RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES · Web viewDuring the study period, 128 nursing women with breast infection were followed. Of these, 102 had mastitis (80%) and 26 had breast

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.

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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.

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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

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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.

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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

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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

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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.

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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

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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.

19

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:-

20

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.

22

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4. Bobak Jensen. Maternity and gynecologic care.5th edition. Published by Mosby. 1992:870-96.

5. Puerperal infection. www.Google.com .

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Gynaecology.8th edition, Published by jaypee brothers medical publishers (P)

Ltd., Newdelhi, Newdelhi.2006:117 - 24.

7. Rashmi Patil. Manual of midwifery practical and theory. 1st edition. Published by

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8. Helen Varney, Jan, M. Kriebs, Carolyn L. Gegor. Midwifery. 4th edition.

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9. Diane M. Fraser, Margaret, A. Cooper. Myles textbook for midwives. 14th

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Youssef AA Risk factors of puerperal sepsis. 2004:79(3 – 4); 311 – 31.

14. Puerperal Mastitis. www.google.com.

15. Dutta DC. Obstetrics including perinatology and contraception. 6th edition.

Published by new central book agency. 2004: 433-44.

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edition. Published by W.B. Sounders Company, Philadelphia.1995: 249-65.

17. Giugliani ER. Common problems during lactation and their management. 2004

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EPDS scores in a group. 2006 Apr: 36(2):100-3.

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25. Betsy Foxman, Hannah D Arcy, Brenda Gillespie, Janet Kay Bob, Kendra

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9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE

11. NAME AND DESIGNATION OF11.1 GUIDE

11.2 SIGNATURE

11.3 CO-GUIDE

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT

11.6 SIGNATURE

12. 12.1 REMARKS OF THE CHAIRMAN & PRINCIPAL

12.2 SIGNATURE 26