RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1NAME OF THE

CANDIDATE AND ADDRESS

Ms. NIJISHA SHARLI

1ST YEAR MSc. NURSING STUDENT

NISARGA COLLEGE OF NURSING,

# 18KIADB,B. KATIHALLY,

INDUSTRIAL AREA, HASSAN,

KARNATAKA.

2NAME OF THE INSTITUTION

NISARGA COLLEGE OF NURSING

HASSAN, KARNATAKA.

3COURSE OF THE STUDY

AND SUBJECT

MASTER OF SCIENCE IN NURSING,

OBSTETRIC AND GYNECOLOGICAL NURSING

4DATE OF ADMISSION TO

COURSE01/07/2011

5 TITLE OF THE STUDY

THE EFFECTIVENESS OF PLANNED TEACHING PROGRAMME ON KNWOLEDGE REGARDING PREVENTION OF POSTPARTUM INFECTIONS AMONG POSTNATAL MOTHERS

5.1STATEMENT OF THE

PROBLEM

“A STUDY TO EVALUATE THE EFFECTIVENESS OF PLANNED TEACHING PROGRAMME (PTP) ON KNWOLEGE OF POSTNATAL MOTHERS REGARDING PREVENTION OF POSTPARTUM INFECTIONS IN SELECTED HOSPITALS AT HASSAN, KARNATAKA.”

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6. BRIEF RESUME OF THE INTENDED STUDY:

6.1) INTRODUCTION

“The ultimate value of life depends upon awareness rather than upon mere survival”.

(Aristotle)

A mother is a woman who conceives, gives birth to, or raises and nurtures a

child. The mother is a woman who holds a position of authority or responsibility.

Maternal love and tenderness: brought out the mother in.1

Postnatal is the period beginning immediately after the birth of a child and

extending for about six weeks. Another term would be postpartum period, as it refers

to the mother.2

Labour and delivery are especially hazardous times of pregnancy. Apart from

the risks of severe bleeding and obstructed labour, life threatening infections can be

introduced into the mother and baby’s organs and bloodstream. ‘Maternal sepsis is a

general term which has been used to include various obstetric and genitor-urinary tract

infections introduced into the mother. The World Health Organization ranks maternal

sepsis as the sixth leading cause of disease burden for the women aged 15-44 years,

after depression, HIV/AIDS, tuberculosis, abortion and schizophrenia. As many as 5.2

million new cases of maternal sepsis are thought to occur annually and an estimated

62,000 maternal deaths will result from the condition. A postpartum or puerperal

infection is any clinical infection of the genital canal that occurs within 28 days after

miscarriage, induced abortion, or childbirth.3

Postpartum infections are probably the major cause of maternal morbidity and

mortality throughout the world. Local spread of colonized bacteria is the most

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common etiology for postpartum infection following vaginal delivery. Endometritis is

the most common infection in the postpartum period. Other postpartum infections

include (1) postsurgical wound infections, (2) perineal cellulites, (3) mastitis, (4)

respiratory complications from anesthesia, (5) retained products of conception, (6)

urinary tract infections (UTIs), and (7) septic pelvic phlebitis. Wound infection is

more common with cesarean delivery2.

Postpartum infections comprise a wide range of entities that can occur after

vaginal and cesarean delivery or during breastfeeding. In addition to trauma sustained

during the birth process or cesarean procedure, physiologic changes during pregnancy

contribute to the development of postpartum infections. The typical pain that many

women feel in the immediate postpartum period also makes it difficult to discern

postpartum infection from postpartum pain.2

Postpartum patients are frequently discharged within a couple days following

delivery. The short period of observation may not afford enough time to exclude

evidence of infection prior to discharge from the hospital. In one study, 94% of

postpartum infection cases were diagnosed after discharge from the hospital.

Postpartum fever is defined as a temperature greater than 38.0°C on any 2 of the first

10 days following delivery exclusive of the first 24 hours. The presence of postpartum

fever is generally accepted among clinicians as a sign of infection that must be

determined and managed.2

The most effective and least expensive treatment of postpartum infections is

prevention. Preventive measures include, good parental nutrition, good maternal

perineal hygiene with through hand washing is emphasized, strict adherence by all

health care personnel to aseptic techniques during childbirth and the postpartum period

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is very important.4 In a study by Yokoe et al in 2001, 5.5% of vaginal deliveries

and 7.4% of cesarean deliveries resulted in a postpartum infection. The overall

postpartum infection rate was 6.0%. Endometritis accounted for nearly half of the

infections in patients following cesarean delivery (3.4% of cesarean deliveries).

Mastitis and urinary tract infections together accounted for 5% of vaginal deliveries.2

6. 2) N E E D FOR THE STUDY:

"An ounce of prevention is worth a pound of cure.”

(Gregory Y. Titelman)

Postpartum and Intra-amniotic infections are important causes of maternal and

neonatal morbidity and mortality. Puerperal infections, frequently associated with

intra-amniotic infection (IAI), are the fourth leading cause of maternal death in the

United States, accounting for 13% of maternal deaths. IAI accounts for 10% to 40% of

cases of febrile morbidity in the peripartum period and is associated with 20% to 40%

of cases of early neonatal sepsis and pneumonia. Postpartum infections develop in 1%

to 7% of women, accounting for more than 200,000 infections annually in the United

States. Thus, intra-amniotic and postpartum infections remain significant public health

problems.5

Postpartum infections remain an important cause of maternal morbidity and

mortality. A significant number of women (1% to 7%) develop postpartum

infections. One of the most complete studies identified postpartum infections in 598

(5.9%) of 10,181 deliveries Thus, approximately 200,000 postpartum infections

occur among the 3.5 million women delivering annually in the United States.5

4

Puerperal fever or childbed fever is a bacterial infection contracted by women

during childbirth or miscarriage. It can develop into puerperal sepsis, which is a

serious form of septicemia. If untreated, it is often fatal.6

Short-course antibiotic prophylaxis reduces by two thirds to three quarters the

incidence of both postpartum Endometritis (PPE) and wound infection among women

undergoing either elective or non elective cesarean delivery. More than 50 trials of

antibiotic prophylaxis after cesarean section have been reported.5

The near-elimination of maternal mortality in Europe and North America

occurred largely during the first half of the 20th century, before the development of

much high-technology equipments and medicines, and it is clear that the similar gains

could be achieved in developing countries within mere decades. The two keys appear

to be access to a skilled attendant, professional trained and competent in midwifery at

every birth, and emergency obstetric services available for referral when serious, but

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mostly treatable, complications occur. WHO estimates that just over half (53%) of all

deliveries in developing countries currently take place with the assistance of a skilled

attendant and emergency services are not accessible in many places.

A set of specific antenatal interventions can also contribute to fewer perinatal,

and possibly maternal, deaths and to reduced morbidity in both mothers and neonates.

Access to appropriate family planning tools can reduce the overall number of

unwanted Pregnancies, and consequently the number of maternal deaths: where the

maternal mortality Ratio is high, each pregnancy is risky. Better spacing of births also

benefits the fetus. When unwanted pregnancies do occur, access to safe abortion will

avoid deaths due to the complications that often occur with unsafe, unskilled

abortions. Irrespective of the legality of abortion, access to post abortion care can also

avoid maternal deaths.7

A study was conducted in the Khyber Agency Pakistan to estimate the

prevalence and to identify the factors associate with vaginal infections among married

women between the ages of 15-49 years. Sectional study was conducted in the month

of July 2005 on 1084 mothers by using random sampling strategy by trained nurses.

The multivariate analysis showed that the associated factors with vaginal infection

were the use of unhygienic material to soak up the lochia [aOR=3.45, 95% CI (1.36,

8.75)], bathing after 40 days [aOR=2.10,95% CI (1.55, 3.14)], and women who did not

receive antenatal care [OR=3.87, 95% CI (1.93, 7.75)]. Also women who did not have

medical facilities available [OR=2.45, 95% CI (1.23, 5.06)] reported of vaginal

infection. This study concluded that there is considerable need for health education

among women and the entire community for the maintenance of hygiene, safe delivery

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through medical personnel and improvement inthe mobility of mothers and female

education8

A functional health system is a necessary part of efforts to achieve maternal

mortality reduction in developing countries. Puerperal sepsis is an infection contracted

during childbirth and one of the commonest causes of maternal mortality in

developing countries, despite the discovery of antibiotics over eighty years ago.

Infections can be contracted during childbirth either in the community or in health

facilities. Drug and technological developments need to be combined with effective

health system interventions to reduce infections, including puerperal sepsis. This

article reviews health system infection control measures pertinent to labour and

delivery units in developing country health facilities. . Organisational improvements,

training, surveillance and continuous quality improvement initiatives, used alone or in

combination have been shown to decrease infection rates in some clinical settings. A

health systems approach is necessary to reduce maternal mortality and the occurrence

of infections resulting from childbirth. Organisational and behavioural change

underpins the success of infection control interventions. A global, targeted initiative

could raise awareness of the need for improved infection control measures during

childbirth3

In 2002-2003, all deaths (n=156) of women aged 15-49 years in a block of

southern Rajasthan were investigated to determine the cause of death and care-seeking

behaviour. Family members of 156 (98%) of 160 deceased women were interviewed

following the comprehensive listing of all deaths among women of reproductive age.

Of the 156 deaths, 31 (20%) were pregnancy-related; 77% of these women died during

the postpartum period, and 74% of the deaths occurred in the home. Direct and

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indirect obstetric causes were responsible for 58% and 29% of the deaths respectively;

12% were injury-related deaths. Medical care was sought for 65% of the women, and

29% were hospitalized. Family perception of not being able to afford treatment at

distant hospitals was a major barrier to seeking care, and 60% of those who sought

care had to borrow money for treatment. Lack of skilled attendance and immediate

postpartum care were major factors contributing to deaths. Improved access to

emergency obstetric care facilities in rural areas and steps to eliminate costs at public

hospitals would be crucial to prevent pregnancy-related deaths.9

6.3) STATEMENT OF THE PROBLEM

“A STUDY TO EVALUATE THE EFFECTIVENESS OF PLANNED

TEACHING PROGRAMME (PTP) ON KNWOLEDGE OF POSTNATAL

MOTHERS REGARDING PREVENTION OF POSTPARTUM INFECTIONS

IN SELECTED HOSPITALS AT HASSAN, KARNATAKA.”

6.4) OBJECTIVES OF THE STUDY ARE:

To assess the pre-test knowledge of postnatal mothers regarding prevention of

postpartum infections.

To prepare and administer PTP on prevention of postpartum infections.

To assess the post-test knowledge of postnatal mothers regarding prevention

of postpartum infections.

To compare the pre-test and post-test scores.

To find out the association between the selected demographic variables with

the posttest knowledge of postnatal mothers.

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6.5) HYPOTHESIS

H1: The post-test knowledge scores of postnatal mothers will be significantly higher

than their pre-test knowledge scores after planned teaching programme.

   H2: There will be significant association between the post-test knowledge scores of

postnatal mothers and the selected socio-demographic variables.

6.6) ASSUMPTION      

This study assumed that: -

1. The postnatal mothers may have less than adequate knowledge regarding

prevention of postnatal infections.

2. The planned teaching programme will enhance the knowledge of postnatal

mothers regarding prevention of postpartum infections.

6.7) OPERATIONAL DEFINITION

1. Evaluation: - It refers to the estimation of outcome of the PPT on knowledge

regarding prevention of postpartum infections.

2. Effectiveness: - It refers to the extent to which the information in the PPT has

achieved the desired out come as measured by increase in post-test knowledge

scores of structured questionnaires.

3. Planned teaching program (PTP): It refers to well planned teaching design to

provide information to improve knowledge of postnatal mothers regarding

prevention of postpartum infections.  

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4. Knowledge: - It is defined as the correct response to knowledge questions as

measured by structured questionnaire and calculated as knowledge score

about prevention of postpartum infections.

5. Postpartum infections:-It refers to any clinical infection of the genital canal

that occurs within 28 days after miscarriage, induced abortion or childbirth.

6. Postnatal mothers: It refers to the period beginning immediately after the

birth of a child and extending for about 6 weeks.

6.8) CRITERIA FOR SELECTION OF SAMPLE

Inclusion Criteria

Postnatal mothers who are;

Admitted at time of data collection in selected hospitals

Willing to participate in the study.

Exclusion Criteria

Postnatal mothers who are;

Not willing to participate in the study.

Not present at the time of data collection.

6.9) LIMITATION OF THE STUDY

This study is limited to: -

1. Sample size of 80 postnatal mothers in selected hospitals at Hassan.

2. 4-6 weeks duration.

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6.10) SIGNIFICANCE OF STUDY

The study signifies the importance of planned teaching programme regarding

prevention of postnatal infections and it will enhance the knowledge of postnatal

mothers and that will enable them to prevent the postnatal infections.

6.11) THEORETICAL FRAME WORK

This study is based on “Widden Back’s Model”.

6.12) REVIEW OF LITERATURE.

Review of literature has been divided into three

1. Review of literature related to general information regarding postpartum

infections

2. Review of literature related to incidence and prevalence of postpartum

infections

3. Review of literature related to prevention and treatment of postpartum

infections

1. Review of literature related to general information regarding postpartum

infections

Zainur RZ, Loh KY conducted a study on "Postpartum morbidity--what we

can do". which says that Postpartum is a crucial period for a mother. During this

period a mother is going through the physiological process of uterine involution and at

the same time adapting to her new role in the family. Many postpartum complications

and infection occur during this period. Among the important obstetric morbidities are

Endometritis, perineal cellulitis, mastitis, pulmonary embolism and puerperal sepsis.

Common surgical complications are wound breakdown, breast abscess and urinary

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fecal incontinence. Medical conditions such as anemia, headache, backache,

constipation and sexual problems may also be present. Unrecognized postpartum

disorders can lead to physical discomfort, psychological distress and a poor quality10

Magee KP, Blanco JD, Graham JM et al conducted a study on “perineal

cellulitis and mastitis after cesarean: the effect of age” which says that the rate of

perineal cellulitis and mastitis after cesarean section in two age groups. The first group

consisted of patients who were 17 years old or younger (teenage group) and the second

group of patients were 35 years of age or older (advanced maternal age group).

Patients in each group were matched for length of labor, length of rupture of

membranes, and the use of prophylactic antibiotics. In the teenage group, 18 of 41

(43.9%) developed perineal cellulitis and mastitis compared with 6 of 41 (14.6%) in

the advanced maternal age group (P < 0.003). This study supports the concept that

young age is a risk factor for perineal cellulitis and mastitis after cesarean section.11

2. Review of literature related to the incidence and prevalence of postpartum

infections:-

Olsen MA, Butler AM, conducted a study on “Risk factors for

endometritis after low transverse cesarean delivery” with an objective to

determine independent risk factors for endometritis after low transverse cesarean

delivery.they performed a retrospective case-control study during in a large tertiary

care academic hospital. Endometritis was identified in 124 (7.7%) of 1,605 women

within 30 days after low transverse cesarean delivery. Independent risk factors for

endometritis included younger age and anemia or perioperative blood transfusion Risk

of endometritis was marginally associated with a proxy for low socioeconomic status,

lack of private health insurance with amniotomy and with longer duration of rupture of

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membranes. Which concluded as Risk of endometritis associated with lack of private

health insurance,poor postnatal care and amniotomy. Knowledge of these risk factors

can guide selective use of prophylactic antibiotics during labor and heighten awareness

of the risk in subgroups at highest risk of infection.12

Bello C, Eskandar M, et al conducted a study on “Staphylococcus

lugdunensis endometritis” a case report with an objective to describe a case of

Staphylococcus lugdunensis endometritis associated with premature rupture of

membranes.A 39-year old woman presented with premature rupture of membrane

(PROM) and underwent an emergency caesarean section at 40 weeks of gestation. Her

endometritis was characterized by a foul odour and was so extensive that the baby was

adherent to the endometrium Recent studies have identified clinical features that are

major risk factors for puerperal infection. Patients of low socioeconomic status

undergoing cesarean section who have had prolonged labor and rupture of membranes

(ROM) incur a 40 to 85% risk of endometritis. Infection occurs generally in less than

10% of women undergoing vaginal delivery, even when complicated by prolonged

ROM, and often in considerably fewer cases.13

A study was conducted in the Gynaecology / Obstetric Unit-II, Liaquat University

Hospital,Hyderabad Pakistan from 1st January 2006 to 30th December 2006 to determine

the frequency, causative factors and outcome of delivery by trained or untrained

personnel. Out of total 2885 maternal admissions 135 patients had various postpartum

problems,61 patients had puerperal sepsis. Majority (67.2%) was less than 30 years of

age and52.5% of low parity. Among study population 67.2% belonged to low scio-

economic group and96% were illiterate. Majority (67%) of women did not receive any

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level of care, only 9.8% hadlevel 3 care. Patients who had vaginal delivery were 93.4%

while 6.6% had caesarean section. Inmajority of patients (57.4%) high grade fever was

the major symptom followed by distension ofabdomen in 26.2%. Evacuation of uterus

and laparotomy were done in 39.3%, only evacuation ofuterus was carried out in 24.6%

and 3.3% had hysterectomy. One third (32.8%) had prolongedhospital stay and other

one third (32.8%) died inspite of all possible measures.The study conclude that in

majority of women sepsis as well as maternal deathwas preventable. It can be reduced

by proper counseling of women about importance of antepartum, intrapartum and

postpartum care and training of Dais and refreshing courses of trainedbirth attendants

(TBAs).14

Malavaud S, Bou-Segonds E et al conducted a study on “Determination of

nosocomial infection incidence in mothers and newborns during the early postpartum

period” with an objective to determine the incidence of postpartum infections in the

mother during the early postpartum period. Over a three-month period, the same

investigator collected 50 different clinical and microbiological, standardized data

related to infectious diseases in parturients and postnatal mothers.Data were collected

on 804 deliveries. The overall rate of postnatal infection was 2.9% (23/804). For

vaginal deliveries, the rate was 1.9% (12/615) and for deliveries by Cesarean section,

the rate was 5.8% (11/189). These results are in line with previously published rates of

postnatal infections, which varied between 0.2% to 2.3% for vaginal deliveries, 1.6%

to 18.9% for Cesarean section,. Regular surveys of the incidence or the prevalence of

postnatal infections are necessary to monitor the effectiveness of educational

programs, aimed to reduce infections.15

Shy KK, Eschenbach DA. Conducted a study on Fatal perineal cellulitis from

an episiotomy site. which says that Perineal cellulitis originating from an episiotomy 14

incision resulted in 20% of the maternal mortality in King County, Washington,

Necrotizing fasciitis is also a fatal, rapidly progressive, often initially unrecognized

condition. Mortality rates range from 30% to 76%. Prognosis depends on the delay of

diagnosis, antimicrobial treatment and surgical excision of all necrotic tissue. A case

of postpartum perineal cellulitis and necrotizing fasciitis arising from episiotomy is

presented. Prompt recognition and aggressive therapy resulted in a favorable outcome

despite significant morbidity.These fatalities occurred because the practitioners were

not aware that post partum infections such as perineal cellulitis and necrotizing

fasciitis can occur in the fatty superficial fascia of the perineum.which concluded as

intervention programme is needed for the health professionals.16

3. Review of literature related to prevention and treatment of postpartum

infections:-

Knowledge, attitudes, and practices of obstetricians and gynecologists

regarding the Centers for Disease Control and Prevention (CDC) recommendations for

prevention of healthcare-associated group A streptococcal (GAS) infections as well as

general management of pregnancy-related and postpartum infections are unknown..

Results show that overall, 53% of providers responded. Postpartum and postsurgical

infections occurred in 3% and 7% of patients, respectively. Only 14% of clinicians

routinely obtain diagnostic specimens for postpartum infections; providers collecting

specimens determined the microbial etiology in 28%. Microbiologic diagnoses were

confirmed in 20% of postsurgical cases. Approximately 13% and 15% of postpartum

and postsurgical infections for which diagnoses were confirmed were attributed to

GAS, respectively. Over 70% of clinicians were unaware of CDC recommendations.

Researchers conclude that Postpartum and postsurgical infections are common.

15

Providing empiric treatment without attaining diagnostic cultures represents a missed

opportunity for potential prevention of diseases such as severe GAS infections.17

Chaim W, Burstein E. Conducted a study on ‘Postpartum infection

treatments: a review” which says that Upper genital tract infections are the most

common complications of the puerperium. Such frequent complications are mastitis

and septic pelvic thrombophlebitis. Several risk factors including obstetrical,

gynaecological, demographic and surgical, are associated with an increased rate of

postpartum infections and their influence is higher after a caesarean than vaginal

delivery. Postpartum infections rate range from 15 to 35%. Their identification should

be prioritized to prevent this complication. The vaginal flora plays a central role in the

development of infections. Prophylactic antibiotic treatment at the time of caesarean

delivery has helped reduce the rate of postpartum infections.18

Cunningham FG, Hauth JC, conducted a study on “Infectious morbidity

following cesarean section. Comparison of two treatment regimens.“ which says that

During a 4-month period 265 women delivered by cesarean section were studied to

determine what effect membrane rupture has on the incidence and severity of

postoperative infection Only 29% of women with intact membranes subsequently

developed endometritis with pelvic cellulitis, in contrast to 85% of those whose

membranes were ruptured for less than 6 hours. Wound and pelvic abscesses were

encountered in less than 1% of women delivered with intact membranes, yet these

complications developed in over 30% of women with membranes ruptured for less

than 6 hours. The incidence of septicemia was four times greater in those women

whose membranes were ruptured for less than 6 hours. Postpartum infection continues

16

to be a leading cause of morbidity in the puerperium.. Patients in labor with ruptured

membranes for more than three hours who undergo delivery by cesarean section19

7. MATERIAL AND METHODS OF STUDY

7.1 SOURCE OF DATA

Data will be collected from the postnatal mothers admitted in the selected hospitals at

Hassan. 

7.2 METHODS OF COLLECTION OF DATA

7.2.1 Research design:

The research design is pre experimental single group pretest posttest design.

GROUP PRETEST INTERVENTION POSTTEST

E O1 X O2

Key:-

E = Postnatal mothers

O1 = Assessment of pretest.

            X = Planned teaching programme on prevention of postpartum infections.

O2 = Assessment of posttest

7.2.2 Research setting:

This study will be conducted in the selected hospitals at Hassan District.

7.2.3 Population:17

Target population: All the postnatal mothers who are admitted in

hospitals at Hassan.

Accessible population: The postnatal mothers who are admitted in

selected hospitals at Hassan.

7.2.4 Sample:

All the postnatal mothers who fulfill the inclusion criteria from the selected

hospitals at Hassan.

7.2.5 Sample size:

The sample consists of 80 postnatal mothers from the selected hospitals.

7.2.6 Sampling technique:

Non Probability convenient sampling technique will be used.

7.2.7 Collection of data:

The data will be collected from the postnatal mothers admitted in selected

hospitals at Hassan.

7.2.8 Selection of tool:

Part A- Socio demographic profile.

Part B- Collection of data is done by using semi structured questionnaire on

knowledge regarding prevention of postpartum infections.

7.3 RESEARCH APPROACH:

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Evaluative approach.

8. VARIABLES

Independent variable: PTP on prevention of postpartum infections.

Dependent variable: Knowledge of the postnatal mothers regarding

prevention of postpartum infections.

Extraneous variables: Socio demographic variables such as age, sex, religion,

type of family, family income, Education, Occupation, Habitant, Dietary

pattern, Religion, Sex of the Baby, Body Mass Index.

9. PLAN FOR DATA ANALYSIS.

Descriptive statistics: The statistical analysis includes frequency,

percentage, mean, and standard deviation

Inferential statistics: Chi -square test will be used to calculate and

analyse the association between scores with selected socio-demographic

variables. The paired‘t’ test is used to find out the significant difference

between pretest and posttest scores.

10. PILOT STUDY:

The pilot study is planned with 10% of the total sample size which will

be conducted in selected nursing colleges at Hassan and that will be excluded in the

main study.

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11. ETHICAL CONSIDERATION

Has the consent being taken from the hospitals?

Yes. Consent has been taken from the selected hospitals.

Has the study require intervention to be conducted on patients or any

other human beings?

Yes. Study conducted on postnatal mothers.

12. LIST OF REFERENCES:

1) Definition of mothers. Allwords.com. English Dictionary

Available on – http:/allwords.com/word-mother.html

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2) Andy W.Wong, Pamela L Dyne. Postpartum infections. April 14, 2010.

Available on – http://emedicine.medscape.com/article/796892 overview.

3) Julia Hussein, Dileep, Sheetal Sharma and Lucia D’Ambrouso. A review of health

system infection control measures in developing countries: what can be tearned to

reduce maternal mortality. May 19, 201.

Available on – http://www.globalization&health.com/content/pdf/1744-8603-7-

14.pdf

4) Lowdermilk, Perry, Kathryn, Robin Webb Corbett. Maternity Nursing. Mosby

Elsevier publication, 7th edition 2006.

5) Michael G, Gravett. Intraamniotic and postpartum infections.2008.

Available on – http://www.glowm.com/index.html?p=glowm.com/section-

view&articleid=76.

6) Puerperal fever, the free encyclopedia. November 20, 2011.

Available on – http://enwikipedia.org/wiki/puerperalfever.

7) H. Gelband, J. Liljestrand, L. nemer, M. Islam, J. Zupan, P.Jha. Maternal and

neonatal , mortality, page-2. WG5 Paper number 5.

Available on – http://who india .org/linkfiles/commissions.

8) Nasreen Ghanil, Rafat Jan Rukanuddin, Tazeen S. Ali. Prevalence and factors

associated with Postpartum Vaginal infection in the Khyber Agency Federally

Administered Tribal Areas, Pakistan.2007.

Available on – http://www.pakmedinet.com/11100

9) Kitri Iyengar, Sharad D. Iyengar, Virendra Suhalka, and Kalpana Dashora.

Pregnancy-related Deaths in Rural Rajasthan, India: Exploring Causes, Context,

and Care-seeking Through Verbal Autopsy. . J Health Popul Nutr. 2009 April.

Available on-http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2761776/?

tool=pmcentrez

10) Zainur RZ , Loh KY. )"Postpartum morbidity--what we can do".TheMedical

Journal of Malaysia. 2006 Dec;61(5):651-6.

Available on- http://www.atgcchecker.com/pubmed/17623974

11) Magee KP , Blanco JD et al, perineal cellulitis and mastitis after cesarean: the

effect of age.American journal of perinatology, 1994 Jan;11(1):24-6. 21

Available on- http://www.library.nhs.uk/booksandjournals/results.aspx?t=Anemia

%2Fprevention+

%26+control&stfo=True&sc=bnj.ovi.amed,bnj.ovi.bnia,bnj.ebs.cinahl,bnj.ovi.eme

z,bnj.ebs.heh,bnj.ovi.hmic,bnj.pub.MED,bnj.ovi.psyh&p=12&sf=srt.publicationda

te&sfld=fld.title

12) Olsen MA , Butler AM, et al, Risk factors for endometritis after low transverse

cesarean delivery, Infection Control and Hospital Epidemiology-The official

journal. 2010 Jan;31(1):69-77.

13) Bello C , Eskandar M, El GR et al, Staphylococcus lugdunensis endometritis: a

case report. West African Journal of Medicine. 2007 Jul-Sep;26(3):243-5.

14) Razia Mustafa Abbassi, Naushaba Rizwan, Yasmeen Qazi and Firdous Mumta

Puerperal Sepsis: An Outcome of Suboptimal Obstetric Care.2009

http://www.lumhs.edu.pk/jlumhs/Vol08No01/pdfs/v8n1oa18.pdf

15) Magee KP , Blanco JD et al, perineal cellulitis and mastitis after cesarean: the

effect of age.American journal of perinatology, 1994 Jan;11(1):24-6.

16) Shy KK , Eschenbach DA. Fatal perineal cellulitis from an episiotomy site. Journal

of Obstetrics and Gynecology. 1999 Sep;54(3):292-8.

17) Chris A Van Beneden,1* Lauri A. Hicks,1, 2 Laura E. Riley,3 and Jay Schulkin4

Provider Knowledge, Attitudes, and Practices regarding Obstetric and Postsurgical

Gynecologic Infections Due to Group A Streptococcus and Other Infectious; 2007:

90189. Published online 2008 January 16. doi:  10.1155/2007/90189

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2248426

18) Chaim W , Burstein E. Postpartum infection treatments: a review, Expert Opinion

on Pharmacotherapy. 2003 Aug;4(8):1297-313.

19) Cunningham FG , Hauth JC, Infectious morbidity following cesarean section.

Comparison of two treatment regimens, The journal of Obstetrics and Gynecology.

2002 Dec;52(6):656-61.

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