RAJIVGANDHIUNIVERSITYOFHEALTHSCIENCES

KARNATAKA,BANGALORE

PROFORMAFORREGISTRATIONOFSUBJECTSFORDISSERTATION

1. / Name of the candidate and address (in block letters) / RINKU MATHEW
1ST YEAR M.SC NURSING,
KARAVALICOLLEGE OF NURSING SCIENCE,
MANGALORE-575013.
2. / Name of the Institution / KARAVALI COLLEGE OF NURSING SCIENCE, NH-66, NEAR KOTTARA CHOWKI, BANGARA,
MANGALORE -575013.
3. / Course of Study and Subject / M. SC. NURSING
OBSTETRICS AND GYNAECOLOGICALNURSING
4. / Date of Admission to the Course / 07-06-2011
5. / Title of the study
A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAM ON PREVENTION OF PUERPERAL INFECTIONS AMONG PRIMI POSTNATAL MOTHERS IN SELECTED HOSPITALS AT MANGALORE.
6. / BRIEF RESUME OF THE INTENTED STUDY
INTRODUCTION
“Prevention is one of the few known ways to reduce demand for health
and aged care services”
Puerperium is the period which starts about an hour after the delivery of the placenta and includes the following six weeks. Puerperal infection is an infection which arises from bacterial invasion of the genital organs during puerperium1. The infection that occurs within 11 days of child birth.2
Now a day, despite scientific and technological advances in different knowledge areas, puerperal infection remains a big problem, due to its prevalence, morbidity and lethality. The WHO claims infection to be primary cause of 15% maternal mortality. It causes at least 75000 maternal deaths worldwide per year. Deaths related to puerperal infection are very rare in the industrialized world. It is estimated 3 in 100,000 birth results in maternal death due to infection. However, the death rate in developing nations may be 100 times higher.3
Most puerperium infections take place after hospital discharge. This is usually 24 hrs after delivery, in the absence of postnatal follow-up as in the case in many developing countries. Many cases of puerperal infections can go undiagnosed and unreported. The predisposing factors leading to the development of infections include home birth in unhygienic conditions, low socio-economic status, poor nutrition, primiparity, anaemia, prolonged rupture of the membranes, prolonged labour, multiple vaginal examinations in labour, caesarean section obstetrical manoeuvres, retained secundines within the uterus and postpartum haemorrhage. Puerperal infection may present as puerperal fever or sepsis, endometritis, wound infection, mastitis, urinary tract infection.4
6.1NEED FOR THE STUDY
Puerperal infection is still one of the leading causes of mortality and morbidity of women in postnatal period. It is known that the delivery type, the insufficient notification ofpostpartum infections cases due to lack of surveillance after discharge, the early discharge of
puerperal women and the patients return outside the institution where the delivery occurred, as well as environmental, individual and maternal factors have been related with the incidence of puerperal infections. With the advent of improved hygienic practices and the introduction of antibiotics, morbidity and mortality from puerperal infection has decreased significantly and infection is no longer the leading cause of maternal mortality.5
In India, maternal deaths from puerperal sepsis accounting for approximately 15% of all maternal deaths. A sixteen year study from northern India found that sepsis was responsible for over 35% of maternal deaths and a study in southern India revealed that sepsis was a leading cause of maternal death responsible for 41.9% of deaths. Demographic and health survey shows that the majority of women do not receive a postnatal check-up and 14% of women who had a birth in the last 5 years reported very high fever in the postpartum period.6
An observational study was conducted in Ayub Teaching Hospital over a period of three years. All patients admitted with diagnosis of puerperal sepsis secondary to genital tract infection were evaluated with through details of history and examination to determine their demographic details, obstetrical profiles, presenting features, state of infectious morbidity, need for intervention and mortality related to puerperal sepsis. It was 1.7% of all obstetrical admissions and 34.4% of postnatal complications. It was seen common among young patient of 15-25 years age, 61(66.3%),of lower parity, 58(63.00%),low socioeconomic status, 60(65.20%), uneducated patients, 72(78.20%),home deliveries 68(73.90%),prolong labour ,54(58.60%), prolong rupture of the membrane from 48-72 hours, 68(73.8%) and deliveries conducted by untrained birth attendant,57(60.5%) puerperal sepsis is an important public health problem contributing to maternal morbidity and mortality. Majority of predisposing factors are preventable. Optimal antiseptic measures and careful monitoring are needed throughout the process of labour.7
A study was conducted in Ife State Hospital of Obafemi Awolowo University Teaching Hospital Complex in Nigeria during the period of January 1986 to December 1995; finding revealed that 1.7% out of 8428 deliveries was diagnosed as having puerperal sepsis. The incidence was higher among unbooked patients (72.2%). Predisposing factors of puerperal sepsis include anaemia in pregnancy; prolonged labour (labour lasting up to 12 hours or more); frequent vaginal examination during labour (more than 5 times); prematurerupture
of the membranes; and no adherence to asepsis during delivery. In addition, the mortality rate was 4.1%. Thus, antenatal care and supervised hospital delivery should be encouraged in order to prevent or reduce the seriousness of postpartum morbidity.8
Educating the primi post natal mothers regarding the prevention of puerperal infection will increase the areas of learning domain and be a healthy motherhood and give birth to healthy child. Thus, the researcher felt that need to assess the knowledge regarding prevention of puerperal infection among primi postnatal mothers and provide structured teaching programme to improve their knowledge.
6.2REVIEW OF LITERATURE:
Review of literature involves systematic identification, location, scrutiny and summary of written materials that contains information on a research problem. Review of literature helps the researcher to gain a broad understanding of the problem and points out the research strategies and specific procedures measuring instruments and statistical analysis that are productive in pursuing the problems. The review also provides the researcher with a perspective on the problem necessary for the interpreting the results of the study. The literature reviewed for the present study is grouped under the following headings.
  1. Studies related to knowledge on puerperal infections.
  2. Studies related to preventive measures of puerperal infections.
  3. Studies related toeffectiveness of structured teaching program.
  1. Studies related to knowledge on puerperal infections:
A clinical study was conducted in Germany, the incidence of puerperal mastitis was evaluated in the course of two 12-months periods with and without additional hand disinfection at the bedside. Disinfection was available throughout both periods for all patients, mounted at the door of each room. Without additional disinfection at the bedside, 32 patients developed mastitis. With reference to the birth rate of 1095 during this period, the incidence of mastitis was 2.9%. When additional bedside disinfection was available,
mastitis dropped to 8 cases per 12 months (1212 birth = 0.66%) (p less than 0.001). A telephone survey, at 55 obstetrical units revealed that 41.8% of maternity clinics do not provide hand disinfectants at the bedside. These results indicate to the breastfeeding mothers, that in the pathogenesis of puerperal mastitis, the essential recommendation emphasizes, the puerperal women practice strict hygiene in maternity.9
A case control study was conducted to determine the risk factors for puerperal sepsis. In this study, included 160 puerperal sepsis cases and 160 controls. A pre- designed interviewing questionnaire was used to collect data. 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.10
Puerperal fever caused by group A streptococci (GAS) is a most serious infection deriving from the birth canal after childbirth or caesarean section and is manifest by fever and/or local signs of infections. Secondary infections in the umbilicus or skin can occur in the newborn child. As approximately 5% of Danish populations are carriers of GAS in nose, throat, rectum and/or vagina the risk of infection is present especially in childbirth. GAS epidemic in the community result in increased risk of hospital-acquired GAS infections. In the literature it is recommended to take action and implement preventive strategies when two simultaneous cases occur in one department. They described the course of seven GAS infections in six patients in the same obstetric ward over a seven week of period, the elucidation by case-control analysis and the implementation of preventive measures. The importance of good hygienic practice.11
A case-control study was conducted in both rural and urban Zimbabwe in 1989-90 to determine the incidence and risk factors for maternal mortality. Information was obtained from various family members as well as from various health and vital statistics records of the women who died and compared to women who delivered without dying. The maternal mortality rate in the rural area selected was determined to be 168 per 100,000 live births
compared to 85 per 100,000 in the urban setting. The major direct causes of deaths in the rural setting were haemorrhage (25%), abortion complications (15%), puerperal sepsis (15%), and eclampsia (5%). The major direct causes of death in the urban setting were eclampsia (26%), abortion complications (23%), puerperal sepsis (15%) and haemorrhage (10%). Compared to a woman who was the only wife of a husband, single women had an increased risk of maternal death of 4.7; divorced, separated or widowed women had an increased risk of 5.6 - 7.1; cohabiting women had an increased risk of 8.0; and being one of several wives had an increased risk of 2.0. Compared to households where the woman's husband was the head of the household, there was an increased risk of 5.8 - 6.6 if the woman herself was the head of the household. If the guardian family was someone other than the wife's or husband's family, the woman was 4 - 5 times more at risk of maternal death.12
  1. Studies related to preventive measures of puerperal infections:
A prospective study was conducted at 3 teaching institutions. 68 women were randomized to receive either amnio-infusion or routine care. Amnio-infusion was through pre exiting internal uterine pressure catheters with a 300-500ML bolus and a 125-150 ML/H constant drip. Chorioamnionitis and endometritis were evaluated as the outcome variables. Women from the amnio-infusion group, n =36, and control group n = 32, had similar times in labour (mean 4 hours), times of ruptured membranes (mean 40 weeks), types of anaesthesia and methods of delivery. Women who received amnio-infusion had significantly less puerperal infection, 9/36, as compared to women in the control group, 16/32 (p <.033, relate risk = .5, confidence interval .26-.94). There were no cases of neonatal sepsis in either group, and there were no complications from the amnio-infusions. In this study, of women high risk for puerperal infection, amnio-infusion was an inexpensive and safe technique for reducing the incidence of infection.13
A cross-sectional cohort study was explored impact of the use of clean delivery-kit on morbidity due to newborn umbilical cord and maternal puerperal infections. Kits were distributed from primary care facilities, and birth attendants received training on kit use. A nurse visited 334 women during the first week postpartum to administer a structured questionnaire and conduct a physical examination of the neonate and mother. Result of bivariate analysis showed that neonates of mothers who used a clean delivery-kit were less
likely to develop cord infection (p = 0.025), and mother who used a clean delivery-kit were less likely to develop puerperal sepsis ( p = 0.024). Result of multiple logistic regression analysis showed an independent association between decreased cord infection and kit- use [odds ratio (OR) = 0.42, 95% confidence interval (CI) 0.18-0.97, p = 0.041)]. Mothers who used a clean delivery-kit also had considerably lower rates of puerperal infection (OR = 0.11, 95% CI 0.01-1.06), although the statistical strength of the association was of borderline significance (P = 0.057). The use of clean delivery-kit was associated with reductions in umbilical cord and puerperal infections.14
  1. Studies related to effectiveness of structured teaching program:
A quasi experimental study was conducted in Fatemieh Hospital Hamadan 2007. This study was done for all midwives in the selected hospital. The standards design by WHO trained to the sample group. The data gathered by: 1) pre-test questionnaire 2) post-test questionnaire and 3) the observational performance checklist. The validity of the tools was increased by the literature reviews and the experts’ comments and the reliability was improved by the test retest. The data were analyzed by the SPSS version 16. The finding showed that there are significant statistical differences between the mean of the midwives’ knowledge (p < 0.005) and clinical performance (p <.001) before and after the education of the postpartum infection.15
A study was conducted in a selected rural community at Mangalore in 2005, on the effectiveness of planned teaching programme on factors influencing low birth weight for 30 primigravida women. The data was collected using structured knowledge questionnaire and one group pre-test post-test design with pre-experimental approach was adopted. The mean percent of pre-test knowledge assessment was 36.0% which increased to 84.77% in post-test. This suggested the effectiveness of planned teaching programme in increasing the knowledge of women on factors influencing low birth weight for primigravida.16
6.3STATEMENT OF THE PROBLEM
“A study to assess the effectiveness of structured teaching programme on prevention of puerperal infections among primi postnatal mothers in selected hospitals at Mangalore.”
6.4OBJECTIVES OF THE STUDY
  1. To determine the level of knowledge on prevention of puerperal infections among primi postnatal mothers.
  2. To evaluate the effectiveness of structured teaching programme on prevention of puerperal infections among primi postnatal mothers.
  3. To find out the association between pre-test knowledge scores of primi postnatal mothers on prevention of puerperal infections with their selected demographic variables like age, educational status, present health status, past illness.

6.5OPERATIONAL DEFINITIONS
Effectiveness: In this study, the effectiveness refers to the extent to which the structured teaching programme has achieved the desired effect about prevention of puerperal infections.
Structured teaching programme: In this study, It refers to the systematically developed instructional programme designed for primi postnatal mothers to provide information regarding prevention of puerperal infections.
Knowledge: In this study, it refers to the ability to know the things, self awareness of primi postnatal mothers on prevention of puerperal infections.
Prevention: In this study, prevention refers to all the activities carried out by primi postnatal mothers in order to avoid the occurrence of puerperal infections.
Puerperal infections:Puerperal infection is an infection occurring in ‘puerperium’ during the period of 6-8 weeks after giving childbirth.
In this study, puerperal infections are puerperal pyrexia, puerperal fever, wound infection, urinary tract infections and mastitis.
Puerperium:Puerperium is the period following childbirth during which the body tissues, specially the pelvic organs revert back approximately to the pre-pregnant state both anatomically and physiologically.
Primi postnatal mother:In this study, primi postnatal mother refers to a women given birth a child at first time.
Maternity hospital:A hospital that provides care to the women during pregnancy, during and after delivery and also for newborn, infants.
6.6ASSUMPTIONS
The study assumes that:
  • Primi postnatal mothers are highly risk to develop puerperal infection due to their unawareness.
  • Primi postnatal mothers in need of proper informationregardingprevention of puerperal infection.
  • The structured teaching programme will enhance the prevention of puerperal infection among primi postnatal mothers.

6.7DELIMITATIONS
The study is delimited to:
  • Primi postnatal mothers who were admitted in postnatal ward.
  • Specific period of six weeks.

6.8VARIABLES
Variables are an attribute of a person or object that varies or takes different values.
  • Independent variables: structured teaching programme.
  • Dependent variables:Prevention of puerperal infection.
  • Demographic variables:age, educational status, present healthstatus, past illness.

6.9HYPOTHESES
All hypotheses will be tested at 0.05 level of significant.
H1:Mean post test score will be significantly higher than the mean pre- test score on prevention of puerperal infections.
H2:There will be significant association between pre test knowledge score of primi postnatal mothers and their demographic variables like age, educational status, and present health status.
7.0 / MATERIALS AND METHODS:
7.1Source of data
Primi postnatal mothers admitted at selected maternity hospital at Mangalore.
7.1.1Research approach
Research approach is a basic procedure for conducting the research study. A research approach tells the researcher what data to collect and how to analyze it. In this study the investigator will choose an evaluative research approach.
7.1.2Research design
The study design selected for this study is pre-experimental one group pre - test and post - test design.
Subject / Pre-test / Administration
of STP / Post test
50 primi postnatal women / O1 / X / O2
O1:Assessment of knowledge on prevention of puerperal infection among primi postnatal before the administration of structured teaching programme.
X:Administration of structured teaching programme.
O2:Assessment of knowledge on prevention of puerperal infection among primi postnatal mothers, after the administration of structured teaching programme.
7.1.3Setting
Study will be conducted in postnatal ward of selected maternity hospital at Mangalore.
7.1.4Population
The population of the present study will be primi postnatal mothers admitted in selected maternity hospital.
7.2METHOD OF DATA COLLECTION
7.2.1Sampling technique
Simple random sampling procedure will be used to select the samples of the study.
7.2.2Sample size
The sample size will be 60 primi postnatal mothers admitted in selected maternity hospital.
7.2.3Inclusion criteria for sampling
The primi postnatal mothers who are:
  • Admitted in the postnatal ward of selected maternity hospital at Mangalore.
  • Mothers who are delivered normally.

7.2.4Exclusion criteria for samplings
Mother who are:
  • Not willing to participate in this study.
  • Not able to read and understand Kannada and English.
  • Initially ill.

7.2.5Instruments intended to be used
Tool 1 : demographic proforma
Tool 2:structured knowledge questionnaire on prevention of puerperal infections.
Tool 3: Structured teaching programme.
7.2.6Data collection method
Prior to data collection permission will be obtained from the concerned Hospital authority for conducting the study. Formal administrative permission will be obtained from the Principal, KaravaliCollege of nursing sciences. Sample will be selected according to the selection criteria. Consent will be obtained from primi postnatal mothers after explaining the purpose of the study.On the first day, the pre-test knowledge score of the primi post natal mothers will be measured by structuredquestionnaire. On the same day structured teaching programme will be administered regarding prevention of puerperal infection. After seven days,post-test knowledge score will be measured by using the same questionnaire method to find out the effectiveness of structured teaching programme on prevention of puerperal infection among primi postnatal mothers.
7.2.7Plan for data analysis
The data will be analyzed by using descriptive and inferential statistics, ie,-mean, mean percentage, and standard deviation. The obtained data will be entered after editing, coding, grouping, tabulation and transferring to a computer file. Chi-square test will be used to find out the association. Analysed data will be presented in the form of tables and graphs.
7.3DOES THE STUDY REQURE ANY INVESTIGATIONS OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS, OR OTHER ANIMALS? IF SO PLEASE DESCRIBE BRIEFLY.
Yes. A structured teaching programme on preventive measures of puerperal infections will be administered to the primi postnatal mothers.
7.4.HAS ETHICAL CONSIDERATION BEEN OBTAINED FROM THE INSTITUTION IN CASE OF THE ABOVE?
Yes, the ethical clearance will be sought from the ethical committee in Karavali College of Nursing Science, Mangalore. Written consent will be obtained from the concerned authority.
8. / REFERENCES
  1. Dutta DC. Textbook of obstetrics. 6th ed. Calcutta: New Central Book Agency (p) Ltd; 2004.
  2. Fraser DM, Cooper MA. Myles textbook for midwives, 14th ed. Philadelphia: Churchill Livingstone; 2003.
  3. Crofton VM. Prevention of puerperal infection. Br Med J 1922 Dec 2;2(3231):1095-6.
  4. Maharaj D.Puerperal pyrexia: a review part second. Obstet Gynecol Surv 2007 Jun;62(6):400-6.
  5. Jovanovic N, Terzic M, Dotlic J, Aleksic S. Prevention of postpartum endometritis; Antibiotic choice. Srp Arh Celok Lek 2009 Sep-Oct;137(9-10):506-10.
  6. Mehta R, Mavalankar DV, Ramani KV, Sharma S, Hussein J. Infection control in delivery care units, Gujarat state, India: a needs assessment. [online]. Available from: URL: 1471-2393.
  7. Shamshad, Shamsher S, Raul B. Puerperal sepsis- stilla major threat for parturient. J Ayub Med Coll Abbotabad 2010:22(3).
  8. Dare FO, Bako AU, Ezechi OC. Puerperal sepsis: a preventable post partum complication. Tropical doctor(impact factor:0.4)05/1998;28(2):92-5.
  9. Peters F, Flick-Fillies D, Ebel S. Hand disinfection as the central factors in prevention of puerperal mastitis. Clinical study and results of a survey. Geburtshilfe Frauenbellkd 1992 Feb;52(2):117-20.
  10. EI-Mahallyaa, Kharboushif, Amer NH, Hussein M, Abdel Salam T, Youssef AA. Risk factors of puerperal sepsis in Alexandria. J EgyptPublic Health Assoc 2004;79(3-4):311-31.

  1. Strobaek S, Zimakoff J, Kristensen KF, Borgon H, Sorensen L, Puerperal fever. A survey of an epidemic using a case controlled study. Vgeskrift For Laeger (1997) volume:159, issue: 26 p-4117-22
  2. Thomas w, Strahan JD, Pregnancy related deaths of African women (ii). Hospital and community based studies, A.I.R.V.S.C. 1999 Mar/Apr;13(3).
  3. Monahan E, Katz VL, Cox RL. Amnioinfusion for preventing puerperal infection. A prospective study. J Reprod Med. 1995 Oct; 40(10):721-3.
  4. Darmastad GL, Hassan M, Balsar ZP, Winch PJ, Gipson R, Santosham M. Impact of clean delivery kit use on new born umbilical cord and maternal puerperal infections. JHealth Popul Nutr 2009 Dec;27(6):746-53.
  5. Khatiban M, Masoumi Z, The effectiveness of the education of the WHO’S recommendations about puerperal infections on the midwives knowledge and clinical performance. HamadanUniversity of Medical Science, Iran.
  6. Veena. Effectiveness of planned teaching programme on factors influencing low birth weight for primigravida women in selected community at Mangalore. Karnataka. Unpublished M. Sc. nursing thesis submitted to Rajiv Gandhi University of Health Sciences Bangalore; 2005.

9. / Signature of the candidate
10. / Remarks of the guide / Recommended. Puerperal infections are highly preventable among postnatal mothers through proper hygienic practice. This study will enhance the knowledge of postnatal mothers and help them to practice these preventive measures during their puerperal period.
11. / Name and designation of (in block letters)
11.2 Guide / MRS.GANGA DEVI
HEAD OF THE DEPARTMENT OF
OBSTETRICS AND GYNAECOLOGICAL NURSING
KARAVALICOLLEGE OF NURSING SCIENCE
MANGALORE.
11.2 Signature
11.3 Co-guide (if any)
11.4 Signature
12 / 12.1 Head of the department / MRS.GANGA DEVI
HEAD OF THE DEPARTMENT OF
OBSTETRICS AND GYNAECOLOGICAL NURSING
KARAVALICOLLEGE OF NURSING SCIENCE
MANGALORE.
12.2 Signature
13. / 13.1Remarks of the Chairman and Principal
13.2Signature

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