RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA, BANGALORE

ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS
FOR DISSERTATION

1. NAME OF THE CANDIDATE Mrs. ASFIYA ANJUM

AND ADDRESS I YEAR M. Sc NURSING,
E.T.C.M. COLLEGE OF NURSING,
P.O. BOX No. 4, KOLAR-563101,
KARNATAKA

2. NAME OF THE INSTITUTION E.T.C.M. COLLEGE OF NURSING,

P.O. BOX No. 4, KOLAR-563101,
KARNATAKA.

3. COURSE OF STUDY AND M. Sc. NURSING

SUBJECT OBSTETRIC AND GYNEACOLOGY

NURSING

4. DATE OF ADMISSION TO THE 0/1/2018

COURSE

5. TITLE OF THE STUDY

TO ASSESS THE EFFECTIVENESS OF LAMAZE BREATHING
TECHNIQUE ON LABOR OUTCOME AMONG PARTURIENT MOTHERS IN
SELECTED HOSPITALS, KOLAR.
6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

Childbirth is more admirable than conquest, more amazing and courageous, with lots of

excitement, relief, anticipation, uncertainty, anxiety or even fear. It might be relaxed and

chatty or tense and apprehensive too.

Pregnancy is a beautiful and natural phenomenon, nine metamorphic months with lots of

excitement, planning and nervousness at the awesome unravelling of life, With a ravishing

experience. Every woman owns the unique experience. It has tremendously powerful stages

of development that bring a woman to motherhood, a couple, to family and a beautiful child

into the world. Labour process may be viewed as a test of womanhood, a test of personal

competence, a peak of experience, and the first act of motherhood. It starts with the onset of

regular uterine activity associated with effacement and dilatation of the cervix and descent

of the presenting part through the cervix.

Labor is defined as rhythmic contraction and relaxation of the uterine muscles with the

progressive effacement and dilation of the cervix, leading to expulsion of the products of

conception. Each experience is unique and calls for a celebration. The fear and anxiety

about childbirth often prevents most women from enjoying this experience an adequate

knowledge about signs of labor and labor and delivery in general can impart a feeling of

confidence and a sense of emotional well-being, very crucial in ensuring a successful

labor.1

During Labor, the woman experiences some degree of stress and discomfort , as the

system responds to the physical changes that prepare to give birth. The Perception of pain is

highly unique and differs from one individual to another.

There are mainly four stages of labor. The first stage of labor is considered to be first from

the onset of regular uterine contractions to full dilatation of cervix. The second stage of

labor last from full dilatation of cervix to birth of fetus. The third stage of labor lasts from

birth of fetus, until the placenta is delivered. The fourth stage starts from expulsion of

placenta to six weeks of post – natal period. On average, labor starts 12-18 hours in a

woman's first pregnancy and tends to be shorter, averaging 6-8 hours in subsequent

pregnancies.2

First stage of labor has been divided in to three phases a latent phase, active phase and

transitional phase. were latent phase being prior to the active first stage and cervix dilates 0-

3/4 cm, Active Phase undergoes more rapid dilatation from 4cm dilated with rhythmic

contractions and complete cervical dilatation. As contractions get stronger, body releases

endorphins—nature's narcotic—to ease labor pain. Transition phase is where cervix dilates

around 8cm to until expulsive contractions brief lull in intensity of contractions.3

Attempts to minimize the pain of labor is non-pharmacologically first began in 20th

century. Natural child birth was pioneered by Grantly Dick Read in 1932. He suggested

that pain of child birth is brought about by fear and tension and recommended passive

muscle relaxation to reduce the pain.4 A muster of non-pharmacological pain relief

measures, as well as pharmacological interventions, are available to women in labor.

Relaxation, breathing techniques, positioning/movement, massage, hydrotherapy, hot/cold

therapy, music, guided imagery, acupressure, and aromatherapy are some self comfort

measures women may initiate during labor to procure an effective coping level for their

labor experience. Women are encouraged to employ a variety of simple, non-

pharmacologic techniques to reduce or vary labor pain without any possible harmful

effects to the mother or infant.5

Breathing is an automatic response to pain as the mother remains in a relaxed state and

respond more effectively to the pain onset, as contraction increases and make it more

productive and promotes oxygen and strengthen both mother and baby.6

Lamaze breathing is a technique used to help and relax during labor. Dr Ferdinand Lamaze,

a French obstetrician, pioneered the Lamaze breathing technique in the late 1950s,

Although the method was initially pioneered in breathing techniques to reduce labor

pains and the techniques utilize several breathing patterns in order to encourage relaxation.

The breathing patterns include inhaling for five seconds, then breathing out for five

seconds. Another option is the two short breaths, then one deep breath exercise that sounds

like “hee hee hooooo.” The last breath should be released through the mouth. Lamaze

breathing techniques are designed to keep focused on breathing—not on pain experienced

during childbirth, according to Modern Stork. Lamaze is also designed to help to conserve

energy while giving birth—this helps to reduce the level of exhaustion following birth. 6

Hence made the investigator to select this technique for study.

The Lamaze method of prepared childbirth involves class sessions for the mother and

her partner in which they learn about the birth process and the mechanisms of labor,

are taught what to expect and what is expected of them during the birth of their child

and are trained in special exercises that develop neuromuscular control, promote

physical conditioning, and eliminate or reduce the need for drugs and instruments

during delivery. Advocates of the Lamaze method do not claim complete absence of

pain during labor and delivery in every case, but they do feel that the method enriches

the lives of the parents in many ways and provides for them a means of sharing the

birth experience that is denied to them in the other methods of hospital deliveries.
6.1 NEED FOR THE STUDY

According to the latest data from 150 countries, currently 18.6% of all births occur by CS,

ranging from 6% to 27.2% in the least and most developed regions, respectively. Latin

America and the Caribbean region has the highest CS rates (40.5%), followed by Northern

America (32.3%), Oceania (31.1%), Europe (25%), Asia (19.2%) and Africa (7.3%). Based

on the data from 121 countries, the trend analysis showed that between 1990 and 2014, the

global average CS rate increased 12.4% (from 6.7% to 19.1%) with an average annual rate

of increase of 4.4%. The largest absolute increases occurred in Latin America and the

Caribbean (19.4%, from 22.8% to 42.2%), followed by Asia (15.1%, from 4.4% to 19.5%),

Oceania (14.1%, from 18.5% to 32.6%), Europe (13.8%, from 11.2% to 25%), Northern

America (10%, from 22.3% to 32.3%) and Africa (4.5%, from 2.9% to 7.4%). Asia and

Northern America were the regions with the highest and lowest average annual rate of

increase (6.4% and 1.6%, respectively).7

In the last decade or so, the numbers have escalated in many parts of the country reaching

as high as 41% of deliveries in Kerala, and 58% in Tamilnadu says a reports(pdf) by the

ICMR school of public health. And it’s happening across both urban and rural areas.

Mumbai saw an exponential growth in c sections in both private and public hospitals,

while one study (Jan 2007 to Dc 2012) demonstrated a spike from 31% to 51% over just

six years in rural Haryana.8

In India, C-section deliveries sky-rocketed since and the NFHS report states that 23.6% of

all babies in Karnataka are delivered under the knife. In Bengaluru, out of 3,683 deliveries

in 2016, around 2,264 were Caesarean births; that is 61.60 per cent at private hospitals

empanelled under the Central Government Health Scheme (CGHS) as against the national
average of 17.2%, according to the fourth National Family Health Survey (NFHS) report.

The highest is in Chandigarh that records 98.35% C-section deliveries. Till 2010, C-section

deliveries in India was around 8.5%, was well below the 10-15% recommendation of

the World Health Organization set as an indicator of maternal health.9

About a million women give birth using the Lamaze method, according to Lamaze

International, the nonprofit organization that teaches people its Lamaze birthing

philosophy. After the rising popularity of the epidural in the 1980s and the common place

theory that a hospital was the only safe place to give birth, the Lamaze method encouraged

expectant mothers to use the breathing training to learn how to cope with the labor pains

without drugs and to give birth at home or in birthing centers with a birthing partner and/or

midwife. This idea challenged the conventional wisdom of using any medical intervention

necessary to deliver the baby so that the mother experienced as little physical pain as

possible.10

Conscious breathing works best in combination with many other comfort strategies. In

Lamaze classes, women no longer spend large amounts of time practicing breathing.

Women move, change position, slow dance, sway on birth balls, learn massage, and

identify the countless other ways they normally relax and find comfort. Each of these

comfort strategies can be used in combination with breathing. In restrictive environments,

breathing may be one of very few comfort strategies available for women in labor. It is one

coping strategy that cannot be taken away.

Lamaze breathing technique refers to the act of breathing at any number of possible rates

and depths. Some women prefer breathing deeply, using their diaphragm to fill their

abdomen with air. Other women prefer light breathing, inhaling just enough to fill their chest.

The goal is to find breathing patterns that have a calming and relaxing effect,breathing
should be at a comfortable rate and should not lead to short of breath or light-headed.

Benefits of practicing Lamaze breathing are

a. Breathing becomes an automatic response to pain,

b. The mother remains in a more relaxed state and will respond more positively to the onset

of pain,

c. The steady rhythm of breathing is calming during labor,

d. Provides a sense of well-being and control,

e. Increased oxygen provides more strength and energy for both the mother and baby,

f. Brings purpose to each contraction, making contractions more productive and

g. Patterned breathing and relaxation can become techniques for dealing with life’s every

day stressors.11

A study conducted on Lamaze practices reveals that the study group was more satisfied with

their labor (p<0.05) process with decrease in the length of delivery.12

When a labour is straightforward, it gets into an automatic mode. It ends in a normal

vaginal birth, where the mother pushes and births her own baby with minimal medical

interference. Lamaze breathing today, unlike 50 years ago, is one of many ways that

women now have to manage contractions, to facilitate the physiologic process of labor, and

to give birth with confidence. Hence the investigator felt the need for Lamaze breathing

technique during the first stage of labor.

6.2 REVIEW OF LITERATURE: -

The review of literature is an extensive, systematic selection of potential sources of previous

work, which acquaints the investigator with fact finding work after scrutinization.13

Review of literature for the present study has been divided into the following headings:

1. Reviews related to effectiveness of Lamaze breathing technique on labor

 outcome.

2. Reviews related to non-pharmacological measures on labor outcome.

Review related to studies on effectiveness of Lamaze Breathing technique:

A study was conducted in England to investigate the effect of psycho prophylaxis

(Lamaze preparation) on labor and delivery among 129 primiparas who had completed

ante-partum Lamaze-training with an equal number of matched controls who had not. The

former was given narcotics less frequently during labor (P 0.001), received conduction

anesthesia less often (P less than 0.001), and had a higher frequency of spontaneous

vaginal deliveries (P less than 0.001) than the control patients which suggest that Lamaze

method had a positive effect on child birth experiences.14

A Quantitative research “study was conducted to assess the effectiveness of Lamaze

breathing exercise on labor pain among primi gravida mothers. The study was conducted at

labour ward, Mahatma Gandhi Medical college and hospital, Puducherry. Simple random

sampling technique (Lottery method) was used to select the samples. Sixty samples were

selected for the study (30 samples each in Experimental and Control group). A Pre-test was

carried out to assess the level of pain during labour using Visual Analogue Scale in both

the groups. In Experimental group Lamaze breathing exercise was administered and

Control group there was no intervention. The study result shows that in experimental group

Pre-test 1 mean value 4.67 , Post-test 1 mean value 4.07 and control group Pre-test 1 mean

value 5.10, Post-test 1 mean value 7.23.In comparing Pre-test 2 and post-test 2 in both

groups. In Pre-test2 mean value 5.90, Post-test2 mean value 4.47 and Control group Pre-

test 2 mean value 8.87 and post-test 2 mean value 9.33. In experimental group at ‘P’ value

0.9341 and control group at ‘P’ value 0.0000. Comparison between Pre-test2 and Post-test

2 of both groups. In experimental group at ‘P’ value 0.0000 and control group at ‘P’ value
0.0015 and the study reveals that there was a significant reduction in level of pain during

labour by using lamaze breathing exercise.15

The study was aimed to determine the effectiveness of Lamaze method on mode of labour

among primigravid women in experimental group& to compare the mode of labour

between experimental &control group mothers. A research design adopted for this study

was True experimental design 67% experimental group mothers had normal delivery &

Mothers those who are in control group (25 %)were delivered normally, The total

Proportion (%) of normal delivery in the Control group=3/12=25% & the Proportion (%)

of normal delivery in the Experimental group=8/12=67%.The test of significance

(difference in proportions) showed the difference was statistically significant (z=2.05;

P<0.05) and hence it is concluded that there was a strong evidence of a difference in the

mode of delivery.16

An experimental research was conducted to assess the effectiveness of Lamaze breathing

on labor pain and anxiety towards labor outcome among primigravida mothers during first

stage of labor. 20 women were selected in control group and 20 were in experimental

group selected by purposive sampling technique, & data were collected. Pain perception in

women of control group was assessed by visual analogue pain perception scale, and in

experimental group, the women were instructed to perform Lamaze breathing technique by

using observational rating scale and after that their pain perception were assessed by the

same visual analogue pain perception scale., and Evaluation of data related to effectiveness

of breathing exercises on labor outcome during labor was done by paired ‘t’-test. The mean

in experimental group was 4.55 and in control group was 7.55 with a standard deviation of

1.234 and 0.944 respectively. The mean % of experimental group is 45.5 and in control
group it is 75.5. The paired t test – value was 3.96 which are highly significant at P< 0.001.

As the result shows, that after receiving the Lamaze breathing exercises, the labor outcome

during first stage of labor was good. 17

An experimental research was conducted to assess the effectiveness of Lamaze breathing

techniques on labor pain and anxiety. Women taken in control group were assessed for

their labor pain, and women in experimental group were instructed to perform Lamaze

breathing exercises during pains and their level of pain & anxiety were assessed and then

compared with women of control group. Methods and Material: The tools used were-

Demographic variables, clinical variables, a visual analogue pain perception scale, and an

observational rating scale for performing Lamaze breathing. Statistical Analysis Used: The

findings were analyzed using ‘t’ test, chi square test, and Karl Pearson formula.

Comparison of level of pain perception between control and experimental group on the

basis of paired ‘t’ test shows that the level of pain perception in control group is higher

than the experimental group. The mean of control group is 7.55 and of experimental group

are 4.55. Mean percent is 75.5% and 45.5% of control and experimental group

respectively. And, SD of control group is 0.945 and of experimental group, it is 1.234. The

‘t’ value is 3.96 and P value is P<0.001 which is highly significant. Result shows, that after

receiving the Lamaze breathing exercises, the labor outcome during first stage of labor was

good and Practice of breathing exercises shortens the duration of labor, and prevents the

complications during labor.18

A study was conducted to determine whether Lamaze childbirth preparation is harmless,

harmful, or beneficial, 500 consecutive Lamaze-prepared patients were compared to 500

hand-picked controls, matched for age, race, parity, and educational level. Lamaze
preparation was found to have a significant beneficial effect in almost every obstetric

performance category. The Lamaze-oriented patients had one-fourth the numbers of

cesarean sections and one-fifth the amount of fetal distress (P less than .005). Postpartum

infection, measured both by maternal febrile morbidity and by the incidence of antibiotic

use, was one-third that of the controls (P less than .005). Similarly, the "prepared" patients

had fewer perineal lacerations and those that occurred were not as serious as those in the

control patients (P less than .005). The control patients had three times as many cases of

toxemia of pregnancy (P less than .005) and twice as many of prematurity (P<0.05).19

Studies related to non-pharmacological method used in labour.

A retrospective observational study was carried out on pain intensity and need for

analgesics with water births and land births with an objective to investigate the intensity of

labour pain experienced and the need for analgesics differs between water and bed births

among 12103 spontaneous singleton births in cephalic presentation of these, 4768 were

water births, 5141 bed births, 1429 Maya stool births and 765 used other birthing methods.

Results revealed that during the different birthing stages, all birthing methods showed an

almost identical intensity of pain, as measured with the visual analogue scale (VAS 0-100)

early dilation phase (VAS 38-54), late dilation and expulsion phase (VAS 70-77) when

looking back during the puerperal period, first time mothers who chose a water birth

remembered the birthing experience as being significantly less painful, than did their bed

birthing sisters (water birth VAS 68.98, bed birth VAS 72.43 and the need for analgesics

was significantly lower among water births and concluded water births remembered the

birthing experience as being less painful than bed birthers.20

 A quasi-experimental study was conducted to assess the effectiveness of circular hip

massage on first stage of labor pain among primi gravida mothers at chrompet govrnment

general hospital. A sample of 60 primigravida mothers with labour pain was selected by

using Non- probability purposive sampling technique. The findings showed that regarding

experimental group 22 (73.3%) are annoying pain and 8 (26.7%) are uncomfortable pain.

None of the mothers are dreadful pain, horrible pain and agonizing pain. Considering the

control group 7 (23.3%) are dreadful pain and 23 (76.7%) are horrible pain. None of the

mothers are agonizing pain. It was concluded that Circular Hip Massage to the

Primigravida Mothers was effective to cope up the level of labor pain. 21

A randomized and quasi-randomized trial review was conducted to determine the effect of

encouraging women to assume different upright positions (including walking, sitting,

standing and kneeling) versus recumbent positions (supine, semi-recumbent and lateral) in

the first stage of labor on 3706 women. Result of this review revealed that the first stage of

labour was approximately one hour shorter for women randomized to upright as opposed

to recumbent positions (MD -0.99, 95% CI -1.60 to -0.39). Women randomized to upright

positions were less likely to have epidural analgesia (RR 0.83 95% CI 0.72 to 0.96).

Walking and upright positions in the first stage of labor reduce the length of labour and do

not have any negative effects on mothers and babies’ wellbeing.22

6.3 STAEMENT OF THE PROBLEM

A study to assess the effectiveness of Lamaze breathing technique on labor

outcome among parturient mothers in selected Hospitals, kolar.

 6.4 OBJECTIVES OF THE STUDY

1. To assess the labor outcome among parturient mothers in group A (Lamaze breathing

with hospital routine measures) Group B (hospital routine measures)

2. To evaluate the effectiveness of group A versus group B on labor outcome among

parturient mothers

3.To determine association between the selected demographic variables with labor,

outcome among parturient mothers in group A and group B.

6.5 OPERATIONAL DEFINITIONS

1. Effectiveness It refers to outcome of Lamaze breathing technique with Hospital

routine measures versus hospital routine measures during first stage of labor, by

using Modified WHO partograph (Maternal outcome) to assess the cervical

dilatation, rupture of membrane, intensity of uterine contraction, duration of labor.

APGAR score in 1 minute and 5 minutes (neonatal outcome) and admission to

NICU.

2. Lamaze breathing: Group A parturient mothers will be encouraged to take two

short breaths, then one deep breath exercise that sounds like “hee hee hooooo.” The

last breath should be released through the mouth, which will be practiced for 20

minutes with the period of 10 minutes rest in left lateral position and the same will

be practiced till full cervical dilatation which will be assessed using Lamaze

breathing chart prepared by the investigator.

3. Parturient mothers: it refers to the primi gravida women, who are in first stage of

labor, admitted in the selected hospitals and undergoing labor process after

completion of 38 gestational weeks.

4. Labor outcome: it refers to both maternal and neonatal outcome

1.Maternal outcome-duration of labor, rate of cervical dilatation, intensity of

 uterine contraction, rupture of membrane, mode of delivery which will be assessed

using modified WHO partograph.

2. Neonatal outcome- APGAR score (at 1 minute and 5 minutes) and admission to

neonatal NICU which will be retrieved from neonatal record.

5. Selected hospitals: ETCM hospital kolar, Hope health care,kolar

6.6 ASSUMPTIONS

1.All parturient mothers are in need of midwifery care during labor

2.Lamaze breathing technique may have a significant influence on labor outcome,

neonatal outcome.

6.7 HYPOTHESIS

NH1: There will be no significant difference in labor, neonatal outcome among group

A and group B at the rate of P<0.05

NH2: There will be no significant association of selected demographic variable with

labor, neonatal outcome in group A and group B at the rate of P<0.05.

6.8 DELIMITATIONS

The study will be delimited to a period of four weeks.

6.9 VARIABLES

Dependent Variable : Labour outcome

Independent Variable : Lamaze Breathing technique

Attribute variable
 Socio demographic data includes age, education status, work pattern, religion,

residential area, type of family, food pattern, habit of doing regular exercise,

medical induction of labor, BMI of the mother, gestational age of the mother,

weight of the baby

7. MATERIAL AND METHODS

7.1 Sources of data

The Data will be collected from mothers who are in first stage of labor with the

completion of 38 weeks of gestation who are admitted in selected hospitals of Kolar.

7.1.1 Research design

Posttest only design is selected for the study.

7.1.2 Setting

This study will be conducted in the labor room of selected hospitals, Kolar.

7.1.3 Population

The population will be primigravida mothers in first stage of labor with 38 weeks

of gestation in selected Hospitals, kolar .

7.2 Method of data collection

7.2.1 Sampling procedure

Simple random sampling technique- Lottery method 2-4 parturient mothers per day

Mother who will take No 1 will be assigned to group A, No.2 to group B

7.2.2 Sample size

The sample for the present study would comprise 60

30 in group A (Lamaze breathing with Hospital routine measures), 30 in group B (hospital

routine measures)

7.2.3 Inclusion criteria

1.Parturient (primi gravida) mothers in first stage of labor (3-4 cm dilatation) who

have completed 38 weeks of gestation available on the time of data collection.

2. Parturient (primi gravida) mothers in first stage of labor (3-4 cm dilatation) who
 have completed 38 weeks of gestation available on the time of data collection.

3.Mother who is willing to sign the written informed consent and participate in the

study.

7.2.4 Exclusion criteria

1.Multi gravida mothers

2.Mother who is not willing to participate

3.Mothers with previous history of cesarean section

4.Mothers with high risk pregnancy.

7.2.5 Instruments intended to be used

Instruments intended to be used in this study is

 Part I: Socio demographic data includes age, education status, work pattern,

religion, residential area, type of family, food pattern, habit of doing regular

exercise, medical induction of labor, BMI of the mother, gestational age of the

mother, weight of the baby

 Part II: Modified WHO partograph (Maternal outcome) to assess the cervical

dilatation, rupture of membrane, intensity of uterine contraction, duration of

labor.

 Part III: Lamaze breathing chart prepared by investigator.

 Part IV: APGAR score of 1 minute and 5 minutes (neonatal outcome) and

admission to NICU which will be taken from neonatal record.

7.2.6 Data collection methods

 Ethical clearance will be obtained from concerned authority.

 Permission will be taken from the authority of the hospital to conduct

 study

 Selection of samples according to planned sampling technique and

inclusion criteria

 Informed Written consent will be taken from the selected parturient

mothers.

 Lamaze breathing technique will be demonstrated by the investigator to

the group A parturient mothers.

 Investigator will encourage the parturient mother to practice Lamaze

breathing for 20 minutes with the period of 10 minutes rest in left lateral

position and continue this till full cervical dilatation along with the other

Hospital routine measures (Ambulation, semi fowlers position, hot

application, massage).

 Hospital routine measures (Ambulation, semi fowlers position, hot

application, massage) will be administered to the group B parturient

mothers.

 Maternal and neonatal outcome will be measured using the

mentioned instruments.

7.2.7 Data analysis plan

Data would be analyzed using the descriptive and inferential statistics

Descriptive statistics

Frequency and % distribution to assess labor outcome and demographic variables.

Mean S.D to analyze the labor outcome in group A and group B.

 Inferential statistics

1. Independent ‘t’ test will be used to assess the effectiveness of group A versus group
B on duration of labor, intensity of uterine contraction.

2. chi square test/ fishers exact score test will be used to assess the effectiveness of

group A versus group B on the rate of cervical dilatation, rupture of membrane,

APGAR score and admission to NICU.

3. one-way ANOVA and chi-square/fishers exact test will be used to associate the

posttest labor out come with demographic variable.

7.3 Does the study require any investigation or intervention to be conducted on

patients or other humans or animals?

yes, the study requires investigation or intervention to be conducted on patients.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Yes. Ethical clearance was obtained from concerned authority.

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Journal de gynécologie, obstétrique et biologie de la reproduction; Tunisia: 2010;39(5):656-

62(2010Oct3) (cited 2010Nov17). http://www.ncbi.nlm.nih.gov/pubmed/20692774.

9. SIGNATURE OF THE
CANDIDATE

10. REMARKS OF THE The research topic selected is relevant and

feasible for the study.
GUIDE
Mrs. T. BEAULAH MERCY MARY
11. NAME AND DESIGNATION Assistant Professor
Department of OBG Nursing
11.1 GUIDE E.T.C.M College of Nursing
KOLAR-563 101

11.2 SIGNATURE OF THE

GUIDE

11.3 CO-GUIDE

11.4 SIGNATURE OF THE

CO-GUIDE
Mrs. T. BEAULAH MERCY MARY
11.5 HEAD OF THE E.T.C.M College of Nursing
KOLAR-563 101
DEPARTMENT

11.6 SIGNATURE OF THE

HOD

12. 12.1 REMARKS OF THE The topic was discussed with the member of
PRINCIPAL research committee and was finalized. She is
permitted to conduct the study

12.2 SIGNATURE