RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 / Name of the candidate and Address / MS. DIANA V
I YEAR M.Sc NURSING,
NAVANEETHAM COLLEGE OF NURSING.
2 / Name of the Institution / NAVANEETHAM COLLEGE OF NURSING, BANGALORE- 43
3 / Course of study and subject / 1ST YEAR M.Sc NURSING (OBSTETRICS AND GYNAECOLOGY)
4 / Date of admission / 30-06-2012
5 / TITLE OF THE TOPIC / “A STUDY TO ASSESS THE EFFECTIVENESS OF STP ON KNOWLEDGE OF POSTNATAL MOTHERS REGARDING CARE OF JAUNDICED NEONATES IN PHOTOTHERAPY IN SELECTED HOSPITAL OF BANGALORE.”

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

A mother’s yearning feels the presence of the cherished child even in the degraded

man.

-  George Eliot

Neonatal jaundice occur in 60 % of term healthy neonates and 80 % of preterm neonates.1 Neonatal jaundice is a term for elevated total serum bilirubin in newborns and infants less than one month of age. In other words neonatal Jaundice is the yellow discoloration of the skin and the white part of the eye (the sclera). It results from having too much of substance called bilirubin in the blood. Bilirubin is formed when the body breaks down old red blood cells. The liver usually processes and removes the bilirubin from the blood. Neonatal jaundice in babies usually occurs because of a normal increase in the red blood cell break down and the fact that their immature livers are not efficient at removing bilirubin from the bloodstream.

There are mainly two types of neonatal jaundice.

·  Physiological jaundice

·  Pathological jaundice

PHYSIOLOGICAL JAUNDICE is due to the physiologic immaturity, immaturity in

Bilirubin metabolism at multiple steps results in the occurrence of neonatal jaundice in the first few days of life .

CHARACTERS OF PHYSIOLOGIC JAUNDICE :

First appears between 24-72 hours of age, Maximum intensity seen on 4-5th day in term neonates, Does not exceed 15 mg/dl and clinically undetected after 14 days.

PATHOLOGICAL JAUNDICE:

Bilirubin levels that deviate from Normal range and require intervention i.e. presence of any of the following signs denotes that jaundice is pathological. Treatment is required in the form of phototherapy.

Clinical jaundice detected before 24 hours of age, Rise in serum bilirubin by more than 5 mg/ dl/ day, Serum bilirubin more than 15 mg / dl, Jaundice persisting beyond 14 days of life and direct bilirubin >2 mg / dl at any time.

PHOTOTHERAPY:

Phototherapy has been used on hundreds of thousands of infants in united states, and perhaps millions of infants worldwide. Infants with neonatal jaundice are treated with colored light called as phototherapy introduced into routine use in the late 1960’s. Phototherapy has been proven effective in several large clinical trials (brown et al . , 1985;Tan and Boey, 1986) and no significant toxicity has been identified.2 Phototherapy involves exposure of the naked baby to blue light of wave length 450-460 nm. The light waves convert the water soluble non toxic forms which are then easily excreted. The advantages of phototherapy are that it is non invasive , effective, inexpensive and easy to use. The disadvantage is that it causes dehydration and skin rashes that disappears when baby is fed and kept hydrated adequately. Frequent feeding every second hourly and change of posture should be promoted in an infant. Eye shades should be fixed, external genitalia may be covered as long as the infant receiving phototherapy.

6.1. NEED FOR THE STUDY

A mother holds her children’s hand for a while, their hearts forever.
Neonatal jaundice is the condition most commonly seen in neonates up to three week. It is the presence of increased concentration of bilirubin in the blood.
Many studies have been conducted on neonatal jaundice worldwide. A prospective study was conducted at University of Chicago on persistence of maternal concerns surrounding neonatal jaundice in 47 Spanish and English speaking breastfeeding mothers. The data was collected by ethnographic interviews using grounded theory method. After data collection, the researcher found that guilt was common with mothers believing that they had caused the jaundice. Mothers voiced alarm about yellow skin and discomfort about jaundice management, and worried about perceived short-term and long-term effects. Key factors in creating perception of jaundice included unexpectedness of and lack of knowledge about jaundice, quality of information received, level of interventions and prolonged duration of illness, and yellow skin colour. The researcher concluded that the practitioner needed to address the persisting misconceptions and concerns about neonatal jaundice with mothers.3
A study was conducted in California on readmission for neonatal jaundice during 1991-2000. The study population was healthy routinely discharged infants. The hospital discharge records were the source of diagnoses, hospital charges, and length of stay information. After the study, the researcher found that readmission rates for jaundice gradually rose after 1994 and peaked at 1998 at 11.34 per 1000. The readmission rates for preterm infants over the study period remained at less than 2 per 1000. Factors associated with hospital readmission for jaundice included gestational age 34-36 weeks, birth weight < 2500 gm, and male gender. In 2000, the readmission rates remained 6% higher than that in 1991.4
According to the All India institute of Medical Sciences protocol in neonatology, neonatal jaundice is the commonest morbidity in neonatal period and 5-10% of all the newborns require interventions for pathological jaundice. Neonates on exclusive breastfeeding have different pattern of physiological jaundice as compared to artificially fed babies. Separate guidelines have been provided for the management of jaundice in sick term babies, preterm and low birth weight babies for jaundice secondary to haemolysis and for prolonged neonatal jaundice.
Nowadays, the incidence of neonatal jaundice is very high. A wide range of literature suggests that the increased incidence of neonatal jaundice is due to the lack of knowledge regarding identification and prevention. Studies support that education to postnatal mothers on neonatal jaundice will be helpful in reducing the incidence.5
The researcher from her own experience, discussion with experts and casual talk with mothers realised that neonatal jaundice is a common problem. So the investigator felt the need to educate the mothers regarding neonatal jaundice.
These studies shows that postnatal mothers lack knowledge regarding care of neonates with jaundice and its treatment and are in necessity in gaining information and knowledge about the same. The STP that will be conducted will help mothers gain adequate information and knowledge.

6.2. REVIEW OF LITERATURE

Review of literature is the writings of recognised authorities and of previous research, which provides the evidence that the researcher is familiar with what is already known and what is still unknown.

Studies related to knowledge of postnatal mothers regarding care of jaundiced neonate.
A cross-sectional study conducted to determine the knowledge, attitude and behaviour of mothers about neonatal jaundice at Ali-ebne Abitaleb Hospital in Zaheban, Iran during April and May 2006. Four hundred mother were interviewed to complete a 21-point questionnaire. After data collection and analysis, the researcher found that the mean attitude score was 18.5±3.7 out of 25 and the mean behaviour score was 6.8±2.3 out of 10.5. Knowledge had a significant association with mother’s attitude and educational level. The results showed a direct correlation between knowledge, attitude and behaviour. The researchers concluded that increasing mothers’ knowledge about jaundice of neonates can be the first step to continue healthy behaviour through education programmes during pregnancy.6
An ethnographic study from the USA examined maternal concerns about neonatal
jaundice. In all, 47 mothers of healthy breastfeeding babies with jaundice were interviewed. The mean maternal age was 27 years. Over half of multiparous mothers had a previous baby with jaundice and three-quarters had breastfed a previous baby. Neonatal jaundice was defined as serum bilirubin > 170 micromol/litre. The interviews were held between 2.5 and 14.5 weeks postpartum. Regarding causes of jaundice, 26 mothers (55%) believed that the quality and quantity of breastfeeding was pertinent to this. In all, 27 mothers (57%) perceived neonatal jaundice to be a serious condition. Of the 20 mothers who were not concerned, ten reported that their baby appeared healthy and was feeding well despite being jaundiced. Of these 20 mothers, five of their babies had breast milk jaundice and five had had blood tests but did not require treatment. The remaining ten women had no concerns because they had received prompt information and reassurance about jaundice. Maternal anxiety increased in proportion to the severity of neonatal jaundice. Most women expressed a preference for being informed about jaundice prenatally, while others wanted information at discharge or only in the event of their baby becoming jaundiced. Preferred formats for communicating information included individual verbal communication, small group discussions, written pamphlets and videos. Mothers requested more detailed information regarding causes of jaundice, information that addressed maternal responsibilities, management procedures, potential effects of jaundice and its treatment, anticipated duration of jaundice, and measures that they could take themselves to prevent jaundice and to care for jaundiced babies.7
A study was conducted on a group of Iranian mothers with icteric newborn in order to identify any wrong knowledge and improper practices related to the neonatal jaundice between June 2004 and February 2007 on 1666 mothers with icteric newborn hospitalised at a single centre. A questionnaire was used to assess the participants' knowledge and practice of neonatal jaundice. A knowledge score was calculated based on the responses. The mean knowledge score was 3.38±1.23 (out of 6). About 77% of the mothers had moderate-to-high level of knowledge of neonatal jaundice. Approximately one-third of the mothers consulted a physician within 24 hour of appearance of jaundice and 13.8% declared that they waited and managed their children with traditional remedies until they sought medical advices. Furthermore, 32.2% of the mothers discontinued feeding their icteric offspring with coloured foods and colostrums. Hence, 42.8% of the mothers acted weakly with regard to their icteric offspring. The health care workers were the participants' major source of information about neonatal jaundice. The study determined a fairly inadequate knowledge of Iranian mothers about the neonatal jaundice with incomparable level of related practices.8

A study was conducted to evaluate maternal knowledge level about neonatal jaundice.

This study was conducted on 161 mothers who had given birth to healthy newborns at Izmir Aegean Gynecology and Obstetrics Hospital between January 2010 and April 2010. A questionnaire was used to assess the mothers' knowledge on neonatal jaundice. Knowledge was evaluated as "sufficient" or "insufficient" based on responses. Sufficiently informed mothers were compared with insufficiently informed group for the knowledge level about neonatal jaundice. The rate of insufficiently informed mothers was 53.6%.Low education level was found to increase the probability of the mothers' knowledge level to be insufficient by 2.1 folds. Being informed beforehand by a previous offspring with jaundice increased the probability of the mothers' knowledge to be sufficient by twofolds. It is found that the mothers' knowledge about neonatal jaundice is insufficient.9

Aobservational cross-sectional study was conducted to determine the knowledge, attitude & behavior on neonatal jaundice of postnatal mothers in Provincial General Hospital (PGH), Badulla. 396 mothers, who delivered at PGH Badulla from 1stMay 2010 to 15thJune 2010, were interviewed using a structured questionnaire. The questionnaire was used to assess the participant’s knowledge, attitude and behaviour The mean knowledge score was 31±14, the mean attitude score 65.7±20.6 and the mean behaviour score 66.1±18.8.on neonatal jaundice. The knowledge of neonatal jaundice among postnatal mothers was low. There was significant correlation between mothers’ attitude and behaviour scores with the knowledge scores.10

A cross sectional study was conducted on Malaysian mothers knowledge and practices

on Care of Neonatal Jaundice. 400 mothers who attended the obstetric clinics or were admitted to the obstetric wards of a general hospital were included. They were surveyed

with a structured set of questionnaire. The results showed that a majority (93.8%) of them knew about neonatal jaundice, and 71.7% knew that jaundice lasting more than 2

weeks was abnormal. However, only 34.3% of them were aware that jaundice appearing during the first 36 hours of life was abnormal. . This study revealed that there

was a wide knowledge gap among Malaysian mothers on care of neonatal jaundice. Placing infants under the direct sun was still a common practice.11

A cross-sectional studywas conducted to identify level of knowledge, belief and attitude on neonatal jaundice among Malay pregnant mothers who live in Seberang Perai Utara state. A total of 150 mothers attended clinics in Seberang Perai Utara, were chosen by systematic random sampling and were interviewed using a pretested questionaire. Results showed about 50.0% of the respondent had inadequate general knowledge on neonatal jaundice, especially the knowledge on complications and identifying the best method of jaundice detection.12

A study was conducted on perceptions of mother towards neonatal jaundice and its management. The results show that some mothers believed that they had caused the jaundice using phrases like “got it from me, did something wrong. Not being a good mother”. Most mothers indicated that the blood testing process was difficult to watch and child, mothers used “screamed” or “suffered” to describe reactions of their neonates. Study concluded that as bilirubin levels increased and higher levels of interventions were needed, mother’s concerns increased. Mothers worried that infants would overheat or become blind and that the lights would be ineffective in lowering bilirubin levels. Several mothers said that the yellow eyes caused them to worry about their infant’s vision.13

Studies related to importance and effectiveness of phototherapy in care of jaundice neonates:

A study was conducted to determine the incidence of severe neonatal jaundice in the newborn, and to identify associated clinical and demographic variables, and short-term outcomes in uk. A prospective population based study was designed in U K and Republic of Ireland, between 1 may 2003 and 31 may 2005. Infants in the first month of life with severe neonatal jaundice were included. 108 infants met the case definition, 106 from U K and 2 from Republic of Ireland. The UK incidence of severe neonatal jaundice was 7.1/100 000 live births (95% CI 5.8 to 8.6). Only 20 cases presented in hospital; 88 were admitted with severe jaundice. 64 (60.4%) cases were male, and 56 (51.8%) were of ethnic minority origin. 87 (80.5%) cases were exclusively breast fed. This is the first large, prospective, population-based study of the incidence of severe neonatal jaundice in the newborn. The clinical and demographic associations and short-term outcomes identified.14