A STUDY TO EVALUATE THE EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE ON KNOWLEDGE OF HOUSE WIVES REGARDING PREVENTION OF UTERINE PROLAPSE AT SELECTED RURAL AREA, BANGALORE.

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

Ms. SHYLIN J

IST YEAR M.Sc. (N) NURSING

OBSTETRICS AND GYNECOLOGICAL NURSING

2011-2013

HARSHA COLLEGE OF NURSING

HARSHA HOSPITAL CAMPUS

193/4, NELAMANGALA BYPASS,

BANGALORE-561223

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS / MS.SHYLIN J
HARSHA COLLEGE OF NURSING HARSHA HOSPITAL CAMPUS
193/4, NELAMANGALA BYPASS,
BANGALORE-561223
2. / NAME OF INSTITUTION / Harsha College Of Nursing
Bangalore
3. / COURSE OF STUDY AND SUBJECT / I year M.Sc. Nursing
Obstetrics And Gynecological Nursing
4. / DATE OF ADMISSION TO COURSE / 06/05/2011
5. / TITLE OF THE STUDY / To Evaluate the Effectiveness of Self Instructional Module on Knowledge of House wives Regarding Prevention of Uterine Prolapse.

6. 0 BRIEF RESUME OF THE INTENDED WORK:

INTRODUCTION:

“Every human being is the author of his own health or disease.”

Sri Buddha.

A woman is the first and foremost a person and, when she bears a child, a mother. Many societies define woman through her fertility and her body is adapted for this by its shape and function. The nurse needs to be familiar with the anatomical features of the women’s and to understand the processes of reproduction but must never forget the social significance of child bearing or that a woman’s body is unique, personal and private.1

The uterus is a hollow pyriform muscular organ situated in the pelvis between the bladder in front and the rectum behind. The uterus is normally supported by pelvic connective tissue and the pubococcygeus muscle, and held in position by special ligaments. 2

Weakening of these tissues allows the uterus to descend into the vaginal canal. Tissue trauma sustained during childbirth, especially with large babies or difficult labor and women who have had one or more vaginal births, is typically the cause of muscle weakness.

The loss of muscle tone and the relaxation of muscles, which are both associated with normal aging and a reduction in the female hormone estrogen, are also thought to play an important role in the development of uterine prolapse. Descent can also be caused by a pelvic tumor; however, this is fairly rare.

Other conditions associated with an increased risk of developing problems with the supportive tissues of the uterus include obesity and chronic coughing or straining. Obesity places additional strain on the supportive muscles of the pelvis, as does excessive coughing caused by lung conditions such as chronic bronchitis and asthma. Chronic constipation and the pushing associated with it cause weakness in these muscles. However, the symptoms may not appear till after menopause, when the damaged muscles lose tone and the ligaments atrophy. 3

The uterus sags down into the vagina, and may even protrude out between the vaginal lips. There are three degrees of utero-vaginal prolapse. In first-degree prolapse, the cervix appears at the vaginal opening only when the woman is asked to bear down. In second-degree prolapse, the cervix descends to the level of the vulva, and in third-degree prolapse, the cervix protrudes outside the vulva. The condition where the entire uterus may protrude outside the vulva, bringing with it both the vaginal walls, is called procidentia. If left untreated it can lead to infections, bleeding and even cancer.

A woman with prolapse may complain of a lump in the vagina or a feeling of “something is coming down”, back-ache and a bearing down sensation, abdominal pain, vaginal discharge, disturbances of micturation, frequency and dysuria, stress incontinence, difficulty in defecation, profuse periods, irregular bleeding and bleeding due to the protruding prolapse becoming ulcerated. If there is a large prolapse, the external swelling may inconvenience the woman in walking and carrying out her every day duties. 4

According to World Health Organization estimates, reproductive ill-health accounts for 33% of the total disease burden in women globally. The global prevalence of genital prolapse is estimated to be 2-20% in women under age 45. In a 2000 study in northern India, of 2,990 married women surveyed for prolapse, cases worsened in 7.6%. 5

According to Journal of Nurse Practitioners reveals that more than 300,000 women undergo surgery of pelvic floor prolapse every year in the U.S.6

An Italian study identified risk factors for prolapse from a 21,449 non-hysterectomized menopausal women from 1999 to 2002. 5.5% among those who had prolapse were found to suggest significant risk factors like number of vaginal births and overweight. Housewives have 3.1 times more prone to develop prolapse than professionals.

A study recently done in 2003 in MGM Hospital in Eastern India, found that genital prolapse count 20 percent of all gynecological admissions in the hospital. Half of them have loose pelvic floor support, resulting in some degree of genital prolapse.

In another multicentre study in India by ICMR from 1999 to 2002 showed genital prolapse to contribute significantly out of total gynecological morbidity.

More educated and economically independent women have better control over cares and access for their own reproductive health problem. It reminds us about their empowerment and decision making power that has effect on outcome. Poor socio economic conditions distance from nearest health center, educational status and heavy works e.g. weight lifting is also related with prolapse. Delivery of big baby has positive association with prolapse. Familial incidence of genital prolapse and chronic pulmonary diseases e.g. asthma, chronic cough are significant to cause genital prolapse due to increased intra abdominal pressure. Few studies show that there is association between heavy works, weight lifting and genital prolapse. 7

Omitting the issue and inadequate attention to genital prolapse is a big lacunae in reproductive health programme in implementation level. The present strategy has failed to protect the reproductive rights and choices of women with prolapse. There is urgent need to boost up preventive, curative cares for genital prolapse in reproductive healthcare programme that may have positive spillover effect on the life cycle approach of women. More research is needed to find out and implement a community based comprehensive reproductive health care approach for women with genital prolapse across all age groups and all geographical locations. Also there is need to find out how to adopt an ideal reproductive healthcare model in a resource limited country like India that is more gender sensitive, feasible and can address neglected areas like genital prolapse. It should also address women’s untapped reproductive decision-making process.

In spite of excellent advances in the field of prevention and management on uterine prolapse, expectations are not always fulfilled. End points of management must be realistically understood.

6.1 NEED FOR THE STUDY

“An ounce of prevention is equal to an ocean of care”.

Motherhood is a beautiful experience, which can turn into a tragedy when the family loses the most precious member of the family, the mother. Each year more than half a million women die in the world from complications of pregnancy and millions more suffer permanent disabilities following these complications. The risk of maternal death for a woman varies from one in 10,000 in well developed countries to one in 50 in the developing countries.8

Uterine prolapse is one of the common clinical conditions met in day- today gynecological practice especially amongst the parous woman. It is in fact a form of hernia. The uterine prolapse is usually associated with variable degrees of vaginal descend.

Globally, an estimated 5,85,000 women die each year due to pregnancy and delivery- related complications, 99% of them die in developing countries.9

According to WHO (1998) many of the maternal complications such as maternal morbidity and mortality arise during labor and delivery and in the first one–two weeks following delivery around 18 million women these morbidities become long-term and are often debilitating. Major acute obstetric morbidities include haemorrhage, sepsis and pregnancy-related hypertension. Longer-term morbidities include uterine prolapse, vesico-vaginal fistula, incontinence, dyspareunia and infertility .10

Up to half of the normal female population will develop utero-vaginal prolapse during their lifetime. 20% of this woman will be symptomatic and need treatment. A North American actuarial analysis revealed that a woman up to the age of 80 years has an 11% risk of needing surgery for pelvic floor weaknesses. Furthermore, if she has an operation, she has 29% risks of requiring further surgery. 11

Prevalence data for prolapse are scattered at best. In a 2002 study in the USA, 27,342 women were evaluated in the Women’s Health Initiative. 14.2% of the 16,616 women who had a uterus were diagnosed with genital prolapse. Another USA study suggests that genital prolapse is present in some 20% of post-menopausal women. In a 2001 study from Egypt, physician diagnosis found that 56% of 509 ever-married women between the ages of 14 and 60 had prolapse. In 2002, 694 parous non-pregnant women in Istanbul were examined and 27% were diagnosed with severe "pelvic relaxation". In 2002 study in southern India, 440 women under the age of 35 were evaluated for gynaecological morbidity, and cases of prolapse were noted in 3.4%. In a 2000 study in northern India, of 2,990 married women surveyed for prolapse, cases worsened in 7.6%.12

The available literature between 1990 and 2004 was reviewed to determine if the nurse's role in the use of vaginal pessaries to treat pelvic organ prolapse and/or urinary incontinence is well defined. Forty-five articles were reviewed, including one written by a physician's assistant, two written by both a physician and a registered nurse, seven written by registered nurses,34 written by physicians ,and one unpublished manuscript. It was revealed that nurses could make a valuable contribution to the bank of information available on the use of vaginal pessaries to treat stress urinary incontinence and pelvic organ prolapse.

A part of nursing assessment of patients in women health clinics, women are asked if they experience symptoms of pelvic organ prolapse. With the information available to women today to help them to manage health related issues, nurses who initially assess these women should pursue the pelvic floor exercise (kegel exercise) by giving written information in a sheet of paper. Interested nurses could make a valuable contribution through research and clinical practice to the limited knowledge in this field. 13

Prevalence estimates vary widely, depending on the population and the way in which women were recruited into studies. One study conducted in the USA (497 women aged 18–82 years attending a routine general gynecology clinic) found that 93.6% had some degree of genital prolapse (43.3% POPQ stage I, 47.7% POPQ stage II, 2.6% POPQ stage III, and 0% POPQ stage IV). Study reveals that the incidence of clinically relevant prolapse was found to increase with advancing parity. 14.6% had non-parous, one to three births had 48.0%; and more than three births had 71.2%.

A Swedish study among 487 women found that 30.8% of women between the ages of 20 and 59 years had some degree of genital prolapse on clinical assessment. The prevalence of genital prolapse increased with age, from 6.6% in women aged 20–29 years to 55.6% in women aged 50–59 years. 14

In developed countries, prolapse is higher in elder age, where as in developing; it is higher in younger age. Study conducted in general population of age from 40 to 60 years in Sweden, showed 9-19% of incontinence and more with aged. Study in India during 1999 -2004 in Bengal, Delhi, Punjab and U.P among patients attending in gynecological private clinics revealed that one in five patients suffer from prolapse. 15

A study of 214 women admitted to the gynecological ward of Osmania hospital, Hyderabad during 1998-2001, observed that uterine prolapse was not necessarily the outcome of repeated childbirth but often followed damage to the pelvic floor after the very first delivery. The general cause of uterine prolapse among 18 of 32 women is due to heavy manual labor within a week to a fortnight following delivery. It's estimated that half of women who have children will experience some form of prolapse in later life, but because many women don't seek help from their doctor. 16

In Karnataka, a retrospective study was conducted on 13 cases of uterine prolapse that were admitted over a five year period from 1999 to 2004, at Chitradurga village. The patients are evaluated with respect to age, symptomatology, degree of uterine prolapse according to POPQ system, associated clinical findings, parity, type of surgery that they had undergone earlier, time interval between hysterectomy and development of uterine prolapse, and the various treatment modalities that were tried. Out of the 13 patients one had bladder calculus and underwent surgery for removal of bladder stone along with the corrective procedures for the uterine prolapse.17

The investigator has come across that though treatments are available many factors inhibit women from obtaining such treatment. They include fear, misconception and lack of knowledge regarding the disease and treatment.

Investigator had seen case of uterine prolapse due to negligence of women and identifying the condition at later stage and providing care then doing the management. Many complication related to pregnancy are occurring due to lack of proper identification in early stage.

Women identification is essential, both in the prevention and the detection of uterine prolapse, so that women can express their needs without fear and are aware of the need for appropriate treatment in the incipient stages of prolapse. Mismanagement or improper care during delivery is the main cause for uterine prolapse. So, women play an important role in prevention and management of uterine prolapse. It is essential that women’s should have adequate knowledge about uterine prolapse. Therefore, the researcher felt the need to assess the knowledge of house wives on uterine prolapse. Hence the need to conduct such a study was felt.

6.2 REVIEW OF LITERATURE

A review of literature related research and theory on a topic has become a standard and virtually essential activity of scientific research projects. “Literature review is a critical summary of research on a topic of interest, often prepared to put a research problem in contact or as the basis for an implementation project.”18