RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES · Web viewIn Karnataka crude birth rate is 22.5 per...
Transcript of RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES · Web viewIn Karnataka crude birth rate is 22.5 per...
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCESBANGALORE , KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. NAME OF THE
CANDIDATE AND
ADDRESS
Ms. YUMKHAIBAM RENUBALA DEVI
GOUTHAM COLLEGE OF NURSING,
MANJUNATHANAGAR,
WEST OF CHORD ROAD,
RAJAJINAGAR,
BANGALORE – 10.
2. NAME OF THE
INSTITUTION
GOUTHAM COLLEGE OF NURSING,
MANJUNATHANAGAR,
WEST OF CHORD ROAD,
RAJAJINAGAR,
BANGALORE – 10.
3. COURSE OF STUDY
AND SUBJECT
M.Sc. NURSING I YEAR
OBSTETRIC AND GYNAECOLOGICAL
NURSING
4. DATE OF ADMISSION
TO COURSE
05.06.2008
.5 TITLE OF THE TOPIC A STUDY TO ASSESS THE
EFFECTIVENESS OF SELF
INSTRUCTIONAL MODULE ON
PREVENTION AND MANAGEMENT OF
EPISIOTOMY COMPLICATIONS
AMONG POST NATAL MOTHERS IN
SELECTED HOSPITAL,
BANGALORE.
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6. BRIEF RESUME OF THE INTENDED WORK:
6.1 NEED FOR STUDY:
Episiotomy refers to a surgical incision of the female perineum
performed by the accoucheur at the time of parturition. It is usually
performed with the scissors when the perineum is stretched and distended
just prior to crowing of the fetal head. The complications of episiotomy
are perineal pain, dyspareunia, incontinence of bowel and stool,
episiotomy dehiscence, infections, pelvic floor defect, sexual
dysfunction.1
According to report on 6, June 2008 the prevalence of episiotomy
procedure was 1.6 million in 1992 versus 7, 16,000 in 2003. The
prevalence of episiotomy is higher in Latin America and the United
States, approximately 40 percent of vaginal deliveries and lower in
Europe with reported rates varying widely from 1% in Swedan to 80 % in
Argentina.2
According to WHO the birth rate in India is 23.8 per thousand
births in 2005. In Karnataka crude birth rate is 22.5 per thousand live birth
while maternal mortality rate is 2 per thousand live birth 2007. In India
23% of women report health problem in first month after delivery related
to episiotomy as perineal tear, urinary incontinence, uterine prolapse. In
2004,29.1% of birth were delivered by ceasarean delivery and 60%
delivered per vaginal.3
A study was conducted on immediate and long term complication
of episiotomy, the main aim was to describe the complications of
episiotomy on 472 post natal mothers. When performed liberally,
episiotomy appears to increase the risk of post partum bleeding. More
restrictive use does not appear to increase the risk of serious perineal
injury. Patients who had an episiotomy complain of perineal pain more
than those with an intact perineum or first or second degree tears. Three
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months after delivery, there was no difference. While episiotomy appears
to be a source of dyspareunia during the first weeks after delivery in
comparison with spontaneous tears. The study reveals that episiotomy
appears to be cause of more perineal pain and dyspareunia during the
early post partum week.4
A study was conducted on episiotomy to review the incidence and
complications associated with episiotomy and perineal tears among 1346
parturients. The prevalence of episiotomy was 46.6% over 90% of the
primigravid parturients had episiotomy. The incidence of episiotomy
decreased with increasing parity while the incidence of spontaneous
vaginal tears increased with parity. The study reveals that greater attention
needs to be paid to selection of women to undergo episiotomy, the
prevention of spontaneous perineal tears and care of episiotomy. 5
Since episiotomy is a surgical procedure care of the surgical site is
very essential to avoid any further complications. Many pharmacological
and non pharmacological treatment are available in the management of
episiotomy thereby prevent the complications.
A study was conducted on reducing post natal pain from perineal
tears by using Lignocaine gel.. The study was to investigate if typically
applied 2% Lignocaine gel was an effective treatment. The method of
study was experimental method. The sample size was 149 women. The
result was using Lignocaine gel had lower average pain scores statistical
significances at 48 hours after delivery. This study suggested that
Lignocaine gel is effective on the second postnatal day.6
A study was conducted on effectiveness of teaching on episiotomy
and perineal care among primipara women of selected Hospital in
Karnataka. The study reveals that knowledge deficit was found in 30
primipara women. The researcher concluded that nurses and midwives
have a major role in identifying and providing necessary supportive-
educative care to clients who have undergone episiotomy.7
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In the view of above studies and from the investigator experience,
it is found that complication is more common among the post natal
mothers who undergone episiotomy. The researcher is thus interested in
imparting the knowledge to the postnatal mothers with episiotomy
regarding prevention and management of episiotomy complications. The
researcher personally felt that there is a need to study in this area and to
change the parental practices through educational intervention.
6.2 REVIEW OF LITERATURE:
Review of literature refers to as broad, comprehensive, in depth, systemic
and critical review of scholarly population and unpublished scholarly
print material ,audiovisual materials and personnel communication.18
The extensive review of literature has been done and it is organized
according to the following headings.
A) Studies related to the complications of episiotomy.
B) Studies related to the management of episiotomy complications.
C) Studies related to the self instructional module as teaching
module.
A) Studies Related to the Complications of Episiotomy:
A study was conducted on puerperal complications of episiotomy.
The objective was to establish the epidemiological variables associated
with episiotomy and their puerperal complications. The episiotomy rate
was 35.6% of all vaginal deliveries. Episiotomies were significantly
associated with primigravidity being performed in 88.5 percent of all
primigravidae. The mean delivery repair interval was 60.5 minutes. The
most common puerperal complications of episiotomy were perineal pain
that lasted an average of 5.5 days. Other complication included
asymmetry 32.9% infection 23.7%, partial dehiscence14.5%,skin tags
7.9%,haemorrhage 5.3% and extension of the incision 1.3%.The study
shows that episiotomy rate is very high among primigravidae and also
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recommended that complications should be reduced by re-acquainting
accoucheurs with the indications for episiotomy.8
A study was conducted on late complications of episiotomy. The
study sample was 467 women. The objective was comparison between
median episiotomy, mediolateral episiotomy and no episiotomy regarding
perineal discomfort, wound healing and anal incontinence. Perineal pain
was reported by 30% of women with mediolateral episiotomy as
compared to19%of those with median episiotomy and 4.5% without
episiotomy.Involuntary passage of faeces in 7%, 9% and 1% respectively.
The study reveals that good healing of adequately reconstructed perineal
tears and the better outcomes of median episiotomy as compared to
mediolateral episiotomy.9
A study was conducted on causes for healing complications in
episiotomy. The aim of the study is to look the most probable causes of
distrubed healing of episiotomy. The study sample was 33 early puerperal
women without infection or risk factors like PPROM, vulvovaginitis,
chorioamnionitis, diabetes, obesity and others. The rate of entirely open
episiotomy is 1.07%. According to the study episiotomy healing is not
influence by age, parity, duration of labour and the weight of neonate. The
study concluded that the shorter time between rupture of membrane
during labour and delivery and used of catgut stitches on the skin of the
perineum shows tendency of poor healing of the episiotomy.10
A study was conducted on factors influencing the use of
episiotomy during vaginal delivery, the objective of the study was to
determine the prevalence of episiotomy to examine factors influencing the
performance of episiotomy and documents complications associated with
the procedure. January, 2001 to December 2005. The sample size was
4172 mothers. There were 1877 episiotomies 45%. 90% of primigravid
parturients had episiotomy. Women undergone episiotomy were younger
mean age 24.7 years, range 16-36 than women without episiotomy mean
age 28.5 year, range 20-43.When controlled for parity and maternal age,
other risk factors were occipito posterior position, vacuum extraction,
forceps delivery, vaginal breech delivery and a history of caesarean
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section. The study shows that episiotomy rate is 45 per 100 vaginal
deliveries. Greater attention needs to be paid in order to avoid major
perineal lacerations and increased length of hospital stay.11
B) Studies related to the management of episiotomy
complications:
A study was conducted on Diclofenac pyrrolidine versus
Ketoprofen for the relief of episiotomy pain. The objective of the study
was to compare the effectiveness and side effect of two analgesics in the
management of post partum perineal pain. Sample size was 261 women
with vaginal delivery with episiotomy and /or a second to third degree
tear were randomly assigned, both received either Diclofenac
hydroxyethyl pyrrolidine 100mg, n=133 or Ketoprofen 100mg, n=128,
both given orally every 12hours upto 48hours as necessary. Side effects
and overall opinion on the two treatments were assessed at 24 hours. The
result was Diclofenac hydroxyethyl pyrrolidine and Ketoprofen had
similar analgesic properties in the first 24 hours postpartum, mean pain
rating 3.1±1.8 and 3.4 ±2.0, mean number of doses in 24 hours 1.4 and
1.3 ± 1.5, and proportion treatment failures 12.8% and 16.4%
respectively. Significantly fewer subjects in the Diclofenac hydroxyethyl
pyrrolidine group than in the Ketofrofen group experienced side effects
6.8% versus 15.6%; p=0.038 with an odd risk = 0.39,95% C1;16-0.95.
The study shows no main differences were found concerning the relief of
pain between the two treatments. Diclofenac Hydroxyethyl pyrrolidine is
preferred choice because it is associated with less adverse reaction,
together with a faster action in the relief of pain .12
A study was conducted on post episiotomy pain. Warm versus
cold sitz bath. The aim of the study was to assess the effectiveness of a
warm versus cold sitz bath in relieving post episiotomy pain. The
experiment was performed on 20 post vaginal delivery with episiotomy.
Sensation, distress, edema, and hematoma rating were obtained pre and
post treatments. The study obtained both therapies were found
comparable, with the exception that cold bath was significantly more
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effective in reducing edema. Clinical research are presented
recommendation for practice in the patients should offered a choice of
therapies .13
A study was conducted on post delivery sex among 242 postnatal
mothers which reveals that 20% of mothers feel physically comfortable
during sex within six months, 57% of women were still having less
frequent sex after 12 months of childbirth. And they concluded, many
women do not desire sex after childbirth because of pain or fear due to
episiotomy.14
A study was conducted on episiotomy raises tear risk in next
delivery, among 600 women which reveals that 47.8% underwent
episiotomy during their first delivery. Moderate lacerations subsequently
occurred in 51.3% of these women during the second delivery,
significantly greater than 26.7% of women who had never had an
episiotomy. The study reveals that obstetric care providers should
encourage to restrict the use of routine episiotomy.15
C) Studies Related to Self Instructional Module (SIM) as
Teaching Module:
A study was conducted on stop the child labour before it stops the
child life. The aim of the study was to assess the effectiveness of self
instructional module on causes, hazards and prevention of child labour
among the mothers. The study sample was 40. The result of the study
shows that self instructional module was found to be effective in terms of
increasing the cognitive behaviour and developing a more favourable
attitude towards child labour. This indicates that self instructional module
was an effective method of imparting information to the mother on child
labour .16
A study was conducted on self care strategies of antenatal mother
attending OPD. The aim of the study was to assess the effectiveness of
self instructional module .The sample size was 60 antenatal mothers .The
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study reveals that self instructional module was found effective in terms
of increasing knowledge of antenatal mothers regarding antenatal care.
The effectiveness was found by computing‘t’ test between the pre test
scores and post test scores. The mean post test knowledge was found to be
significantly higher than the mean pre test scores .17
6.3. STATEMENT OF THE PROBLEM:
A study to assess the effectiveness of Self Instructional Module on
prevention and management of episiotomy complications among the post
natal mother in selected hospital, Bangalore.
6.4. OBJECTIVES:
1. Assess the existing knowledge regarding the prevention and
management of episiotomy complications among the post natal
mothers in pre test scores.
2. Assess the effectiveness of Self Instructional Module regarding
prevention and management of episiotomy complications in
pretest and post test scores.
3. Determine the association of knowledge regarding prevention and
management of episiotomy complications with selected
demographic variables.
6.5. OPERATIONAL DEFINITIONS :
1. Knowledge: - Refers to the response of subjects on self administered
questionnaire on management and prevention of episiotomy
complications before and after the Self Instructional Module.
2. Effectiveness: - Refers to the gain in knowledge as determine by
significant difference in pre test scores and post test scores.
3. Self Instructional Module: - Refers to a booklet of contents prepared
by the investigator and validated by experts .It contains the meaning,
complications, management and prevention of episiotomy
complications, which will be provided to the subjects for self reading
and gaining information.
4. Episiotomy complications: - Refers to the complications that occurs
after vaginal delivery with episiotomy like perineal pain, episiotomy
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dehiscence, dyspareunia, anal and bladder incontinence, edema, etc.
5. Management: - Refers to the methods of pharmacological and non
pharmacological therapies in treating the episiotomy wound thereby
preventing complications.
6. Prevention: - Refers to protecting the episiotomy and the perineum
from complications in the post natal mothers.
7. Postnatal mothers: - Refers to both primi and multi mothers after
childbirth with episiotomy from first day to 45 days.
6.6. HYPOTHESIS :
H1: There will be a significant difference between pre test and post test
knowledge scores on prevention and management of episiotomy
complications among the post natal mother at the level of P<0.05.
H2: There will be a significant association between the knowledge score
of post natal mother regarding prevention and management of episiotomy
complications with selected demographic variables.
6.7. DELIMITATIONS :
1. The study is delimited to post natal mother delivered per vaginally
only.
2. Post natal mothers who are available at the period of study.
3. Measurement of knowledge scores of post natal mothers once
before and after effectiveness of Self Instructional Module.
6.8. PROJECTED OUTCOME :
1. The study will enhance the knowledge of post natal mother on
management and prevention of episiotomy complications and help in
increasing autonomy and operate in a desirable manner to achieve
positive health.
2. The study will generate new knowledge on attitude of management
and prevention of episiotomy complications.
7. MATERIALS AND METHODS:
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7.1 SOURCE OF DATA Post natal mothers with episiotomy
from selected hospital, Bangalore.
7.2. METHODS OF COLLECTION OF DATA
7.2.1 SAMPLING CRITERIA
INCLUSION CRITERIA 1. Post natal mother with
episiotomy in a selected
hospital.
2. Post natal mother available from
the first day of delivery.
3. Who understand the language
Kannada, English and Hindi.
EXCLUSION CRITERIA 1. Not willing to participate in the
study.
2. Mother who delivered else
where.
7.2.2. RESEARCH DESIGN Pre-experimental one group pretest
post test design will be adopted.
7.2.3. VARIABLE UNDER STUDY
INDEPENDENT VARIABLE
DEPENDENT VARIABLE
ATTRIBUTE VARIABLE
Self Instructional Module on
prevention and management
of postnatal complications.
Knowledge of post natal
mothers.
Age, socioeconomic status,
education.
7.2.4. SETTING OF THE STUDY Study will be conducted in the post
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natal ward in a selected hospital,
Bangalore.
7.2.5. SAMPLING TECHNIQUE The researcher will adopt
convenience sampling technique.
7.2.6. SAMPLING SIZE The sample size consists of 40 post
natal mothers.
7.2.7. TOOL FOR RESEARCH 1. A structured questionnaire to
assess the demographic variables
among the post natal mothers.
2. A structured questionnaire to
assess the level of knowledge on
prevention and management of
episiotomy complications.
7.2.8 DATA COLLECTION An informed consent will be obtained
from the concerned authority, an
informal consent will be obtained
from the subjects .The purpose of the
study will be explained and structured
questionnaire will be administered to
the subject to assess the knowledge
level as pretest. Subsequently, a Self
Instructional Module on prevention
and management of episiotomy
complications will be given to the
sample. Following this on 5th day the
investigator will reassess the
knowledge scores by post test using
the same structured questionnaire.
Study duration is 30 days.
7.2.9. METHOD OF DATA
ANALYSIS
AND PRESENTATION
By using descriptive and inferential
statistics .The plan of data analysis
will be as follows –
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1. Organise the data in a master
sheet or computer.
2. Frequencies and percentage for
analysis of background data.
3. Mean, median, SD, and ‘f’ values
determine the significance.
4. Chi-square test to determine the
association.
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR
INTERVENTION TO BE CONDUCTED ON PATIENTS OR
OTHER HUMAN OR ANIMALS? IF SO, PLEASE DESCRIBED
BRIEFLY.
Yes, the study will be conducted among postnatal mothers
in a selected hospital.
7.4. HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM
THE HOSPITAL AUTHORITY OF THE PARTICULAR
INSTITUTION AND PATIENTS?
Yes, ethical clearance and informed consent will be obtained from
the institutional authorities and the mothers. Privacy, confidentiality and
anonymity will be guarded, scientific objectivity of the study will be
maintained with honesty and impartially .
8. LIST OF REFERENCES:
1. Dutta DC. Textbook of obstetrics. 4th Ed. New central agency(p)Ltd
Chintamoni Das Lane; Calcutta. (2001). Page -605.
2. Julian N Robinson, Charles J Lockwood, Vanessa A Barss.
Prevalence of episiotomy procedure. Last literature review version 16.
May 2008;16(2).
3. Bulletin of World Health Organisation.
4. Langer B, Minetti A. Immediate and long term complication of
episiotomy. Gynecol Obstet Biol Rrprod (Paris)Feb2006; 35(1
12
suppl) : 1S59 - 1S67.
5. OtoideV.O, Ogbonmwan S.M, Okonofuaf.E. Episiotomy.Department
of obstetrics and gynaecology. University of Benin.Nigeria.
6. Anna Corkill, Tina Lavender, Stephen A, Walkinshawand Zarko
Alfirevic. Reducing post natal pain from perineal tears by using
Lignocain gel. Liverpool, United Kingdam.
7. Noronha Judith Angelita. Effectiveness of teaching on episiotomy and
perineal care. Nursing Journal of India. May 2004.
8. Sule S T, Shittu SO.Puerperal complications of episiotomy.
Department of Obstetrics and gynaecology, Ahmadu Bello University
Teaching Hospital, zaria, Nigeria.
9. Regeth JC, Buerklen A, Hirsch H A.Late complication of episiotomy.
Universitats frauenklinik, Schleichstr. 4 , D- 7400 Tubingen
10.Dimitrov A , Tsenov D, GanevaG. Causes for healing complications in
episiotomy. Akush Ginekol(Sofiia).2000; 40(4):17-20.
11.Chigbu B, On were S,Aluka C, KamanuC, Adibe E. Factors
influencing the use of episiotomy during vaginal delivery. Department
of Obstetrics and Gynaecology, Abia.Nigeria.
12.Fabio Facchinette, Maria Luisa Casini,Loredana Costabile, Barbara
Malavasi , Vittorio Unfer. DiclofenacPyrrodine versus Ketoprofen.
Acta Obstetricia et Gynecologica Scandinavica. Oct.2005; 84(10);
Page 951-955.
13.Lolafoy,Elizabeth A. Genden. Postnatal pain.University of Missouri,
Columbia. MO 65211.
14.Ayandrali Dutta. Post delivery sex. 23th Sep.2008;IST
15.J.B Sharma,Nupur Gupta,Pakhee Aggarwal, Suneeta Mitta.Jun
17,2008; IST
16.Ms. N. Ramanjamma. The effectiveness of Self Instructional Module
on Causes, hazards and prevention of child labour among the mothers.
Dept. of Pediatric of Nursing. Goutham College of Nursing,
Bangalore. 2007; p-96.
17.Ms. Enu Boro. The effectiveness of Self Instructional Module on self
care strategies of antenatal mothers. Dept of obstetrics and
Gynecological Nursing, Goutham College of Nursing, Bangalore.
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2007; P-77
18. Basavanthappa BT. Nursing Reaserch.1ST Ed. New Delhi; Jaypee
Brother; 2003.P.49-50.
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