Rajiv Gandhi University of Health Sciences, Karnataka
Bangalore
Annexure II
SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1 / Name of the candidate and address / MISS. TINTU THOMAS1St YEAR MSc. NURSING.
FATHER MULLER COLLEGE OF NURSING.
MANGALORE – 575002
2 / Name of the institution / FATHER MULLER COLLEGE OF NURSING, KANKANADY
MANGALORE-575002
3 / Course of study and subject / MSc NURSING
(OBSTETRICS AND GYNECOLOGICAL NURSING)
4 / Date of admission to course / JUNE 1st 2013
5 / Title of the topic / PREVENTION OF PERINEAL TRAUMA BY PERINEAL MASSAGE AMONG MULTIGRAVID WOMEN.
6. Introduction
“The truth for women living in a modern world is that they must take increasing responsibility for the skills they bring into birth if they want their birth to be natural”
Common knowledge trust
Anatomically the perineum is bounded above by the inferior surface of the pelvic floor, below by the skin between the buttocks and thigh.1
The perineum is a very important part of a women’s body and it plays a special role during childbirth, as it stretches to allow the baby’s head through.
Preparation for delivery begins during pregnancy with the hormones Progesterone and Relaxin softening muscles and ligaments to encourage stretching, this process occurs throughout the body and the perineum and pelvic floor are no exception.1
Women frequently suffer perineal trauma while giving birth. Perineal trauma is defined as any damage to the genitalia during childbirth, either spontaneously or due to an episiotomy. Perineal trauma during childbirth is associated with short and long term morbidity. Perineal damage may result in urinary and fecal incontinence, painful intercourse, persistent perineal pain and weakness of the pelvic floor musculature.2
Perineal massage is a way to prepare the perineal tissues for the birthing process. Perineal massage is a technique that slowly and gently stretches the skin, muscle and tissues between the vagina and rectum. Perineal massage increases the elasticity of the perineum, reduces the risk of perineal tearing during delivery and it can be performed by a pregnant women, her partner or a birthing assistant such as midwife. Ideally, perineal massage should be performed daily during the last six weeks of pregnancy.2
6.1 Need of the study
Trauma to the perineum during childbirth can cause significant pain and disability in women,especially in the immediate postpartum period. Trauma can occur either intentionally (episiotomy) or unintentionally (laceration). While episiotomies only affect the perineal body, which is the area between the vagina and the anus, lacerations can occur in the labia, vaginal wall, and anterior vaginal structures in addition to the perineal body. Perineal trauma is classically divided into six categories: intact, 1st through 4th degree lacerations, and episiotomy. Tearing during childbirth is a common occurrence among women who have a vaginal birth.2
According to national centre for health statistics shows there were almost 6.4 million normal deliveries in 2005 among woman of all ages. According to WHO, the number of normal delivery rate being very high 72.30% per thousand birth. The risk of perineal infections ranges from 2.8% to higher than 18%, the risk of infection can be as high as 20%. All the maternal death in Asia are due to high population density, poverty, low female literacy, infections due to episiotomy and poor health services.3
The incident of maternal death is steadily rising during the last decade there has been 2 to 3 fold rise in the incidence from the initial rate of about 10% of maternal morbidity rate. A very high level of maternal mortality over 500 maternal deaths per 1, 00,000 live births are generally associated with perineal sepsis due to episiotomy wound.4
In Karnataka female population constitutes 43% of total population. According to census of India, the total percentage of normal deliveries with episiotomy is 58.6% in Karnataka . The crude birth rate is 22.5 per thousand live birth rate while maternal mortality rate is 2 per thousand live births in 2007. The very high level of maternal mortality are generally associated with perineal sepsis, harmful practices, infections related to episiotomy wound, and low female literacy increase maternal mortality rate.5
Perineal massage has been used in different countries and cultures throughout much of human history. It is a method of preparing the outlet of the birth passage, particularly the perineum for the stretching and pressure sensation during the birth of the baby. Recently studies show that antenatal perineal massage for reducing perineal trauma.1
In India, the benefit of massaging the perineum is bringing more consciousness and awareness to an area of the body whose messages many ignore. The vagina and perineum store possible physical and emotional trauma in their tissues, and doing some kind of internal physical touch may help to resolve or integrate those areas back into wholeness so they are less likely to hold the woman back during labour. A woman who is relaxed and surrendering to the process will have more responsive tissues and may be less likely to tear.
As the researcher worked as a staff nurse in maternity ward, she found that multigravid women receive episiotomy which could have been avoided and found that women preferred normal delivery without episiotomy but had very minimal knowledge regarding measures to avoid perineal trauma, this prompted the researcher to carry out this study because as a midwife it is very essential to provide adequate knowledge regarding the techniques of perineal massage and ways to perform it to avoid unwanted episiotomies and perineal trauma. If this study is found effective perineal massage can be recommended to adopt in the clinical practice to prevent perineal trauma.
6.2 Review of literature
A single blinded prospective controlled trial was conducted at Yafee Medical centre, Israel in the year 2008 to evaluate the effectiveness of antenatal perineal massage in increasing the likelihood of delivering with an intact perineum. It included 234 nulliparous women with a singleton fetus. The episiotomy rates, overall spontaneous tears and intactperineumrates were similar in the study and control groups. Women in the massagegroup had slightly lower rates of first-degree tears (73.3% vs 78.9% P= 0.39) and slightly higher rates of second-degree tears (26.7% versus 3% P= 0.05) , although both of these outcomes did not reach statistical significance.9
A randomized and quasi-randomized controlled trials study was done at Master Health Services, Australia in the year 2006, on antenatal perineal massage for reducing perineal trauma. A total of 2497 women were included in comparing perineal massage with control. Antenatal digital perineal massage from approximately 35weeks gestation reduces the incidence of perineal trauma requiring suturing (mainly episiotomies 0.74-0.95) and women are less likely to report perineal pain at three months postpartum (regardless of whether or not an episiotomy was performed 0.24-0.87).6
An observational study with one arm of a randomized controlled trial was conducted in five secondary and tertiary care hospitals in the Provinence of Quebec, Canada in the year 2001 to determine how women who practiced perineal massage during pregnancy assessed the technique. Total of 763 women were included in the massage group and (79%-82%) women said they would massage again if they were to have another pregnancy.8
A retrospective descriptive study was conducted at Salem Women’s Clinic, USA in the year 2000 to investigate the associations between perineal lacerations and thirteen variables associated with the incidence of perineal lacerations, the particular interest was the variable of prenatal preparation of the perineum. The sample included 307 multiparous and 61 primiparous women. The study concluded that teaching perineal massage to primiparous women and multipararous who had episiotomies with their previous births is a useful intervention. The initial chi square indicated that five of the 13 were significantly associated with the degree of lacerartion: parity, maternal age, maternal position at delivery, length of second stage of labour and prenatal perineal massage. It suggests that further study may help clarify the optimum frequency, timing, and technique of massage.10
The randomized single-blond prospective study carries out at Watford General Hospital, UK. It involved 861 nulliparous women with a singleton pregnancy and was conducted between June 1994 and Oct 1995. The results showed a reduction of 6.1% in 2nd or 3rd degree tears in women assigned to the massage group compared to those receiving no massage. It provided a much larger benefit in those aged over 30 years old.7
6.3 Statement of the problem
“A Quasi experimental study on prevention of perineal trauma by perineal massage among multigravid women in a selected hospital of Mangalore”
6.4 Objectives of the study
1. To compare the effectiveness of perineal massage in prevention of perineal trauma in experimental group to that of control group.
2. To find the association of perineal trauma with selected variables like age, education, profession, parity, and expected weight of the baby.
6.5 Operational definitions
1. Perineal trauma: Perineal trauma refers to the break in integrity of skin by episiotomy, tears which are further classified into first degree, second degree, third degree and fourth degree.
2. Perineal massage: Perineal massage refers to the stretching and stimulation of the perineum by a pregnant woman from 36 weeks of gestation for at least 10 minutes per day.
Steps of perineal massage:
i. Wash the hands thoroughly with soap and water
ii. Cut the nails short.
iii. Either prop up or have a squatting position, use a lubricant.
iv. Place the thumbs about 1’ (3cm) inside the vagina and press down towards the anus and to the sides of the vaginal wall.
v. Slowly and gently massage the outer lower half of the vagina, using a ‘U’ shape technique.
vi. Perform the exercise for 10 minutes each day.
6.6 Assumptions
1. The women will learn the technique and practice perineal massage.
6.7 Delimitations
This study is delimited to multigravid women,
· in the 3rd trimester of pregnancy
· have second or third living baby
· are willing to participate
6.8 Hypothesis
H1- There will be significant difference in the scores of perineal trauma among experimental and controlled group.
H2: there will be a significant association of perineal trauma with selected demographic variables like age, education, profession, parity and expected weight of baby.
Materials and methods
7.1 Source of data
Multigravid women with 36 weeks of gestation and above in their third trimester following in the ante natal Outpatient department.
7.1.1 Research design
Post test only control group design will be used in this study.
7.1.2 Setting
The study will be conducted in the antenatal OPD and labour room of Father Muller Medical College Hospital, which is a multi specialty hospital with 1250 beds. The antenatal OPD has approximately 100 patients visiting every day. The labour room is well equipped and has been divided into active and passive unit. The active unit has three Cubic’s for normal cases and a separate septic cubic. The passive side has minor OT and eclamptic room. The number of deliveries per month varies from 190- 200.
7.1.3 Population
The study population consists of Multigravid women.
7.2 Method of collection of data
7.2.1 Sampling procedure
Sample- Multigravid women in their third trimester of pregnancy.
7.2.2 Sample size
Forty Multigravid women who are in their third trimester of pregnancy.
20 Experimental group
20 Control group
7.2.3 Inclusion criteria
Multigravid women
i. With gestational week of 36 and above
ii. Who have previously had a spontaneous normal vaginal delivery
iii. Who have previously had a caesarean section.
iv. Who understand English, Hindi or Malayalam
7.2.4 Exclusion criteria
i. The woman has an active vaginal infection.
ii. Preterm rupture of membranes.
iii. Is in High risk pregnancy and previous history of vacuum or forceps delivery and previous third degree or fourth degree tears.
7.2.5 Instrument intended to be used
Baseline Performa
Observational check list on perineal trauma.
7.2.6 Data collection methods
1. The informed consent will be obtained from multigravid women prior to the study.
2. Perineal massage will be taught to the multigravid women in their third trimester of pregnancy during their visit to the antenatal Outpatient department.
3. Occurrence of any perineal trauma will be observed in the second stage of labour by using an observational checklist on perineal trauma.
7.2.7 Data analysis plan
Data analysis will be done using both descriptive and inferential statistics.
Demographic variables will be analyzed descriptively by frequency and percentage distribution with the help of column, bar and pie diagrams.
A “t” test and a chi square [χ2] test will be used to determine the effect and association of perineal massage on perineal trauma.
7.3 Does the study require any investigation or interventions to be conducted on patients or other humans or animals? If so please describe briefly
Yes, Perineal Massage will be taught in the third trimester in order to prevent perineal trauma. The investigator will obtain the consent of the subject prior to the study.
7.4 Has ethical clearance been obtained from your institute in case of 7.3?
1. It has been obtained.
2. Confidentiality and anonymity of the subjects will be maintained.
3. An informed consent will be obtained from the subjects prior to the study.
8. List of references
1. Dutta DC. Textbook of obstetrics. 6th ed. New Delhi (India): New central book agency; 2004.
2. Williams FL, Flory C, Mires GJ. Episiotomy and perineal tear in low risk primigravida. Journal of public health medicine 1998 Jun 1; 7(9):980-3.
3. Reproductive and health indicators data base: available from: http//www.who.vit.reproductive indicators/countrydata
4. Statistics available from http;//www.childinfo.org/antenatalcare countrydata.php
5. Demographicdata available from http://enwikipedia.org/wiki/karnataka
6. Beckmann MM, GarrettAJ. Antenatal perineal massage for reducing perineal trauma. British Journal of Obstetrics and Gynecology 2006 August1; 104(7):741-44.
7. Shipman MK, Boniface DR, Tefft ME, McCloghry F. Antenatal perineal massage and subsequent perineal outcome. British Journal of Obstetrics and Gynaecology1997 Jul; 104(7):787-91.
8. Eason E, Labrecque M, Wells G, Feldman P.Preventing perineal trauma during childbirth.Obstetrics and Gynaecology2000 Mar; 95 (3):464-71.