RAJIV GANDHI UNIVERSITY OF THE HEALTH SCIENCES, KARNATAKA,
BANGALORE
PROFORMA SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 / NAME OF THE CANDIDATE AND ADDRESS / MS. SATHYABAMA.PC/O MUTHUKUMARAN.TRANGARAJ building ground floor,
OLD PANCHAYAT OFFICE ROAD,CHIKKABANAVARA P/O,
BANGALORE – 560090
2 /
NAME OF THE INSTITUTION
/ GOLDFINCH COLLEGE OF NURSING,#150/24, KODIGEHALLI MAIN ROAD,
MARUTHI NAGAR, BANGALORE – 560092
3 / COURSE OF STUDY AND SUBJECT / 1ST YEAR M.SC. NURSING
OBSTRETICS AND GYNAECOLOGICAL NURSING,
DISSERTATION PROTOCOL
4 / DATE OF ADMISSION TO COURSE / 15 – 06 -20085 / TITLE OF THE TOPIC / A STUDY TO ASSESS THE EFFECTIVENESS OF SELF-INSTRUCTIONAL MODULE REGARDING PREVENTION OF PUERPERAL SEPSIS ON KNOWLEDGE AND PRACTICE OF POSTNATAL MOTHERS IN A SELECTED HOSPITAL, BANGALORE.
6
6.1 / BRIEF RESUME OF THE INTENTED WORK:
INTRODUCTION:
Mother is at once the sea and shore
Our freedom and our past
With her we launch our daring ship
Yet keep the things that last– Gorden .N.
Motherhood is a distinct bio-psychosocial process that transforms and broadens the role of a woman into that of a mother. Puerperium is a period, where the experiences are intense physical and emotional stress due to exhaustion, anxiety and excitement. Each mother has to adjust the physical changes in her own body due to involution and lactation as well as puerperal complication mainly puerperal infection, bleeding, eclampsia etc. Puerperal infection causes a number of distressing conditions into postnatal women1 (Noronha .J, 2003).
The post partum is a crucial period for the mother. She is happy having seen the fruit of her labour but the risk of disorders also continues. After having completed an uneventful pregnancy, some women remain healthy others suffer due to various disorders. Further in developing country like India, where malnutrition and anemia is rampart, women are more prone to get infected. There are chances of puerperal infection in the genital urinary tract and caesarean section, wound infection. Woman in post partum period are in need of greater awareness to prevent puerperal infection there by to prevent further problems in puerperal period.
Epidemics of puerperal sepsis were responsible for about two – thirds of maternal mortality in the eighteenth and nineteenth centuries. The incidence and severity of these infections declined dramatically in the second part of the present century, for reasons including decreased virulence of the infecting organisms, improved living conditions, greater attention to aseptic techniques and the use of antibiotics. Recent reports have suggested a resurgences of virulent group A streptococcal causing soft – tissue invasion, septic shock and DIC. An epidemic of group A streptococcal infection occurred in Norway in1987 – 1988. When it caused toxic shock syndrome it was labeled by the media as the ‘killer bug’, and when the presentation was necrotizing facilities the term was ‘flesh – eating bacteria’3.
6.2 / NEED FOR THE STUDY:
Pregnancy and childbirth are normal physiological process and outcomes of the pregnancies are mostly good. However, a few pregnancies and childbirth expose mothers at risk. Puerperal sepsis or pyrexia is one of the risks, which will develop after delivery, which is often, and unpredictable. Puerperal pyrexia or infection pregnant women need obstetric care to manage this complication2. (Gulani. K. K, 2005).
The bacteria responsible for the majority of puerperal infection arise from the streptococcal or staphylococcal species. The streptococcus bacterium has a chain like formation and may be hemolytic or non hemolytic and aerobic or anaerobic; The most common species associated with puerperal sepsis is the beta hemolytic s. pyogenes. Staphylococci are most frequent cause of wound infections; where these bacteria are coagulates positive they form clots on the plasma, which can lead to more widely spread systemic morbidity. There is additional concern about their resistance to antibiotics and subsequent management to control spread of the infection. Regardless of the location of care, postpartum women and health care professionals should be aware of how infection can be acquired and should pay particular attention to effective hand washing techniques and the use of gloves where there is direct contact with wounds or areas in the body where bacteria of potential morbidity are prevalent.
Puerperium is the period following childbirth during which the bodies tissues, specially the pelvic organs revert back approximately to the pre pregnant state both anatomically and physiologically. Puerperium begins as soon as the placenta is expelled and lasts for approximately 6 weeks when the uterus becomes regressed almost to the non-pregnant size3 (Dutta .D.C, 1997).
Diebel .J, (2002) 4 reported that the incidence of puerperal infection was 1% - 8% of the post partum female population in the United States. One of the main causes of the maternal death in worldwide was puerperal infection (15%).
Puerperal sepsis is the second most common cause of maternal mortality in the developing world. Shiliang .L et al., conducted study in Port Blair on risk of maternal post partum infections associated with mode of delivery reported that the incidence of puerperal infection was 0.48%.
/ One of the main causes of maternal mortality in India was sepsis (15%). Gupta .M.C and Mahajan B.K, (2003) 5reported that in Delhi the main cause of maternal mortality was sepsis accounts to 28%.
Puerperal infection was higher following caesarean delivery It contributes to most of the maternal deaths6 (Daftary et al., 2006). In Uttar Pradesh, the cause for maternal death was abortion, toxaemia, bleeding, puerperal infection and anaemia wound infections (1.3%).
Thomas et al., (2006) 7conducted a study on review of maternal mortality in tertiary care in Bangalore concluded that puerperal sepsis (17.3%) was the one of the main cause of MMR. Found that one of the main cause of maternal deaths was puerperal infection (11.8%).
The possible reasons for infection are in unhygienic environment with poor resources, failure of the doctors or nurses, to detect the early signs of puerperal infection to the postnatal mother before discharge from the hospital. Ali et al., (2006) reported that in Pakistan the incidence of vaginal infections was 3% due to the use of unhygienic cloth and cotton for lochial discharges.
Puerperal sepsis was commonly seen in unlooked patients (71.2%) and the predisposing factors were anaemia in pregnancy (69.2%) prolonged labour (65.7%) frequent vaginal examinations in labour (50.7%) premature rupture of membranes (31.5%) and non-adherence to asepsis during delivery.
Dhlen et al., (2007) 8conducted a study in Australia on risk factors for severe perineal trauma. The common problems associated with episiotomy are unsatisfactory anatomical results, increasing blood loss, perineal pain, dysparenia and genital tract infection.
After delivering the baby, women has to keep the perineum clean and pads should be changed frequently. Recommended that after delivery changing sanitary pads frequently and perineal wash at least three times daily will prevent puerperal sepsis.
Nathan et al., (1993) 9revealed that a dramatic decline in the prevalence of serious puerperal infection caused by group a beta hemolytic streptococcus been observed through most of the 20th century.
Adequate pre-operative care, primarily wound cleansing and intravenous antibiotics, early repair of episiotomy was found to be effective. In Australia due to the abandoning use of masks and gowns has reduced the puerperal sepsis incidence. However, in recently developed countries and still in many developing countries puerperal sepsis was a killer.
A study on health problems related to early discharge of Turkish woman found that woman discharged from hospital in the first 24 hours after birth should be educated about the problems that may arise during the post partum period, promoting health education that encourages women to seek appropriate and timely care.
Infection control increases during delivery these can be reduced by limiting the frequency of vaginal examination and avoiding all unhygienic practices related to delivery should be strongly recommended. A study in US on professionals regarding infection control and epidemiology, findings revealed that specific recommendations to promote improved hand washing practice to reduce the transmission of pathogenic microorganisms to patients and personnel health care settings.
Midwifery assistants appear to be little standardization in the qualification, training was provided to improve their skills and knowledge. Midwives have a role in providing this training and supervising midwifery assistants.
Self-instructional module is a learning package planned and prepared from the beginning till end with an aim to facilitate self-learning. It is self explanatory, self sufficient, self directed, self motivating and self evaluating also less time consuming, appropriate for the target and one and more effective than feature method (Shankara Narayanan, 1997).
The investigator during her practice in the hospital and community observed that most of the post partum mothers had lack of knowledge about puerperal sepsis and its prevention. Further, various studies also reported that there is a lack of knowledge on puerperal sepsis and its prevention among postnatal mothers. If puerperal infection is not treated promptly, it leads to so many complications like septicemia endometritis, salphingitis, peritonitis, etc. By means of teaching program the post natal mothers will gain knowledge regarding prevention of puerperal infection and also these will promote the health of the mother. Hence, the investigator wanted to test the effectiveness of SIM on knowledge related to practice regarding puerperal infection and prevention among postnatal mothers.
6.3 / REVIEW OF LITERATURE:
A literature review is a written summary of the state of existing knowledge on a research problem. The talk of reviewing research literature involves the identification, selection, critical analysis and written description of existing information on a topic10 (Polit and Hungler, 2003).
Shanty .J, (2004) 11stated that, the puerperium refers to the six week period, which follows child birth, during this time, the pelvic organs return to the non pregnant state, the physiocological changes of pregnancy are renewed and lactation is established.
Puerperium is defined as being from delivery of the placenta to the end of the 6th postnatal week. Nathan (2003) 9concluded that the puerperium consists of the period following the delivery of the baby and placenta to approximately six weeks postpartum.
Puerperium is the period following child birth during which the body tissues especially the pelvic organs revert approximately to the pre-pregnant state both anatomically and physiologically (Jacob .A, 2005). Melson .K.A. et al., (1999)12 reported that puerperium usually extends from after the third stage of labour to 6 weeks after delivery.
The postpartum period or the puerperium has traditionally been considered from the time from the birth of the neonate until six weeks post the birth. During the postnatal six weeks, maternal physiological systems return to their pregnant state.
Daftray .N.S and Chakravarthi .S, (2003) 6suggested that genital tract sepsis remains the most important cause of puerperal pyrexia. Puerperal sepsis remains the most important cause of morbidity and mortality following child birth.
Puerperal pyrexia is defined as rise in temperature to 100.4°F (38°C), occurring any time during the first 14 days of child birth (or) a temperature above 99°F on three consecutive days during this period. Puerperal infection is an infection of the reproductive tract associated with child birth that can occur at any time from after delivery to six weeks.
Post partum infection is defined as fever of first 24 hours after births. Occurring on at least two of the first 10 days after birth exclusive of the first 24 hour. The most common cause of fever in puerperium is genital tract sepsis. The most common site is the uterine cavity however other genital tract sites may also be involved.
Bonnur .J and Dunlop .W (2005), 13concluded that in post partum period, genital tract sepsis occurs at 11%. Alauddin .M, (1986) found that the major causes for MMR was obstructed labour and sepsis caused by abortion.
In US puerperal infection occurs in 3% of all women who had vaginal birth. It occurs in 15% to 20% of those who had caesarean births14 (Mckinney et al., 2000). Found that in US the overall postpartum sepsis rate was 6.0% with rates of 7.4% following caesarean section and 5.5% following delivery.
Puerperal sepsis (13.3%) was the common problem in South Africa (M. A study conducted by Tharaux .D.C et al., (2006) 15in France on post partum mortality and caesarean delivery, findings shows that higher incidence of puerperal infections seen in caesarean delivery than normal vaginal delivery.
According to National Maternal Mortality Surveillance (1999) in China concluded that, the causes of maternal deaths were obstetric hemorrhage, pregnancy induced hypertension, heart disease, amniotic fluid embolism, puerperal infection and hepatic disease and these six causes constituted 81.6% of the total.
One of the common causes for puerperal infection was following prolonged rupture of the membranes (or) prolonged labour episiotomy wounds of perineal tears found that factors for wound infection was poor surgical technique, low socioeconomic status, extended duration of labour and ruptured membranes, chorioamnionitis and obesity.
The main causes for puerperal sepsis is anaemia in pregnancy, prolonged labour, frequent vaginal examinations in labour PROM and not observing proper aseptic techniques during labour and delivery16 (Misra .R, 2007).
The predisposing factors leading to the development of puerperal sepsis include home birth in unhygienic condition, low socio economic status, poor nutrition, primi parity, anaemia, prolonged rupture of membranes, prolonged labour, multiple vaginal examinations in labour, caesarean secundins within the uterus and postpartum hemorrhage.
The Common causes requiring consideration include endomyometrtis, UTI, episiotomy infections, infected surgical wound caesarean section, chest infection following general anesthesia, breast infections and thrombo phlepitis 6(Daftary .N.S and Jain .N, 2006).
Thresyamma C.P, (2003) found that problems during post partum were as follows; localized infection may be seen in infected wound and occasionally in abscess form. Pelvic infection leads to salphingitis and peritonitis causing salpingitis. Pertonites may lead to parametritis causing cellulitis. Other common problems are infection in urinary tract, breast and wound area.
The uterus infection is localized into the uterus and its wall, the infection spreads to the uterus (metritis) and serosa (peritonitis). A study conducted by Bang .R.A et al., (2004) in Gadchiroli, India on maternal morbidity during labour and the puerperium in rural homes and the need for medical attentions, shows that, the possible problems during puerperal period were :
a) Urinary tract infection : Frequency, dysuria, haematuria, 95% caused by E-coli, proteus and klebshella. b) Genital tract infections : tender bulky uterus, prolonged bleeding, painful inflamed perineum. C) Mastitis : Painful, hard, red breast, nipple trauma and cellulites. d) Post operative infection following caesarean section : Painful, red suture line, deep tenderness on palpation and pink colored lochia.
The most common postpartum infections are metritis, wound infection, urinary tract infections, mastitis and septic pelvic thrombophlebitis 14 (Mckinney et al., 2000). French .L.M and Small .F.M (2007) conducted a study in USA on Antibiotic regimens for endometritis after delivery. In his study, he concluded that postpartum endometritis was more common after caesarean section and also it occurs when organisms invade the vagina and leads endometrial sepsis during labour and birth.
Liston et al., (2007) 17conducted study in Canada on maternal mortality and severe morbidity concluded that caesarean group had increased post partum risks of cardiac arrest (3%) wound hematoma (5.1%), puerperal infection (3%) and venous thromboembolism (2%). In Africa 56% were presented with sepsis in the reproductive tract and 35% with pain and puerperal sepsis. Episiotomy causes a lot of pain post operatively and the risk of subsequent sepsis was higher.
In general, the more extensive the laceration or episiotomy, the greater the chances for infection and breakdown the wound. More tissue is devitalized in large episitomy, thereby providing greater opportunity for contamination (Gupta .K et al., 2004). Lack of knowledge on hygiene or lack of access to facilities that permits adequate hygiene increases the risk for postpartum infections14 (Mckinney et al., 2000). In postpartum wards mothers had poor knowledge regarding postpartum care breastfeeding (26.06%), rest (25.83%), perineum care (13.12%), treatment and follow-up care (8%).
After discharge from the hospital mothers are readmitted to the hospital due to surgical wound infection (87.6%). This is due to lack of knowledge regarding wound care in puerperal period.
Dougherty .L and Lister .S.C, (2004) 18reported that ideally, perineal hygiene should be attended after the general bath or at the very least, the water and wipes should be changed and clean once utilized. It is generally acknowledged that soap and lotions can be used for the perineal care.
Misra .A, (2000) 16recommended that vulva should be cleaned always from above, downward moving towards to the anus, sitz bath and ice pack are given for the women with episiotomy. The postnatal mother has to take calories, proteins and calcium.
Family welfare department, (2005) recommended that postnatal mother has to do perineal wash after elimination wash in antero posterior direction from the vulva to the anus, changing the perineal pads every 4 – 6 hours, in case of clothes, it has to be washed with plenty of soap and water dry them in sunlight and daily bath.
The women have to wipe from front to back and to change the perineal pads frequently. Good hand washing techniques are emphasized. Adequate fluid intake and diet are important14 (Mckinney at al.).
Swab downs of the perineum are necessary for every 4 – 6 hours when the women has an episiotomy or until she is ambulant and showering, vulval pads if used, should be changed when soiled, after vulval toilet and bathing Gentle exercises commence 24 hours after delivery. These exercises should be repeated five times a day, but it is important to avoid excessive exercise when muscles are still recovering from the process of birth recommended that use of (0.6%) chlorhexedine, vaginal wipes for prevention of infection is well tolerated and seems safe.
Initial treatment should be directed toward opening and cleaning the wound and providing warm sitz bath helps to promote the circulation and wound healing9 (Decherney, Alan .H and Nathan .L, 2003).
Sitz bath (or) hipbath is used to relieve discomfort, especially after perineal (or) rectal surgery (or) childbirth. The bath promotes wound healing by cleaning the perineum and anus increasing circulation and reducing inflammation.