.7. Sampling criteria:
Inclusion criteria:-
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Primigravida mothers who are attending antenatal OPD.
Primigravida mothers who are between the age group of 20 to 35 years.
Primigravida mothers who can communicate Kannada (or) English.
Primigravida mothers who are willing to participate in the study.
Exclusion criteria:-
Primigravida mothers who are admitted in the hospital.
Primigravida mothers who cannot communicate Kannada or English.
Primigravida mothers who are the age group below 20 years and above
35 years.
Primigravida mothers who are not present at the time of data collection.
7.2.8. Tool of data collection:-
Structured Interview schedule will be used for data collection.
The tool consists of two sections.
Section: A
Consists of demographic data of the subject which includes age, education,
occupation, income, religion, source of information, obstetrical history.
Section: B
The structured interview schedule to assess the knowledge regarding selected
aspects of [puerperal sepsis, mastitis and postnatal depression] puerperal
complications and its prevention among primigravida mothers who are attending
antenatal OPD.
7.2.9 .Method of data collection:
Structured interview schedule will be used to collect the data from the
primigravida mothers who are attending antenatal OPD. The purpose of the study
will be explained and consent of the participant will be obtained to involve in the
study. Tentative period of data collection will be 6 weeks. Before that tool for data
21
collection will be prepared and after validation by the experts, the further refinement
of the tool will be done after that the pilot study will be conducted.
7.210. Data analysis and interpretation:
Data will be analyzed on the basis of objectives and testing of hypothesis by
using descriptive and inferential statistics. The frequency, percentage, mean and
standard deviation will be used for the descriptive statistics. In inferential statistics
the chi-square test will be used to find the association between post test knowledge
level with their selected demographic variables and paired ‘t’test will be used to
assess the effectiveness of structured teaching programme on selected aspects of
puerperal complications and its prevention. The results will be presented in the form
of tables, graphs and diagrams.
7.3. Does the study require any investigation (or) intervention to be conducted
on patient/sample population or other humans or animals?
Yes. The study will be conducted on the Primigravida mothers who are
attending antenatal OPD in SNR hospital at kolar district. Since it is pre -
experimental study it requires interventions in the form of teaching regarding
selected aspects of puerperal complications and its prevention, it will not harm to
the mothers.
7.4. Has ethical clearance been obtained from your institutes?
Yes. Prior to the study the formal permission will be obtained from the
concerned authorities of SNR hospital in kolar, to conduct a study and also from
research committee of AECS Pavan College of nursing in kolar. The purpose of the
study will be explained to the Primigravida mothers who are attending antenatal
OPD in SNR hospital. Privacy, confidentiality and anonymity will be guarded.
Scientific objectivity of the study will be maintained with honesty and impartiality.
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