RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
BANGALORE.
PROFORMA FOR REGISTRATION OF SUBJECT FOR THE
DISSERTATION
SUBMITTED BY
MS.DEEPA RAJAN
OBSTETRICAL AND GYNAECOLOGICAL NURSING,
2012-2014
SOUTH EAST ASIAN COLLEGE OF NURSING,
K.R.PURAM
BANGALORE
PROFORMA FOR REGISTRATION OF SUBJECT FOR THE
DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS / MS.DEEPA RAJANFIRST YEAR M.Sc. NURSING
SOUTH EAST ASIAN COLLEGE OF NURSING
K.R.PURAM
BANGALORE.
2. / NAME OF THE INSTITUTION / SOUTH EAST ASIAN COLLEGE OF NURSING
K.R.PURAM,
BANGALORE.
3. / COURSE OF THE STUDY AND SUBJECT / MASTER DEGREE IN NURSING,
OBSTETRICAL AND GYNAECOLOGICAL NURSING
4. / DATE OF ADMISSION / 3 JULY 2012
5. / TITLE OF THE TOPIC / “A STUDY TO ASSESS THE EFFECTIVENESS OF VIDEO ASSISITED TEACHING ON KNOWLEDGE REGARDING PREVENTION AND MANAGEMENT OF BREAST ENGORGEMENT AMONG POSTNATAL MOTHERS IN SELECTED HOSPITALS ,BANGALORE’’
6.0 BRIEF RESUME OF THE INTENDED WORK
6.1 NEED FOR THE STUDY:
“Who fed me from her gentle breast, and hushed me in her arms to rest, and on my cheek sweet kisses prest? –My Mother
Anne Taylor
Breastfeeding is the feeding of an infant or young child with breast milk directly from female human breasts (i.e., via lactation) rather than from a baby bottle or other container. Babies have a sucking reflex that enables them to suck and swallow milk. It is recommended that mothers exclusively breastfeed for six months or more, without the addition of infant formula or solid food. After the addition of solid food, mothers are advised to continue breastfeeding for at least a year. The World Health Organization recommends nursing for at least two years or more. Human breast milk is the healthiest form of milk for babies. Breastfeeding promotes health and helps to prevent disease. Experts agree that breastfeeding is beneficial and have concerns about the effects of artificial formulas.1
Correct breast feeding technique goes a long way in ensuring successful breast feeding. Incorrect technique may contribute to breast engorgement. The most common problems associated with the breast feeding are breast engorgement, mastitis, cracked or sore nipple, inverted nipple etc. Out of these breast engorgement and mastitis are the most common and severe problems that the mother encounters with.1
Breast engorgement is a common breast complication in puerperium. It is due to exaggerated normal venous and lymphatic engorgement of the breast which precedes lactation.Unrestricted initiation of breastfeeding as early as possible is the best way to reduce the occurrence of breast engorgement.Breast engorgement is responsible for puerperal fever in 13.3% of non - breast feeding mothers. Although many medications are compatible with breast feeding, it is always a good idea to minimize the use of medications when nursing.2
The incidence rate of breast engorgement all over the world is 1:8000 and in India it is 1:6500. Engorgement symptoms occur most commonly between 3rd or4th day of postpartumand more than two – thirds of women develop tenderness on 5thday of postpartum but some develop as late as 9th– 10th day of postpartum. Two – third of women experience at least moderate symptoms and 20% post- natal mothers especially primigravida mothers are affected with breast engorgement from 0 – 4 days of postnatal period.Lactational mastitis has been estimated to occur in 2 to 10 % of breastfeeding women.2In prospective studies of breastfeeding women, the incidence of breast engorgement per infant nursed has been reported to be as low as 2.5 % among United States women, 24 % among Finnish women, and 27.1 % among Australian women. In a population-based study conducted in Scotland in the pre-antibiotic era, the incidence of breast engorgementwas 8.9 %.2
Observational studies conducted in the USA , Finland , New Zealand , and Australia suggested that up to 20–25% of breastfeeding women developed engorgement during the course of lactation and approximately 20–35% of women who developed had experienced recurrent episodes.2
National surveys have shown that painful breasts are the second most common reason for giving up breastfeeding in the first two weeks after birth in the UK. One factor contributing to such pain was breast engorgement. Views differ as to how engorgement arises, although restrictive feeding patterns in hospital are likely to have contributed in the past.3
Epidemiological Research and Surveillance Management Directorate, Eastern Cape Department of Health, South Africa, stated thatBreast engorgement is a painful and unpleasant condition affecting large numbers of women in the early postpartum period. During a time when mothers are coping with the demands of a new baby it may be particularly distressing. Breast engorgement may inhibit the development of successful breastfeeding, leading to early breastfeeding cessation, and is associated with more serious illness, including breast infection.1
The National Family Health Survey (NFHS) has indicated that painful breast is the second most common reason for giving up breast feeding in the first two weeks after birth in India. . It is reported that 20-85% of the mothers are affected by breast engorgement.1
According to sample registration scheme, the female population of Karnataka in June 2009 was about 25.9 million. Field work conducted during December 2007 to April 2008 in Karnataka showed that 70% of urban mothers & 55% of rural mothers received postnatal care within 2 days of delivery out of which 72 to 85 % of post natal mothers developed breast engorgement.. Among every 10 mothers, 6 mothers suffered with breast engorgement.4
Breast engorgement incidence rate is high in primiparaous mother and patient with inelastic breast. A descriptive study on breast feeding problems in the first six months of life in rural Karnataka among 420 mother infant pairs showed that the onset of breast feeding problems occurred in 31.7% of women during the first month of life and 76.9% in the first week, 7.7% in the second and 15.4% in the third week respectively.5
A study was conducted at Swaroop Rani Nehru and Kamala Nehru memorial hospital Allahabad among 600 postnatal mothers to know the complications associated with breast in the postnatal period and to promote early breast feeding and to teach advantages of demand feeding.The results of the study showed that 20% mothers had breast complications. 43.33% had breast engorgement, 15.83%had cracked nipples, 10% had retracted nipples, 8.33%had cracked and sore nipples.7.5%had cracked and retracted nipple, 7.5% had failed in lactation and 3.33% had breast abscess. Hence the study suggested to teach the postnatal mothers on prevention and management of breast complications which helps for successful breast feeding.6
During the clinical experience, the investigator came across many postnatal mothers who experienced difficulties in breast feeding their new-borns due to breast engorgement. Hence the investigator is motivated to help the postnatal mothers by undertaking a study to assess the effectiveness of video assisted teaching on knowledge regarding prevention and management of breast engorgement.
6.2. REVIEW OF LITERATURE:
“Literature review is a critical summary of research on a topic of interest to put a research problem in the context or as the basis for an implementation project.”
- Polit and Hungler
A descriptive study was conducted to assess the knowledge, attitude, practice and problems of postnatal mothers regarding breast feeding. The study revealed that 65 of the population knew how to prevent breast engorgement, 56 of the population remarked that frequent sucking is essential to prevent breast engorgement. Multipara mothers (57) had more knowledge when compared with primi-para mothers (8). Regarding treatment of breast engorgement, 76 of the population knew the measures to get relief from the breast engorgement, 59 of the population had the opinion that the manual expression of the breast milk will relieve breast engorgement, 12 of the population said that hot water fomentation will relieve breast engorgement, 34 of the population had correct attitude of giving breast milk to the premature child. There is significant difference in the attitude between primipara (6) and multipara (12) mothers living in the nuclear family set up on this aspect of breast feeding.7
A study was conducted among 400 women to assess the effects of frequent breastfeeding compared with less frequent breastfeeding in the early days after birth. There were significant methodological limitations in some of the studies. Compared to two hourly, three hourly or on demand breastfeeding, restricted (less frequent four hourly breastfeeding) was associated with greater discontinuation of breastfeeding by four to six weeks postpartum (RR 1.53, 95% CI 1.08-2.15). Restricted breastfeeding was associated with increased incidence of sore nipples (RR 2.12,95% CI 1.22-3.68),engorgement (RR 2.10,95% CI 1.25-3.21), and the need to give additional (formula) feeds (RR 3.14,95% CI 1.24-8.00).The study concluded that more frequent or on demand breastfeeding is associated with fewer complications.8
A descriptive study was conducted on Provider management and support for breastfeeding pain in USA. The results identified that the rate of breast feeding was 56.4%, and among them 23% had pain on breastfeeding during the first year and the major reasons for pain were mastitis (67.5%), candida (32.4%), engorgement (18.0%), nipple tenderness (8.1%), and clogged milk ducts (4.5%).Mastitis and candida was treated frequently with medications and non-pharmacological measures were rarely recommended . Few referrals were documented to specialized providers such as lactation consultants or community support groups. The study concluded that inadequate breast feeding support and management wereevident and non-evidence based recommendations were routinely practised and suggested that primary care providers should adopt evidence based practises for breast feeding and breast feeding pain which support women in successfully reaching their breast feeding goals.9
A study was conducted on a range of different treatments for breast engorgement using acupuncture, cabbage leaves, cold gel packs, pharmacological treatments and ultrasoundin South Africa. The result showed that women had improvements in pain and other symptoms irrespectiveof whether they received active treatment or not, one study showed that women receiving acupuncture had greater improvements and study on cold pack showed no difference. The study concluded that there was no sufficient evidence from trials on any intervention to justify widespread implementation and recommended that more research is needed on treatments for the painful and distressing condition.10
A study was conducted to investigate the association between length of postpartum stay and duration of breast feeding and breast feeding problems with special focus on early hospital discharge among Swedish women. Results expressed that the median duration of breast feeding was 7 months in women discharged on day 1 and 8 months in women discharged on any of the following days (p = 0.66). Early discharge was associated with the maternal characteristics such as older multipara, many children, positive experience of the first breast feeding after birth, low education, economic problems, smoking and lack of support from the partner.Late discharge was associated with operative delivery, preterm birth and low infant birth weight. However no differences were found between the six groups in discontinuing breast feeding. Breast feeding problems such as engorgement and mastitis did not differ but women discharged on day 6 or later had fewer problems during first week and more problems in 4-8 weeks of postpartum. The study concluded that maternal characteristics may be more important predictors of the duration of breast feeding than length of stay in hospital after the birth and suggested that the effect of domiciliary support needed further research.11
A randomized controlled trial was conducted at level 3 medical teaching hospital to determine the effects of two breast care methods among 54 postpartum women with breast engorgement of whom the experimental group received scrapping(Gua-Sha) therapy and the controlled group received traditional breast care(massage and heating). The result showed a statistical difference between the two groups at 5 and 30 minutes after intervention (p‹.001) in terms of body temperature, breast engorgement, pain levels and discomfort. The study concluded that Gua-sha therapy was an effective technique in the management of breast engorgement and suggested that nurses can handle breast engorgement problems more effectively by using it in primary care and thus helping the patient both physically and psychologically.12
An evaluative study was done to assess the effectiveness of treatments for the alleviation of symptoms in breastfeeding women experiencing engorgement in UK.Eight trials, involving 424 women, were included. Three different studies were identified which used cabbage leaves or cabbage leaf extracts.No overall benefit was found. Ultrasound treatment and placebo were equally effective. Use of Danzen (an anti-inflammatory agent) significantly improved the total symptoms of engorgement when compared to placebo (odds ratio (OR) 3.6, 95% confidence interval (CI) 1.3 - 10.3) as did bromelain/trypsin complex (OR 8.02, 95% CI 2.8-23.3). Oxytocin and cold packs had no demonstrable effect on engorgement symptoms. Study concluded that cabbage leaves and gel packs were equally effective in the treatment of engorgement. Since both cabbage extract and placebo cream were equally effective, the alleviation in symptoms may be brought about by other factors, such as breast massage. Ultrasound treatment was equally effective with or without the ultra-wave emitting crystal; therefore its effectiveness was more likely to be due to the effect of radiant heat or massage. Pharmacologically, oxytocin was not an effective engorgement treatment while Danzen and bromelain/trypsin complex significantly improved the symptoms of engorgement. The study suggested that initial prevention of breast engorgement should remain the key priority.13
An exploratory study compared the effect of two methods of breast feeding on breast engorgement, mastitis, infantile colic and duration of breast feeding among 150 mothers at Flinders medical centre, South Australia. The results showed that the experimental group had a lower incidence of breast engorgement in the first week(61.4% versus 74.3% ; p<0.02) and colic over the first six months(12% versus 23.4%;p<0.02) . There was no significant difference between the two groups in the incidence of mastitis over 6 months and the length of breast feeding. Majority of mothers in experimental group (63%) felt that it was necessary to offer the second breast at the end of the feed to satisfy their infants hunger. The study identified that the “perceived insufficient milk supply syndrome” was the main reason given for cessation of breast feeding for both the groups and provides data to advice nursing mothers about the two methods of breast feeding to avoid complications.14
Hormonal profiles in lactating and non-lactating women immediately after delivery and their relationship to breast engorgement wasstudied in Australia. Human placental lactogen (HPL), oestrone, oestradiol and progesterone levels in plasma were measured before and during the first seven days after delivery in women who did not breast feed. The results confirmed the rapid clearance of placental steroids from the circulation after delivery. Plasma prolactin levels remained elevated during the early puerperium and the range of values were the same in non-breast-feeding women and a group of breast feeding women. The results showed that there is no obvious endocrine basis for the differences in degree of breast engorgement experienced by non-lactating puerperal women and confirmed the results of previous studies showing that levels of oestrogen and progesterone decline sharply after delivery, while levels of prolactin decline more gradually during this period.15