RAJIVE GANDHIUNIVERSITY OF HEALTH SCIENCES BENGALURU

KARNATAKA

SYNOPSIS PERFOMA FOR REGISTRATION OF

SUBJECT FOR DISSERTATION

Mrs. Rosebi Joseph

First Year Msc Nursing

Obstetrical and Gynecological Nursing

Year 2010-2011

BRITE COLLEGE OF NURSING ,BENGALURU

RAGIVE GANGHIUNIVERSITY OF HEALTH SCIENCE

BENGALURU,KARNATAKA

PERFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. / NAME AND ADDRESS OF
CANDIDATE / Mrs.ROSEBI JOSEPH
I YEAR M.SC NURSING
BRITE COLLEGE OFNURSING
SY.NO:69,B W S S B COLONY
CHIKKAGOLLARAHATTY
BENGALURU-91
2. / NAME AND ADDRESS OF THE
COLLEGE / BRITE COLLEGE OF NURSING
SY.NO:69,B W S S B COLONY
CHIKKAGOLLARAHATTY
BENGALURU-91
3. / COURSE AND STUDY AND SUBJECT / FIRST YEAR M.SC NURSING
OBSTETRICS AND GYNAECOLOGICAL NURSING.
4. / DATE OF ADMISSION / 01.10.2010
5. / TITLE OF THE TOPIC / A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME REGARDING NEONATAL JAUNDICE AMONG PRIMIGRAVIDA MOTHERS IN A SELECTED HOSPITAL AT BENGALURU

6.BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“Health should mean a lot more than escape from death,or for

that matter escape from disease”

-K.PARK

Pregnancy and child birth are special event in women’s lives,and indeed in the lives of their families1. Proper care of the newborn babies forms the foundation for the subsequent life not only in terms of qualitative outcome without any medical and physical disabilities newborn is an important link in the chain of events from conception to adulthood.2

Newborn undergo many profound physiological changes at birth. Because they have been released from a warm,darkened liquid filled environment,which has met all of their needs,into chills gravity by based,outside world.3

Neonatal mortality rate can be defined as neonatal deaths of infants weighing above 1000gm during first 28 days after birth per 1000 live birth. Current neonatal mortality rate in India is 43.4 per 1000 live births. Almost 50% of neonatal deaths occur within first one week of life and majourity of within the first 24 hours of life4.

Neonatal jaundice is the yellowing of skin and other tissues of a newborn infant. A bilirubin level of more than 85 umol/l (5mg/dl) manifests clinical jaundice in neonates whereas in adults a level of 34 umol/l (2mg/dl) would look icteric. In newborns,jaundice is detected by blanching the skin with digital pressure or that it reveals underlying skin and subcutaneous tissue. Jaundice newborns have an apparent icteric sclera,and yellowing of the face,extendind down onto the chest.this condition is common in upwords of 70% of newborns.

NEED FOR THE STUDY

Currently infant mortality rate at national level is 67.6% per 1000 live births where as neonatal mortality rate is 43.4 per 1000 live births. The most important cause of neonatal death in the community is due to neonatal infections.5

Neonatal jaundice is a disorder that affects nearly 50% of all newborns to at least a small degree. The yellow coloration of the skin and sclera of the eyes is due to the accumulation of bilirubin in adipose tissue and its adherence to collagen fibers. In neonatal jaundice, the excess bilirubin is not due to an abnormal level of red blood cell destruction. It is due to the inability of the young liver cells to conjugate bilirubin, or make it soluble in bile, so that it can be excreted and removed from the body by the digestive tract. This inability is corrected, usually within one week, as the liver cells synthesize the conjugation enzymes. If uncorrected, sufficiently high bilirubin concentrations can cause brain damage. Frequent feedings of a newborn with jaundice increase gastrointestinal tract motility and decrease the likelihood of reabsorbing significant amounts of bilirubin in the small intestine. Radiation from sunlight alters the chemical form of bilirubin, making is easier for the liver to excrete.

Despite recent attention to newborn health much remains to be done to achieve sustained high courage of effective interventions,especially in poor communities where most newborn all born and die in the first week of life. Primigravidae may be due to early marriage,which is culturally,and religiously acceptable in some areas they may have poor knowledge regarding neonatal jaundice. The other further which may lead to poor knowledge,are low socio economic status,low education and career aspiration residence in a single parent home and poor family relationship. Mothers are having low knowledge,on neonatal care which impacts the care given to their newborn.6

Here the investigator felt the need of provision of information and adequate knowledge regarding the neonatal jaundice which will help to improve the knowledge of mother to adopt and maintain healthy practice thereby reducing the neonatal mortality and morbidity.

Hence the investigator is interested to assess the effectiveness of structured teaching programme regarding neonatal jaundice among primigravida mothers.

.REVIEW OF LITERATURE

Review of literature is a systematic identification,local or scruting and summary of written materials that contain information on research problem.

This chapter deals with the literatures related to knowledge of primigravida mothers regarding neonatal jaundice and the effectiveness of structured teaching programme. In present study,review of literature will Fall on:

1.Review of literature related to neonatal jaundice.

2.Review of literature related to the study.

Review of literature related to neonatal jaundice:

Neonatal jaundice is the yellowing of the skin and other tissues of a newborn infant. A bilirubin level of more than 85umol/l (5mg/dL) manifests clinical jaundice in neonates whereas in adults a level of 34umol/l (2mg/dL) would look icteric. In newborns jaundice is detected by blanching the skin with digital pressure so that it reveals underlying skin and subcutaneous tissue. Jaundice newborns have an apparent icteric sclera, and yellowing of the face, extending down onto the chest. This condition is common in upwards of 70% of newborns.

In neonates the dermal icterus is first noted in the face and as the bilirubin level rises proceeds caudal to the trunk and then to the extremities.7

Notoriously inaccurate rules of thumb have been applied to the physical exam of the jaundiced infant. Some include estimation of serum bilirubin based on appearance. One such rule of thumb includes infants whose jaundice is restricted to the face and part of the trunk above the umblicus, have the bilirubin less than 204umol/l (12mg/dL) (less dangerous level). Infants whose palms and soles are yellow, have serum bilirubin level over 255umol/l (15mg/dL) (more serious level).

Studies have shown that trained examiners assessment of levels of jaundice show moderate agreement with icterometer bilirubin measurements.8

Neonatal jaundice is caused by a buildup of bilirubin in the baby's blood. Sometimes, for a variety of reasons, the infant's liver isn't able to process bilirubin, resulting in jaundice, according to MedlinePlus. Infant jaundice often doesn't require treatment, beyond frequent feedings. If the problem persists, the next steps phototherapy, according to MedlinePlus.In phototherapy, the infant is treated with special lights. The baby's body absorbs the light, helping break down and eliminate the bilirubin. In severe cases, an exchange transfusion (the baby's blood is replaced with fresh blood) or intravenous immunoglobulin may be required. Phototherapy replaced phenobarbital as a treatment for jaundice more than 50 years ago.17

Jaundice tends to develop because of two factors - the breakdown of fetal haemoglobin as it is replaced with adult haemoglobin and the relatively immature hepatic metabolic pathways which are unable to conjugate and so excrete bilirubin as quickly as an adult. This causes an accumulation of bilirubin in the blood (hyperbilirubinemia), leading to the symptoms of jaundice.

If the neonatal jaundice does not clear up with simple phototherapy, other causes such as biliary atresia, PFIC, bile duct paucity, Alagille's syndrome, alpha 1 and other pediatric liver diseases should be considered. The evaluation for these will include blood work and a variety of diagnostic tests. Prolonged neonatal jaundice is serious and should be followed up promptly.

Severe neonatal jaundice may indicate the presence of other conditions contributing to the elevated bilirubin levels, of which there are a large variety of possibilities.These should be detected or excluded as part of the differential diagnosis to prevent the development of complications.

Breastfeeding jaundice" or "lack of breastfeeding jaundice," is caused by insufficient breast milk intake,9 resulting in inadequate quantities of bowel movements to remove bilirubin from the body. This can usually be ameliorated by frequent breastfeeding sessions of sufficient duration to stimulate adequate milk production. Passage of the baby through the vagina during birth helps stimulate milk production in the mother's body, so infants born by caesarean section are at higher risk for this condition.

Whereas breast feeding jaundice is a mechanical problem, breast milk jaundice is more of a biochemical problem. The term applies to jaundice in a newborn baby on.
  • First, at birth, the gut is sterile, and normal gut flora takes time to establish. The bacteria in the adult gut convert conjugated bilirubin to stercobilinogen which is then oxidized to stercobilin and excreted in the stool. In the absence of sufficient bacteria, the bilirubin is de-conjugated by brush border β-glucuronidase and reabsorbed. This process of re-absorption is called enterohepatic circulation.
  • Second, the breast-milk of some women contains a metabolite of progesterone called 3-aipha-20 beta pregnanediol. This substance inhibits the action of the enzyme uridine diphosphoglucuronic acid (UDPGA) glucuronyl transferase responsible for conjugation and subsequent excretion of bilirubin. In the newborn liver, activity of glucuronyl transferase is only at 0.1-1% of adult levels, so conjugation of bilirubin is already reduced. Further inhibition of bilirubin conjugation leads to increased levels of bilirubin in the blood
  • Third, an enzyme in breast milk called lipoprotein lipase produces increased concentration of nonesterified free fatty acids that inhibit hepatic glucuronyl transferase, which again leads to decreased conjugation and subsequent excretion of bilirubin

Despite the advantages of breast feeding, there is a strong association of breast feeding with neonatal hyperbilirubinemia and thus risk of kernicterus, though this is uncommon. Serum bilirubin levels may reach as high as 30mg/dL. Jaundice should be managed either with phototherapy or with exchange blood transfusion as is needed. Breast feeds however need not be discontinued. The child should be kept well hydrated and extra feeds given.

Infants with neonatal jaundice are treated with colored light called phototherapy. Physicians randomly assigned 66 infants 35 weeks of gestation to receive phototherapy. After 15±5 the levels of bilirubin, a yellowish bile pigment that in excessive amounts causes jaundice, were decreased down to 0.27±0.25mg/dl/h in the blue light. This suggests that blue light therapy helps reduce high bilirubin levels that cause neonatal jaundice.11

Phototherapy works through a process of isomerization that changes trans-bilirubin into the water-soluble cis-bilirubin isomer.12,13In phototherapy, blue light is typically used because it is more effective at breaking down bilirubin (Amato, Inaebnit, 1991). Two matched groups of newborn infants with jaundice were exposed to intensive green or blue light phototherapy. The efficiency of the treatment was measured by the rate of decline of serum bilirubin, which in excessive amounts causes jaundice, concentration after 6, 12 and 24 hours of light exposure. A more rapid response was obtained using the blue lamps than the green lamps. However, a shorter phototherapy recovery period was noticed in babies exposed to the green lamps.Green light is not commonly used because exposure time must be longer to see dramatic results.

Ultraviolet light therapy may increase the risk of or skin moles, in childhood. While an increased number of moles is related to an increased risk of skin cancer(14,15,16). it is not ultraviolet light that is used for treating neonatal jaundice. Rather, it is simply a specific frequency of blue light that does not carry these risks.

Neonatal jaundice is caused by a buildup of bilirubin in the baby's blood. Sometimes, for a variety of reasons, the infant's liver isn't able to process bilirubin, resulting in jaundice, according to MedlinePlus. Infant jaundice often doesn't require treatment, beyond frequent feedings. If the problem persists, the next step is phototherapy, according to MedlinePlus.In phototherapy, the infant is treated with special lights. The baby's body absorbs the light, helping break down and eliminate the bilirubin. In severe cases, an exchange transfusion (the baby's blood is replaced with fresh blood) or intravenous immunoglobulin may be required. Phototherapy replaced phenobarbital as a treatment for jaundice more than 50 years ago.17

Since the mid-20th century, however, it has been replaced by phototherapy, which treats the baby with light. Since phenobarbital improves liver function, one possible approach is to give it to mothers just before they give birth to help prevent jaundice. However, there's been insufficient research to support such treatment, according to a 2007 Cochran review of the literature.18

Infants with cord bilirubin levels less than 2.0 mg/dL have only a 4 percent chance of developing hyperbilirubinemia and a 1.4 percent chance of needing phototherapy. However, if serum cord bilirubin levels are more than 2.0 mg/dL, the infant has a 25 percent chance of developing subsequent hyperbili-rubinemia Rataj J et al reported that if cord bilirubin was under 1 mg% the jaundice occurred in 2.4% newborns, where as 89% of the infants with cord bilirubin above 2.5 mg% becamejaundiced.19Knudsen A found that if cord bilirubin was below 20 mumol/l, 2.9% became jaundiced as opposed to 85% if cord bilirubin was above 40 mumol/l. Furthermore, 57% of jaundiced in-fants with cord bilirubin above 40 mumol/l required phototherapy, but only 9% if cord bilirubin was 40 mumol/l or lower (p less than 0.003) 20

A serum bilirubin >6mg/dl on the first day of life had 90% sensitivity of predicting a subsequent TSB >17mg/dl between 2nd and 5th day of life. At this critical serum bilirubin value, the negative predictive value was 97.9%. No cases with TSB of <6mg/dl in the first 24 hours required phototherapy treatment value of measuring cord bilirubin concentration in ABO-incompatibility has been investigated by Riesenberg et al who found that all infant with cord bilirubin level s higher than 68mumol/l, developed severe jaundice. The study done by Seidman et al found that the risk of significant hyperbilirubinemia was 1.6% in cases whose bilirubin level was <5 mg/dL at 24 hours of life, whereas that risk was 6.6% in cases whose bilirubin level was 5 mg/dL at 24 hours of life 21.The maternal and umbilical cord bilirubin concentration at delivery, a yellow skin colour on the first post-natal day, an increase in the yellow skin colour during the first 24 h or postnatal life, and carbon monoxide excre-tion are all associated with the later development of neo-natal jaundice in the healthy, mature newborn infant22.

Review of literature related to the study

Based on the AAP(2004) guidelines,23 mothers should:

* Be encouraged to breastfeed.

* Supplementation with formula or water is not recommended.

* Breastfeed 8 to 12 times per day especially for the first few days.

* Seek breastfeeding support as needed.

* Monitor output to gauge successful breastfeeding hydration.

* Keep follow-up appointments with clinician based on infant's risk factors.

* Receive written patient education materials pertaining to jaundice.

* Ask questions.

* Know who and when to call.

* Report increasing jaundice at once.

* Know that a blood test is the best way to determine bilirubin level.

* Be aware that putting their infant in sunlight, inside or outside, is NOT considered a safe and reliable treatment for jaundice.

Historically, neonatal jaundice was monitored in the hospital nursery while mother and newborn recovered for 3 or more days after the birth. During this hospitalization, breastfeeding patterns were established, role transition was supported, and jaundice issues were addressed.

According to Bestable,2008: it is importantthat more be known about the maternal experience with neonatal jaundice in order to inform the development of appropriate postpartum educational strategies. There are numerous studies pertaining to the risk factors, identification, and treatment strategies for hyperbilirubinemia, ABE, and kernicterus;, but little is known about the contemporary American mother's perspective of having an infant with neonatal jaundice; The purpose of this study, therefore, was to fill that gap in the nursing literature by describing the lived and educational experience of mothers having an infant with neonatal jaundice.24

Bhutani et al 2006,George 2005:When mothers receive inappropriate or conflicting infant care advice neonatal outcomes may be adversely impacted. Providing consistent and accurate education is foundational to the role of the nurse. It is essential, therefore, that nurses caring for women and infants learn the evidence about newborn jaundice, adhere to the guidelines from professional organizations such as AAP(2004) and provide their patients with accurate education in both written and verbal formats before discharge as available through organizations such as AAP, Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN,2006 ), CDC, March of Dimes, and PICK if the harmful effects of hyperbilirubinemia and kernicterus are to be avoided. Identification of barriers to such education for parents should be a priority in nursing research.25

Martel 1999:The current practice of discharging mothers and infants 24 to 48 hours following birth, however, results in bilirubin levels peaking at home rather than in the hospital, thus shifting the primary responsibility for early detection and treatment of neonatal jaundice to the postpartum mother. Home phototherapy is now available due to the advent of fiberoptics in the early 1990s; this practice has become feasible, safe, and acceptable for treating infants with hyperbilirubinemia. It is essential that mothers, as the primary caretaker, have a clear understanding of how to recognize neonatal jaundice and how to respond appropriately, since early recognition and prompt treatment decrease the likelihood of development of the potentially permanent sequelae of kernicterus .26

PROBLEM STATEMENT

A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME REGARDING NEONATAL JAUNDICE AMONG PRIMIGRAVIDA MOTHERS IN A SELECTED HOSPITAL AT BANGALORE.

6.3.OBJECTIVES

  • To assess the level of knowledge on neonatal jaundice among primigravida mothers.
  • To determine the level of knowledge of the primigravida mothers on neonatal jaundice after structured teaching programme.
  • To associate the findings based on the demographic variables of the knowledge of the primigravida mothers on neonatal jaundice before and after the structured teaching programme.

6.3.1. HYPOTHESIS