RESEARCH PROPOSAL

1. STATEMENT OF THE PROBLEM

A STUDY TO THE ASSESS THE EFFECTIVENESS OF KEGEL EXERCISE

AND PRONE POSITION ON AFTER PAINS AND INVOLUTION OF UTERUS
AMONG POSTNATAL MOTHERS AT ERODE GOVERNMENT HOSPITAL.

INTRODUCTION

“ God could not be everywhere and therefore he made mothers”

Childbirth is one of the most important events in a woman’s life. The wonder of
motherhood is the enjoyable journey that is felt only by the mother after giving birth of
rebirth by giving birth to a child. A mother, even though she is born earlier in this world,
perceives an experience. It brings about remarkable changes in her normal life and
introduces an exposure to a new role within her.
Childbirth includes different stages, and in every stage, the mother plays a unique
role in experiencing the important events that occur throughout her journey. The different
stages are broadly classified into three main aspects, namely, antenatal period, intranatal
period, and postnatal period. Postnatal period is the most vulnerable period for the mother
and the newborn baby. Many mothers experience physiological, psychological and social
changes during this period. There are many types of postnatal ailments experienced by
the mother such as afterpains, irregular vaginal bleeding, leucorrhoea, cervical ectopy
(erosion), backache, retroversion of the uterus, anaemia, breast problems and episiotomy
discomforts.
The first 6 weeks after the birth of the baby is known as postpartum period or
puerperium. During this time, mothers experience numerous physiological and
psychological changes. Main changes occur for uterus is involution of the uterus and
descent of the fundus. Involution begins immediately after the delivery of the placenta.
During involution uterine muscles contracts firmly around the maternal blood vessels at
the area where the placenta is attached. This contraction controls bleeding from the area
when the placenta is separated.
There are many reasons for the sub involution of the uterus. Sometimes it can be
associated with certain factors such as inadequate breast feeding, lack of maternal care
during pregnancy and puerperium. Other complications of puerperium include early
postpartum haemorrhage, hypovolemic shock, thromboembolism, puerperal infections.
Certain complications may be fatal and would be recognized early and dealt with prompt
care. Maternal mortality and morbidity rates measures the risk of women dying from
puerperal causes.
Eventually, after the birth of the baby placenta separates from the wall of uterus
and expelled. Immediately the uterus contracts tightly to seal off open blood vessels on
uterine wall at placental site. These uterine contractions called after pains. Afterpains
refers to the infrequent, spasmodic pain felt in the lower abdomen after delivery for a
variable period of 2-4 days. These abdominal cramps are caused by postpartum
contractions of the uterus as it shrinks back to its pre-pregnancy size and location.
Presence of blood clots or bits of the afterbirth leads to hypertonic contractions of the
uterus in an attempt to expel them. The uterus loses muscle tone during subsequent
pregnancies due to its contraction-relaxation cycle and causes afterpains, and is vigorous
pain in multiparous woman.
Uterine muscle tone decreases with increase in number of pregnancies and this
may leads to more severe cramping. Breast feeding the baby stimulates the production of
the hormone oxytocin by the pituitary gland. Oxytocin triggers the let-down reflex that
releases milk from the breasts and also causes the uterus to contract even more. This
effect creates additional abdominal discomfort. Cramping will be most intense during 1st
day after the delivery and should tapper off on 3 rd day. Afterpains will be relieved if the
womb remains firmly contracted. When the bladder is full it is unable for the uterus to
contract and it tends to relax, thus prohibiting relief from afterpains.
Labour is one of the major life-events, a woman will experience. Its memory will
remain with her. Any negative impressions may give rise to psychological disturbance
with her and the whole family. There are varieties of non pharmacological methods for
pain relief which are important for postnatal period. They are massage, counter pressure,
hydrotherapy, breathing patterns, heat and cold packs, position changes, relaxation
techniques, music, aromatherapy, birth doulas and acupressure points. Among non
pharmacological methods, position change, abdominal muscle exercise and uterine
massage are more effective.

NEED FOR THE STUDY

The postnatal period is a time of maternal changes that are both

retrogressive(involution of uterus and vagina) and progressive (production of milk for
lactation, restoration of the normal menstrual cycle, and beginning of a parenting
role).Protecting a women’s health as these changes occur is important for preserving her
future childbearing function and for ensuring that she is physically fit to incorporate her
new child into her family. The physical care a woman receives during the postnatal
period can influence her health for rest of her life. Most women experience some degree
of discomfort during the postnatal period. Common causes of discomfort include pain
from uterine contractions (afterpains), perineal lacerations, episiotomy, haemorrhoids,
sore nipples, and breast engorgement.
Most women expect and experience afterpains after the labour process. Intensity
of pain experienced, varies from one woman to another. Afterpains is managed in various
ways according to the following indicators such as frequency, duration and intensity of
uterine contractions, the women’s emotional behaviour, her response to afterpains.
Postnatal health problem needs close attention. It is estimated that approximately about
58% women experience tiredness, 23% perineal problems, 42% backache, 24%
haemorrhoids, 13% bowel problems, 23% sexual problems, 20% vaginal bleeding, 46%
urinary incontinence, and 43.5% women experience after pains.
Association of afterpains with multiparity and breastfeeding is well known.
However, women may experience afterpains regardless of their parity and breast feeding.
Women themselves have described the pain equal to the severity of moderate labour
pains. A survey on childbearing experiences showed that 71% of women finding
difficulty while feeding the baby. The most common reason they gave was cramping pain
during breast feeding. Cramping intensity may vary with parity, in which multipara
mothers are more prone to get severe afterpains than primi mothers.
Afterpains are the abdominal cramps that are caused by postpartum contractions of
the uterus as it shrinks back to its pre-pregnancy size and location. In short, afterpains
signals the process of involution. Immediately after delivery, the uterus begins the
process of involution or reduction in size. A woman can best help her abdominal wall to
return to good tone by using proper body mechanics and posture, getting adequate rest
and by performing exercises. Deep breathing exercises help to feel better physically and
emotionally; alternate leg raising exercises, Kegel exercise and early ambulation will
encourage uterine contractions, helps in restoring the muscle strength and conditions the
abdominal muscles. Exercises to strengthen abdominal and pelvic muscles and finally
hastens the process of involution.
During the investigator’s clinical experience, it was found that a number of
postnatal mothers experienced afterpains, which caused great discomfort, making it
difficult to adapt to their new maternal role. If afterpains are extremely painful or they
persist for over a week, it may be a good idea to nurse to explore possible complications
which might be causing contractions, such as unexpelled tissue which the uterus is trying
to get rid off, So the role of a nurse is to find out an effective way to alleviate pain and
make the postnatal period of the mother indeed the happiest period of her life. The
happiness is screened by the pain of the uterine contractions (afterpains) and thus it
motivated the investigator to undertake an experimental study to portray the effectiveness
of Kegel exercise and prone position on reduction of afterpains and involution of uterus
among postnatal mothers.

STATEMENT OF THE PROBLEM

A study to the assess the effectiveness of kegel exercise and prone position on after
pains and involution of uterus among postnatal mothers at Erode Government
Hospital.

OBJECTIVES

1. To assess the pre-test and post-test scores of afterpains and involution of uterus
among postnatal mothers in experimental and control group.
2. To determine the effectiveness of Kegel exercise and prone position on afterpains
and involution of uterus among postnatal mothers in experimental group
3. To compare the effectiveness of Kegel exercise and prone position on afterpains
and involution of uterus among postnatal mothers in experimental and control
group.
4. To find an association between pre-test level of afterpains and involution of uterus
among postnatal mothers with their selected demographic variables

HYPOTHESES

H1: There will be significant difference between the mean pre-test and post-test scores of
afterpains and involution of uterus among postnatal mothers in experimental group .
H2: There will be significant association between the pre-test level of afterpains and
involution of uterus with selected demographic variables of postnatal mothers.

OPERATION DEFINATIONS

1. Effectiveness: Effectiveness refers to “producing the intended result” (Oxford Senior

Learner’s Dictionary). In this study effectiveness refers to the extent to which Kegel
exercise and prone position have reduced the afterpains and hastened the process of
involution of uterus among postnatal mothers. It is measured by Numerical Pain Rating
Scale and clinical proforma

2. Kegel Exercise: Refers to repeatedly contracting and relaxing the pelvic floor muscles.
It should be done for 3 days and 3 times a day. Postnatal mother should contract and relax
the pelvic floor muscles for 10 seconds. Likewise 10 repetitions should be done each
time.

3. Prone Position: Refers to positioning of postnatal mothers to lie on their abdomen

with a supporting pillow with face turned aside and hands extended. It should be done for
3 days and 3 times a day, by lying in prone position for 3-5 minutes at 30 minutes
interval. Likewise 3 repetitions should be done each time.

4. Afterpains: It is the infrequent, spasmodic pain felt in the lower abdomen after
delivery for a period of 1-3 days due to the contraction of the uterus as it shrinks back to
its pre-pregnancy size and location, and also helps in expelling the placental bits. It is
measured by Numerical Pain Rating Scale.

5. Involution of uterus: It is the return of the uterus to a prepregnant state after delivery.
It is measured with clinical proforma which consist of fundal height, consistency of
uterus and lochia (odour, amount of bleeding and number of pads used).

6. Postnatal mothers: In this study it refers to women who had normal vaginal delivery
within 1-3 days of their postnatal period.

ASSUMPTION

• Post natal Mothers will experience reduce in after-pains after practicing this Kegel
exercise and adopt prone position
• The degree of after pains will vary from mother to mother

DELIMITATION

 The study is limited to mothers who are underwent normal vaginal deliveries
 The study is limited to mothers age between 18 – 35 years.
CONCEPTUAL FRAME WORK

Conceptual frame work is a complex whole of interrelated concepts or abstracts

that are assembled together in some rational scheme by virtue of their relevance to a
common theme . A conceptual model provides for logical thinking for systematic
observation and interpretation of observed data . The model also gives direction for
relevant questions on phenomena and points out solutions to practical problems as well as
serves as a spring board for the generation of hypothesis to be used.
The conceptual framework used for this study is based on General System
Approach. It was developed by Ludwig Von Bertanlanfy (1968) and modified by J.w.
Kenny and is called open system model. The system consists of a set of interacting
components with a boundary that filters the type and rate of exchange with the
environment whole person. The system is defined as “set of components or units
interacting with each other within a boundary that filters both the kind and rate of flow of
inputs and outputs from the system.” The general system theory is concerned with
changes due to interaction between the various factors (variables) in a situation. In human
beings interaction between person and environment changes continuously. The general
system theory provides a way to understand the many influences on the whole person and
the possible input of change of any part of the whole.

Concept
The main concept of general systems theory or input, throughput and output.
• The input refers to any other form of information, energy or material that enters in to the
system through its boundary.
• Throughput refers to the process whereby system transforms, creates and organizes.
• Output refers to energy , information or matter that is transferred to the environment as
a result of the throughput.

Input:
The input in the present study refers to the baseline variables for both experimental
and control group of post natal mothers such as age, educational status, occupation,
income of the family, family support, type of family, variables such vas height, weight ,
pre assessment of afterpains by numerical pain scale and involution of uterus assessed by
clinical proforma ( observe the consistency of uterus and measuring the fundal height and
amount or colour of the lochia.)
Throughput:
Throughput is the use of biological, psychological and socio cultural sub systems
to transform the inputs. Throughput is the process that occurs at some points between
input and output process which enables the input to be transformed in to output such a
way that it can readily used by the system. In this study, throughput refers to pretest level
of after pains and involution of uterus in experimental group among postnatal mothers
and the process of administering kegel exercise and prone position. And assess the post
test level of afterpains and involution of uterus among post natal mothers. Routine care
was given to control group of post natal mothers.

Output:
Output is the return of matter, energy and information to the environment in the
form of both physical and psychological behaviour. In this study , it refers to improve the
involution of uterus and reducing afterpains by administering of kegel exercise and prone
position in experimental group .

Feedback:
According to the theorist, feed back is the information of environmental responses
to the system. Output is utilized by the system in adjustment, to the interaction with the
environment. The effectiveness of kegel exercise and prone position in involution of
uterus and afterpains level is considered as the difference observed and expected.
METHODOLOGY
RESEARCH DESIGN

The term ‘Research Design’ is the structural frame work for study implementation
and it is blue print for the study (Talbolt 1995) Quasi experimental research design was
adopted in this study with an experimental and control group.

Exprimental group: Q 1 X Q2
Control group: Q3 Q4

Q1 : Pre assessment of the afterpains and involution of uterus among post natal mothers in
experimental group.
Q2 : Post assessment of the afterpains and involution of uterus among postnatal mothers
in experimental group.
X: Administration of Kegel exercise and prone position among post natal mothers in
experimental group.
Q3: Pre assessment of the afterpains and involution of uterus among post natal mothers in
control group.
Q4 : Post assessment of the afterpains and involution of uterus among post natal mothers
in control group.

Manipulation
Process to making the subject to do Kegel exercise for 10 seconds for 3 times a
day, 10 repetitions each time for three days among the postnatal mother and also same
post natal mothers made to lie in prone position for 3- 5 minutes for 3 times a day at 30
minutes interval, 3 repetitions each time for three days.

Control group - This group consists of 30 postnatal mothers from day one delivery, and
routine care was provided. Experimental group: This group consist of 30 postnatal
mother from day one delivery. There were selected for experimental group and there
were made to do kegel exercise and prone position.

SETTING OF THE STUDY

The location for conducting the research is referred to as setting (Burns and
Groove 2002) . The research settings are the specific places of research where data
collection is made. The selection of the setting was done on the basis of the feasibility for
conducting the study, availability of the subjects and geographical proximity. Setting for
the present study will the postnatal ward at Erode government hospital, Erode. Though
many hospitals are there in the private sector, people residing in and around Erode prefer
government hospital to meet their health care needs. This is because of economical
reasons as well as availability of health care facilities and infrastructure in this institution.
This was selected because of the investigator’s acquaintance with the setting, easy
accessibility and co-operation of the authorities.

STUDY POPULATION

Postnatal mothers from day one delivery admitted in the postnatal ward at Erode
government hospital.

SAMPLE
 Polit and Hungler (1999) state that a sample consists of the subject of the
population selected to participate in the research study. To fulfill the objective of the
study, the postnatal mothers admitting in the postnatal ward were selected.

SAMPLING TECHNIQUE

Non probability purposive sampling will be used to select the samples.

CRITERIA FOR SAMPLE SELECTION

Inclusion Criteria for sampling

1. Postnatal mothers with singleton gestation that had normal vaginal delivery.
2. Postnatal mothers with singleton gestation that had normal vaginal delivery with or
without episiotomy.
3. Post natal mothers who are willing to participate.
4. Post natal mothers who are able to speak and understand the tamil.
Exclusion criteria for sampling
1. Postnatal mothers with operative deliveries.
2. High risk factors like postpartum haemorrhage, placenta accreta, shock, pulmonary
embolism, uterine rupture, puerperal sepsis and multiple pregnancy.
3. Who are not willing to participate
4. Less than 18 years & more than 35 years.

SAMPLE SIZE

The sample size for the study will comprise of 60 postnatal mothers. Out of which,
30 will be in experimental group and 30 in control group.

DEVELOPMENT AND DESCRIPTION OF THE TOOL

Tool is developed after extensive review of literature from various text book,
journals, internet search and discussion and guidance from the experts in the field of
nursing, Department of obstetrics and gynecology and physiotherapist.

It has two sections 1 &2 as follows:

Section -1
• Part A – Demographic proforma to collect baseline data.
• Part B – Numerical Pain Rating scale to assess level of afterpains.
• Part C – Clinical proforma to assess involution of uterus.
It consist of : -fundal height
-Consistency of uterus
-lochia
–colour and odour of lochia.

Scoring Technique

Pain: To find out the level of pain, numerical rating scale was used and was given score
from 0-10 the following score indicates the level of pain
Pain rating Scale Mark
No pain 0 0
Mild pain 1-3 1
Moderate pain 4-6 2
Severe pain 7-9 3
Worst possible pain 10 4

Involution of uterus : To find out the performance of involution uterus by assessed daily
measuring the fundal height, palpate the consisting of the uterus and observing the lochia
( colour, odur and amount )

SECTION-B
Observation schedule on Measurement of Fundal height postnatal mothers on Involution
of uterus
Instruction:-
The observer measures the Fundal height of postnatal mothers and fill the appropriate
space.

s.no Patient time pretest Post test

D1 D2 D3
cm cm Cm

Scoring:
<11cm = Good involution
12-13 cm = Fair involution 3rd day, 3rd provision
13-14 cm = Slow involution

VALIDITY OF THE TOOL

Data collection tool is an instrument that measures the variables of interest of the
study accurately precisely and sensitively. In the present study Gynecologists, nursing
and medical experts will validate the entire sections of the tool. The experts will request
to check the relevance, sequence an adequacy of the content. Based on their suggestion
the tool will reframed.

RELIABILITY OF THE TOOL

After the pilot study, reliability of the tool will assess by using interrater method.
pretest, and posttest method. Correlation coefficient values pain and involution of uterus
will calculated.
.
Development of protocol for kegel exercise and prone position

Investigator making the subject to do kegel exercise for 30 postnatal mothers for
10 seconds for 3 times day, 10 repetitions each time for 3 days and same 30 postnatal
mothers is made to lie in prone position for 3 to 5 minutes for 3 times a day at 30 minutes
interval, 3 repetitions each time for 3 days. It consist of effectiveness regarding kegel
exercise and prone position on reducing the afterpains and improving the involution of
uterus among postnatal mothers.

ETHICAL CONSIDERATION

The study objectives, intervention and data collection procedure will approve by
the research and ethical committee of the institution. The research proposal will approve
by the experts prior to the pilot study and permission for the main study will obtain from
the Director and Head of the hospital , government hospital , Erode . An informed
consent will obtain from each postnatal women before starting the data collection.
Assurance was given for confidentiality and privacy.

PILOT STUDY
 Pilot study is a trail run for the main study, to test the reliability, practicability and
feasibility of the study. A formal permission will obtain from the Director and Head of
the hospital, Government hospital , Erode. The pilot study will conduct in postnatal ward
of the Government hospital , Erode . 6 postnatal mothers will select for pilot study. Each
three(3) for experimental group and control group. Non probability purposive sampling
technique will use. The tool will feasible to administer and hence no further modification
was done. Find the result.

DATA COLLECTION PROCEDURES:

Formal permission will obtain from the Director and Head of the government
hospital , Erode. The data collection will take for the period of 4weeks. The selected
postnatal mothers will assured that the data collected will be kept confidential. Samples
will selected by using non probability purposive sampling technique. Daily 2 samples in
experimental and in control group will selected for this study. In control group-level of
afterpains and involution of uterus will be assessed every day morning and evening for
3days through numerical pain rating scale and clinical proforma and also routine care will
provid. In experimental group –Pre intervention pain score and involution of uterus will
be assessed among postnatal mothers through numerical pain rating scale and measuring
the fundal height each day morning before giving interventions. Process to making the
subjects to do kegel exercise for 10seconds for 3 times a day , 10 repetitions each time for
three days and also made to lie in prone position for 3-5 minutes for 3times a day at 30
minutes interval , 3repetition each time for three days. The post intervention pain score
and involution of uterus will be assessed by the same tools each day. In control group
routine care provided.

Phase-1: Pre assessment

The investigator will be introduced herself and established rapport by explain the
purpose. Informed consent will obtain and confidentiality willbe maintained. In pre
assessment demographic variables, numerical pain rating scale and clinical proforma will
be used. The researcher spent 90 minutes for each postnatal mothers in administering of
kegel exercises and prone position Thirty post natal mothers were initiated to do kegel
exercise for 10 seconds for 3times a day 10 repetition for each time for three days
postnatal mothers were made to lie on prone position for 3 to 5 minutes for three times a
day at 30 minutes interval, 3 repetition each time for three days. Pre test will be assessed
every day morning before doing kegel exercise and prone position for 3 days.
Phase- II: Post assessment
The investigator will conduct the post assessment of afterpains and involution of
uterus assess by numerical pain rating scale and clinical proforma every day evening after
third provision of kegel exercise and prone position for 3 days. The data analyzed will be
edited , coded and entered in excel sheet. The data will analyze using SPSS version 10. A
probability of less than 0.05 was considered to be significant.

DATA ANALYSIS PLAN

1. Demographic variables in categorical/dichotomous willbe given in frequencies with
their percentages.
2. Afterpains and involution of uterus score will be given in mean and standard deviation.
3. Difference between EXPERIMENTAL and CONTROL will analyse using student
independent t-test .
4. Association between level of afterpains and involution of uterus with demographic
variables are calculated using chi square test.
5. Differences between experiment and control score will be analysed using mean
difference with 95% Confidence interval and proportion with 95% confidence interval.
6. Simple bar diagram, Multiple bar diagram, ,Pie diagram will be used to represent the
data .
7. P<0.05 was considered statistically significant

2. "EFFECTIVENESS OF BREAST MASSAGE ON REDUCTION OF

BREAST ENGORGEMENT AMONG MOTHERS UNDERGONE
CAESAREAN SECTION ADMITTED IN GOVERNMENT HOSPITAL AT
ERODE.”

INTRODUCTION
“Breast milk is a gift that Can only be given by giving oneself”
Breast milk is the perfect food for normal neonate. It is the best gift a mother can
give her baby. It contains all the nutrients for normal growth and development of a baby
from the time of birth to first six months of life. Proper proportion and in a form that is
easily digested and absorbed .Infants need to be given only exclusive breast feeding for
the first six months of life.“If the winter comes can the spring be for behind.”Great poet
says that the spring is followed by winter. That reveals that the joy after suffering. But
labour does not come to end with child birth. The mothers do suffer much difficulty after
childbirth.

Child birth is a process beautifully designed by nature and care following the birth
of the baby also essential for maintenance of health of both mother and child. Child birth
is a transcendent event with meaning far beyond the actual physiological process. The
primiparous mother and the mother with inelastic breast are likely to be involved in
breast complication. The factors like exaggerated normal venous and lymphatic
enlargement of the breasts which precedes lactations in turn prevents escape of milk from
the lacteal system leads to engorgement of breast (Marie, 2009)
A postnatal mother may leave the hospital as soon as she is medically stable,
though the average for spontaneous vaginal delivery (SVD) is 3-4 days, and the average
caesarean section postnatal stay is 6-8 days. The major focus of postpartum care is
ensuring that the mother is healthy and capable of taking care of her newborn, equipped
with all the information she needs about breastfeeding, reproductive health and
contraception, and the imminent life adjustment Post partum is the six weeks interval
between the birth of the newborn and the return of reproductive organs to their normal
nonpregnant state. . (Bobake 2000)

BACKGROUND OF THE STUDY

The rise in circulating prolactin acts upon the alveoli of the breast and stimulate
milk production during the first 3-4 days of puerperium of the breast become heavy and
engorged. The breast is hard, painful and sometime flushed. The areola will typically feel
hard rather than soft, with tight skin that may appear shiny. The nipple may increase in
diameter and become flat and taut, making a latch on challenging. (Kelly mom 2012).
The mammary gland is a milk producing gland which is composed largely of fat.
It is a complex network of branching ducts & sac-like structures called lobules, which
produce milk. Breast tissue fluid drains through the lymphatics into the lymph nodes
located in the auxilla and behind the sternum. Breast engorgement and nipple trauma are
the complications associated with breastfeeding and considered as the most significant
factors impacting on breastfeeding in the first weeks of motherhood. (Lowen 2000)
According to Academy of breastfeeding medicine protocol committee, 2000,
Breast engorgement is defined as "the swelling and distension of the breasts, usually in
the early days of initiation of lactation, caused by vascular dilation as well as the arrival
of the early milk. The common causes of engorged breasts are other feeds given to baby
before starting breastfeeding, delayed starting of breastfeeds, long intervals between
feeds, early removal of the baby from the breast while breast feeding, bottle-feeding and
any other restrictions on breastfeeding.
Adequate management of engorgement is important for successful long-term
lactation. The goal of treatment of breast engorgement is to relieve discomfort and
control swelling. It includes, ice packs, an uplift support bra to minimize edema &
frequent feeding. New breastfeeding mothers have several options for relieving normal
postpartum breast engorgement such as breast massage, application of warmth, cold
compresses, and hand expression or use of a breast pump. (Journal of midwifery and
women’s health 2004)
Breast massage is defined as the technique entails specific kneading, rubbing, and
squeezing strokes applied to the soft tissue of the breast to increase lymph and blood
flow. Before feeding, gentle massage toward the nipple allow some milk to flow out and
help to soften the nipple for easier latch. During nursing, gentle compress and massaging
will stimulate the letdown of milk. It is the easiest and cheapest method. Massage
controls the blood circulation and tissue fluid circulation. For the problem of engorged
breast which results into accumulation of milk in breast causing lumps, breast massage
helps in reducing engorgement. (Rowenabennet 2000).
Breast massage is an easy, readily available and cost effective miraculous method
to reduce the breast engorgement. It does not require elaborate preparation and
instruction. It is an evidence based practice to control breast engorgement in post natal
period.

NEED FOR THE STUDY

The breast is engorged if the mother is unable to feed the baby frequently or
thoroughly enough to drain the breast in the first few days after birth. This is very
important even though only a small amount of milk production right after delivery.
Engorgement can make it difficult for the baby to breast feed effectively. If the breast feel
hard, swollen, throbbing, lumpy, uncomfortably full or painful likely to be engorged. (En
espanol jan 2012)
A descriptive study was conducted to identify the concerns of breastfeeding
mothers during the first 20 weeks postpartum. The study concluded that proportion of
mothers expressing concerns decreased over time, but some concerns such as breast
engorgement & nipple tenderness persisted over the 20 weeks. Engorgement is a well
known but poorly researched aspect. (lowdermilk 2005)
Global incidence of lactational mastitis vary as low as 2% and up to 50%. Mastitis
is an inflammation of the breast that is most commonly caused by milk stasis rather than
infection. Non-infectious mastitis can usually be resolved without the use of antibiotics.
“Without effective removal of milk, non-infectious mastitis was likely to progress to
infectious mastitis, and infectious mastitis to the formation of an abscess.” A recent study
from Glasgow suggests an incidence of 18%. In approximately 3% of those with mastitis
a breast abscess may result in complication. (WHO 2007)
As milk production increases, over-distention of the alveoli causes the
milksecreting cells to become flattened & occlude the capillary blood circulation
surrounding the alveolar cells. Congestion contributes to edema & obstructs lymphatic
drainage of the breasts, stagnating the system that rid the breasts of toxins, bacteria, &
leading to mastitis. In very severe cases can cause numbness or tingling of the hands from
pressure on the nerves. In addition, a protein called the feedback inhibitor of lactation
(FIL) accumulates in the mammary gland during milk stasis. It acts as a major trigger of
apoptosis, that causes involution of the milk-secreting gland,collapse of the alveolar
structures and the cessation of milk production. (Kelly mom 2004)
An interventional study was conducted on treatments for breast engorgement
during lactation in andrapradesh. Total samples in this study were 64. The researcher
concluded that although some interventions may be promising, there is not sufficient
evidence from trials on any intervention to justify widespread implementation and more
research is needed on treatments for this painful and distressing condition.
Global and Indian data exist to show that breast feeding promotes infant survival
and growth, protects the infant against infections; the mother gets some protection from
next pregnancy. However, women’s are having one more advantage from the breast
feeding. Complete breast feeding must prevent the mother from breast complication
includes breast engorgement, inverted nipple etc. (Medline plus 2005)
A survey conducted about breast feeding pattern and breast complication in India.
Around 27% women’s initiate breast feeding within one hour after delivery. More than
half of the women 57% give pre-lacteals to their new born. Study revealed that the early
breast feeding will help to prevent the breast engorgement. Steps taken for the protection
and promotion of breast-feeding from the 1970’s have been effective (surveys done by
National Nutrition Monitoring Bureau 1, 2003).
The theme of the world breastfeeding week (August 1-7), for the year 2010 is
“Mother support, going for the gold.” The theme emphasizes that the mother child dyad
is a single individual unit and appropriate support for the mother during pregnancy and
lactation holds the key for optimal survival, growth and development of the child.
(Pubmed 2010)
A retrospective survey of 34 breast feeding mothers in Ireland. From the data the
following recommendations were suggested for further study. Class preparation for breast
feeding with longer duration nursing. Breast massage & manual expression of colostrums
during breast feeding prevents sore nipples and postpartum breast engorgement. (Whitley
N 2000).
From the above studies and statistical data, it is clear that breast engorgement
occurs in 80 % of post partum mothers and if we ignore, it can develop into mastitis and
breast abscess. So there is a need to conduct this study.
So the investigator felt that this study need to be conducted to assess the
effectiveness of breast massage on reduction of breast engorgement among mothers
undergone caesarean section admitted in hospital. The investigator being a nurse
interested in non pharmacological measures. The expert in the field and many researchers
has given idea about breast massage on reduction of breast engorgement during post natal
days. Therefore the researcher interested in study to evaluate the effectiveness of breast
massage on reduction of breast engorgement among mothers undergone caesarean section
admitted in government hospital , Erode .

STATEMENT OF PROBLEM:

“A Quasi experimental study to assess the effectiveness of breast massage on

reduction of breast engorgement among mothers undergone caesarean section admitted in
government Rajaji hospital , Erode.

OBJECTIVES OF THE STUDY:

1. To assess the pre-test level of breast engorgement among mothers undergone caesarean
section in experimental and control group.
2. To find out the effectiveness of breast engorgement among mothers undergone
caesarean section in experimental group and control group.
3. To compare the pre-test and post- test level of breast engorgement among mothers
undergone caesarean section mothers in experimental group and control group.
4. To associate the post-test level of breast engorgement among mothers undergone
caesarean section in experimental and control group with their selected demographic
variables. (Age, education, occupation, gravida, postnatal day, time when feeding started,
duration of feeding and frequency of breast feeding).

HYPOTHESES:

H1: Mean post -test level of breast engorgement among mothers undergone
caesareansection mothers in experimental group will be significantly lower than the mean
post- test level of breast engorgement among mothers undergone caesarean section lower
segment caesarean mothers in control group
H2: There will be a significant difference between mean pre-test and post- test level of
breast engorgement among mothers undergone caesarean section in experimental and
control group.
H3: There will be a significant association between post -test level of breast engorgement
among mothers undergone caesarean section mothers in experimental and control group
with their selected demographic variables. (age, education, occupation, gravida, post
natal day, time when feeding started, duration of feeding and frequency of breast
feeding).

OPERATIONAL DEFINITIONS
Assess
It refers to the process of making a judgment or forming an opinion.
Effectiveness
It refers to the outcome of breast massage on reduction of breast engorgement among
caesarean mothers who are having breast engorgement, reducing after intervention. This
was assessed by using standard breast engorgement scale.
Breast massage
The term refers to the massaging breast gently prior to feeding by using the finger pads
the kneading and circular motion massage from chest wall towards nipple for 10-15
minutes twice a day for 3 days. Clock wise massage for right side breast and Anti-clock
wise massage for left engorged breast. Next starts rotary movement on the nipple to
promote lymphatic flow and express the breast milk with the use of both hands. Repeat
the breast massage after 2 hours..
Breast Engorgement
Breast engorgement refers to the redness, warmth, firmness, heaviness, tenderness and
swelling in one or both breast.
Reduction
It means minimizing the breast engorgement from the previous stage after giving breast
massage.
Caesarean Mother
Primi, second gravida & multi gravid mothers within the age group of 20 to 35 years,
who undergone caesarean deliveries by incision through the lower abdominal wall and
uterus, for the period of 3–5 post -operative days.

ASSUMPTIONS:
1. Breast engorgement may cause pain, tenderness, discomfort and heaviness to the
mother’s undergone caesarean section.
2. Breast massage may help to reduce the breast engorgement among mothers undergone
caesarean section.
3. Breast engorgement is not given attention it may leads to mastitis & breast abscess
leading to poor feeding of neonate.

DELIMITATIONS:

1. The Study was delimited to the lower segment caesarean section mother with breast
engorgement.
2. The study was delimited to the age group of 20 to 35 years.
3. The study was delimited to those who are willing to participate.

4. The Study was delimited to 4 weeks period of time.

5. The study was delimited to 60 lower segment caesarean section mothers.

CONCEPTUAL FRAMEWORK

Conceptual framework provides an understanding of the phenomenon of interest,

philosophical views and reflects assumption. Conceptual framework used for this study is
based on helping art of clinical nursing theory. Helping art theory was proposed in the
year 1964 by Weidenbach. The theory vision of nursing practice closely parallels the
assessment, implementation, and evaluation of the nursing process. It consists of three
components such as identification, ministration and validation. Identification refers to
viewing the patient as an individual with unique experiences, and understanding the
patient’s perception of the condition. Ministration refers to provision of help by providing
nursing care and validation refers to a collection of evidence that shows the patient’s need
fulfilled and that, the functional ability has been restored as a direct result of the nurse’s
actions. This theoretical framework is used in the present study to evaluate the effect of
breast massage on the level of breast engorgement among caesarean section mothers.
The components of helping art theory include:
1. Identification
2. Ministration
3. Validation

1. Identification
 Identification begins with establishing a therapeutic relationship with mothers. In
this phase, the researcher identifies mothers who undergone caesarean from medical
records and collects the necessary demographic data. After collecting the baseline
information, breast engorgement is assessed using Standardized breast engorgement
scale.

2. Ministration
Ministration phase includes preparation of articles, preparation of mothers and
administration of breast massage for 10 to 15 minutes in each breast twice a day for three
days with the interval of 2 hours in experimental group. No intervention was given to
control group. Assessment breast engorgement using standardized breast engorgement
scale was done for mothers in both experimental group and control group.

3. Validation
In this phase, the researcher assess level of breast engorgement by standardized
breast engorgement scale after breast massage and evaluates the effect of breast massage
in experimental group and evaluation without breast massage in the control group.
RESEARCH METHODOLOGY

RESEARCH DESIGN
The term ‘Research Design’ is the structural frame work for study implementation
and it is blue print for the study (Talbolt 1995) Quasi experimental research design was
adopted in this study with an experimental and control group
Exprimental group: Q1 X Q2
Control group: Q3 Q4

.Key:
X – Breast massage.
Q1 – Pre assessment level of breast engorgement among experimental group.
Q2 – Post test level of breast engorgement among experimental group.
Q3 – Pre assessment level of breast engorgement among control group
Q4 - Post test level of breast engorgement among control group

VARIABLES

Dependent variable: Breast engorgement

Independent variable: Breast massage

SETTING OF THE STUDY

The location for conducting the research is referred to as setting (Burns and
Groove 2002) . The research settings are the specific places of research where data
collection is made. The selection of the setting was done on the basis of the feasibility for
conducting the study, availability of the subjects and geographical proximity. Setting for
the present study will the Female post operative ward at Erode government hospital,
Erode. Though many hospitals are there in the private sector, people residing in and
around Erode prefer government hospital to meet their health care needs. This is because
of economical reasons as well as availability of health care facilities and infrastructure in
this institution. This was selected because of the investigator’s acquaintance with the
setting, easy accessibility and co-operation of the authorities

POPULATION
 Population is the entire aggregation of cases that meet designated set of criteria.
(Polit &Beck).The study population consists of mothers who were undergone caesarean
section.

SAMPLE
The study samples consist of mothers who underwent ceaseran section and
admitted in , female post operative ward with fulfilling the inclusive criteria.

SAMPLE SIZE
Sample size was 60 caesarean mothers. Out of which 30 of them were allotted to
the experimental group and 30 of them in the control group.

SAMPLING TECHNIQUE
The sampling technique used for this study was non probability purposive
sampling

CRITERIA FOR SAMPLE SELECTION

Inclusive Criteria
1. Caesarian mothers with mild, moderate, and severe breast engorgement.
2. Caesarian mothers in the age group of 20 to 35.
3. Caesarian section mothers on 3 rd to 5 th post- operative days.
4. Caesarian section mothers were willing to participate.
Exclusive Criteria
1. Caesarian mothers receiving lactation suppressants for breast engorgement.
2. Caesarians mothers with mastitis, breast abscess, retracted nipple, bleeding or cracked
nipples.
3. Caesarian mother, with any systemic illness & obstetrical complication.
4. Caesarean mother who are taking alternative therapy for breast engorgement.

DEVELOPMENT AND DISCRIPTION OF TOOLS

The tool has two sections. The tool constructed in this study was divided as
follows,
SECTION –A
The baseline data profile comprised of age, education, occupation, gravida, post
natal day, time of feeding started after delivery, duration of breast feeding, frequency of
breast feeding among mothers underwent caesarian section with breast engorgement.
SECTION –B: SIX - POINT ENGORGEMENT SCALE
 The scale was formulated by Hill and Humenick (Pamela.D.Hill and Sharron.S.
Humenick) in the year 1994. This is a standardized scale used to assess the severity of
breast engorgement Standardized tool consist of six criteria regarding breast
engorgement. The criteria under appearance of breast includes, soft, no change in the
breast, slight changes in the breast firm, beginning tender in the breast, firm tender, very
firm and very tender.

SCORING PROCEDURE - SECTION –B

Assessing the level of breast engorgement among caesarian section mothers.
When the breast is soft, score 1 is given
When breast is having slight changes score 2 is given
When the breast is firm, non tender it carry score 3
When the breast is firm, beginning tenderness it carry score 4 is given
Firm, tender breast carry 5 score.
Very firm, very tender breast carry 6 score.

Interpretation of score:
• Score 1 : Normal
• Score 2 and 3 : Mild engorgement
• Score 4 and 5 : Moderate engorgement
• Score 6 : Severe engorgement

DESCRIPTION OF INTERVENTION
Procedure
Step 1:
Select an appropriate place and provide privacy to the caeseran mothers. Before doing the
intervention explains the procedure to the mother.
Step 2:
Wash hands before and after the procedure. Ask the mothers to lie down on the bed. At
first expose the both breast assess the breast engorgement by using the standardized
breast engorgement scale.
Step 3:
Make the fingers like pads by using the right hand and support the breast by left hand.
Step 4:
Give the soft, gentle, circular, kneading motion massage to the engorged breast. For right
side engorged breast clock wise massage provided from center to periphery and for left
side engorged breast anti clock wise massage from center to periphery for 10-15 minutes
in each breast twice a day for 3 days. Duration between the both breast massage is 2
hours.
Step 5:
Next starts rotary movement on the nipple to promote lymphatic flow and express the
breast milk with the use of both hands.
Step 6:
Advice the mother to feed the baby after the breast massage. Repeat the massage after the
interval of 2 hours and continue this procedure for 3 days.
Step 7:
Finally wash hands and assess the breast for the level of engorgement by using the
standardized breast engorgement tool. Record the procedure with date and time.

CONTENT VALIDITY
The content validity of the tool will establish on the opinion of one medical expert
in the field of obstetrics and gynecology and four nursing experts in the field of obstetric
and gynecological nursing.

RELIABILITY
Reliability of the standard tool will test by the investigator after pilot study. The
reliability of the standard tool will determined by test-re test method.

ETHICAL CONSIDERATION
Ethical clearance will obtain from Institutional Ethical Committee (IEC) and the
permission will obtain from the respective hospitals for data collection. Informed consent
will obtain from the samples. The written consent will obtain from each participant
before data collection. Assurance will given to the study participants regarding
confidentiality of the data collected

PILOT STUDY

The pilot study is a trial run for major study. The tool used for the pilot study to
test the feasibility and practicability. The pilot study will conducted in government
hospital , Erode.. A formal permission was obtained from the Director of the government
hospital, erode. The period for pilot study one week.
The investigator will introduce her to the mothers and establish rapport with the
mothers. Six samples will selected for pilot study using purposive sampling technique.
Data pertaining to demographic variables will collected by interview method.
Investigator will assess pre test level of breast engorgement during post natal days by
using the six point engorgement scale.
Data collection will done in the same setting for a period of six days. The
investigator select six samples by using purposive method of sampling technique. Out of
six samples three samples will allotted for experimental group, and three samples will
allotted for control group.
The investigator will give breast massage for the sample of experimental group.
Control group mother will receive hospital routine care. At the end of the intervention,
the post test level of breast engorgement will scored for both groups. And according to
the findings the investigator modifies the study.

PROCEDURE FOR DATA COLLECTION

The investigator will get formal permission from the Principal and research ethical
committee of Annai JKK Sampooraniammal College of nursing. Erode government
hospital will selected for data collection. Data collection period will be conducted for
four consecutive weeks.The investigator collect the data for the 6 days a week from
Monday to Saturday and from 7 am to 5 pm. During the data collection day the
investigator select two to three sample based on inclusive criteria and by using purposive
sampling technique. The samples will fulfill the inclusive criteria during 3 rd and 5 th
post natal day .The investigator establish rapport with the mothers. They will be assured
that no physical or emotional harm would be done during the course of the study. The
investigator will instruct about the benefits of breast massage to the mother. Data
pertaining to the demographic variables will be collected by interview method. Breast
massage intervention will done for duration of 10 to 15 minutes to all samples in the
experimental group. This intervention will repeat with the interval of 2 hours.
For 3 days. Hospital routine intervention was given for each sample in control
group. Investigator assessed post test level of breast engorgement during 3rd to 6th
postnatal days by using six point engorgement scale for both mothers in experimental and
control group. The same procedure followed for the consecutive weeks.

PLAN FOR DATA ANALYSIS

After data collection, data were organized, tabulated, summarized and analyzed.
The data were analyzed according to objectives of the study by using both descriptive and
inferential statistics.

Descriptive analysis
  Frequency and percentage distribution was used to analysis the demographic
variables of the post natal mothers in experimental and control group.
 Frequency and percentage distribution was used to assess the pre and post test
level of breast engorgement among caesarian mothers.
 Mean and standard deviation was used to assess the pre and post test level of
breast massage on reduction of breast engorgement among caesarian mothers.

Inferential stastistics
 Paired t - Test was used to compare the pre and post test level of breast
engorgement during 3rd to 5th post-operative day for both experimental and
control group of caesarian mothers.
 Unpaired t- test was used to compare pre and post- test level of breast massage on
reduction of breast engorgement between experimental group with breast massage
and control group of caesarian mother.
 The Chi –Square was used to find out the association between level of breast
engorgement among experimental and control group of caesarian mothers with
their selected demographic variables.

3. A STUDY TO ASSESS THE EFFECTIVENESS OF HOT APPLICATION ON

EPISIOTOMY WOUND HEALING AND PAIN AMONG THE POSTNATAL
MOTHERS AT GOVERNMENT RAJAJI HOSPITAL , ERODE.

INTRODUCTION

The introduction of many minds into many fieldsof learning along a broad spectrum
keeps alive questions about the accessibility, if not the unity , of knowledge.
(Edward Levi).
BACKGROUND OF THE STUDY
According to, World Health Organization (WHO) recommends that the
episiotomy rate should be around 10%, which is already a reality in many European
countries. Currently the use of episiotomy should be restricted and physicians are
encouraged to use their clinical judgment to decide when the procedure is necessary.
There is no clinical evidence collaborating any indication of episiotomy, so until the
present moment it is not yet known whether episiotomy is indeed necessary in any
context of obstetric practice.
 According to WHO, the first published account of episiotomy in a medical journal
was in 1810, but it took another hundred years for it to become a normal part of obstetric
practice. There are earlier reports from London in 1741. There has been considerable
debate about the place of episiotomy - more often fuelled by preconceptions than
evidence.
 In the early 1970s it was often advocated that there were two reasons for
episiotomy; one was a primigravida, and the other a previous episiotomy. In other
words, every vaginal delivery should be accompanied by episiotomy.
 It was argued that this reduced the risk of tears and subsequent problems from
prolonged bearing down, such as prolapse. The evidence for the latter was
somewhat tenuous.
 The uncritical liberal use of episiotomy was opposed by consumer groups,
including the National Childbirth Trust, and these very high rates of episiotomy
have been reversed.
The rate of episiotomy in England decreased from 51% in 1975 to 15% in 2010-11,
although this is only an approximate comparison because the statistics methodology was
changed in 2006.
The overall rates for third-degree and fourth-degree perineal tears in England in 2011-
2012 were.
 Primiparous: 4% following spontaneous vaginal delivery and 6.9% following
instrumental delivery.
 Multiparous: 1.4% following spontaneous vaginal delivery and 2.5% following
instrumental delivery.
There is considerable international variation in the rate of episiotomy. According to the
Royal College of Obstetricians and Gynaecologists (RCOG) guideline published in 2007,
it was then 8% in Holland, 14% in England, 50% in the USA and 99% in Eastern Europe.

Aasheim et al., (2011) Rates of episiotomy are reduced when Health Care
providers (HCPS) use ‘hands off’ technique during labour and birth. For example, no
hand(s) on the perineum and limited manual assistance for the birth of the shoulders.

In addition to the “hands off” technique, the use of warm compress on the
perineum is associated with a decreased occurrence of perineal trauma (tears and/or
episiotomy).

Beckman and Stock, (2013). While research supporting perineal massage (once
or twice a week) for prevention of tears and/or episiotomy has mixed results, it appears to
have the most impact on first-time mothers who give birth vaginally as it reduces the
likelihood of episiotomy (by 16%) and reduces prolonged perineal pain .

NEED FOR THE STUDY

Birthing is the most profound initiation to spirituality a woman can (Robin

Lim)
Motherhood is a beautiful process, where by mothers safely delivers a child. It is the
magic of creation. Care must be given to ensure safe birth. Safe motherhood initiative
announced in the year 1987 had set targets to reduce maternal mortality by 50% one
decade. The safe motherhood aims at enhancing the quality of life and women through
adoption of a combination of health and non health strategies. Glazers et al (1996), as
cited by Calvert and flaming (2000) have addressed the extent and causes of morbidity by
self- reported questionnaire. Their conclusions are that maternal postnatal morbidity is
extensive and that it is unrecognized by health professional. Midwives have an important
role to play in the care of perineal wounds following childbirth. It is important that
midwives recognize the need for research based practice.
Episiotomy is an incision made on the perineum during a vaginal delivery to
facilitate and explicit delivery and to prevent perineal tear.
Although its use in childbirth has steadily declined in recent decades, literature
says in developed countries like United States and United Kingdom, episiotomy rates has
decreased to 8% to 10% but actual use remains common in many hospital settings. Our
institution being a tertiality care teaching hospital, the incidence of episiotomies per
month is approximately 40%- 70 % while the rate of restrictive groups are 27.6%.
Journal of American science [2012] Most women have some degree of discomfort
during the first few postpartum days. One often common causes of discomfort is
episiotomy. Nursing interventions are intended to reduce the discomfort and allow the
woman to take care of herself and her baby. Simple interventions that can decrease the
discomfort associated with perineal trauma is applying an ice pack, moist or dry or
topical applications, cleansing the perineum with a squeeze bottle and taking a warm
shower or a sitz bath.
In India, the overall rate of episiotomy was 40.6% among the midwifes performed
episiotomies at a lower rate (21.4%), faculty (33.3%) and private care providers (56.6%).
The need for the Sitz bath during episiotomy is represented by a reduction of mean score
from 4.1 to 0.15 and standard deviation from 0.66 to 0.3. The findings of the study
consistent with the findings.
 Pillitere (1994) says that every woman needs attention to perineal cleanliness in
the postpartum period to prevent infection, as lochia may dry and harden in the vulva and
perineum. It furnishes the bed for bacterial growth because the vagina lies in the close
proximity to the rectum. Also there is always the danger that bacteria will spread from the
rectum to the vagina and cause uterine infection.
Episiotomy pain often interferes with basic daily activities for the woman such as
walking, sitting, passing urine and defecating and also negatively impacts on motherhood
experiences.
Seven randomized controlled trials (RCTS) of liberal versus restrictive use of
episiotomy assessed pain outcome. The most common primary outcome was perineal
status after the birth .All seven studies reported incidences of episiotomy in liberal use
and in restrictive it was third and fourth degree lacerations or extensions. The most
common secondary outcome was pain in the days immediately after the birth. In the two
groups used Numeical pain scale to assess the pain and classified responses into
categories of mild, moderate or severe. Orally they have reported the composite score of
the 0-10 item scale. Thus pain assessment is very important contributor for professionals
especially midwives, as traditionally they are left to manage the episiotomy wound.
Episiotomy wound care starts immediately after suturing the wound in order to
reduce pain and heal wound . There are some general treatments for perineal care such as
cold packs and ice packs applied to perineum for the first 24 hours. Kegal exercises are
taught by nurses to strengthen the pelvic floor muscles and it speeds up the wound
healing process.
Apart from all the important significant therapy hot application[sitz bath
with potassium permanganate 1 gram] is widely used in many different hospital settings
and proved effective in managing the episiotomy wound pain and healing and also in
minimizing secondary complications.
The investigator had observed that hot application with pottasium permanganate is
used in various hospital settings for the treatment of episiotomy wound .Generally
accepted therapeutic protocol are however missing as each institution working with hot
application with potassium permanganate has its ownprotocol or adopted from various
other institution which are not adequately verified .Though the standard protocols are not
available still the literature supports the benefit of potassium permanganate as an
effective treatment for episiotomy wound healing. So the investigator strongly feels the
need to implement hot application with potassium permanganate in our institution in
treating episiotomy to provide comfort, prevent infection ,reduce pain and promote
wound healing ultimately reducing the hospital stay of patients. Further this study will
help to formulate a standard protocol for our hospital and benefit the nurses of maternity
unit.
Today, when the cost of medical treatment and care is so
increasing.Economical care of patients with episiotomy can be provided, if nurse and
midwives realize the relevance of their care and potential impact of the advocated
procedure in wound healing.

STATEMENT OF THE PROBLEM

A study to assess the effectiveness of hot application on episiotomy wound healing

and pain among the postnatal mothers at Government rajaji hospital , Erode.

OBJECTIVES

 To assess the effectiveness of post test of episiotomy wound healing and pain
among the postnatal mothers in both experimental and control group.
 To compare the significant difference between the experimental group and control
group of post test of episiotomy wound healing and pain among the postnatal
mothers.
 To correlate the post test of episiotomy wound healing and pain among the
postnatal mothers in both experimental group and control group.
 To determine the association between the post test of episiotomy wound healing
and pain among the postnatal mothers in both experimental and control group with
their selected demographic variables such as Age of the mother, parity,
educational status, occupation, body built, type of family, history of present
medical illness, indication of episiotomy, birth weight of the newborn and types of
episiotomy.

HYPOTHESES

H1-There will be a significant difference between the experimental and control group of
post test of episiotomy wound healing and pain among the postnatal mothers.
H2-There will be a significant correlation between the post test levels of episiotomy
wound healing and pain among the postnatal mothers in both experimental and control
group.
H3-There will be a significant association between the post test level of episiotomy
wound healing and pain reduction among the postnatal mothers in both experimental and
control group with their selected demographic variables such as Age of the mother,
parity, educational status, occupation, body built, type of family, history of present
medical illness, indication of episiotomy, birth weight of the newborn and types of
episiotomy.

OPERATIONAL DEFINITION

EFFECTIVENESS
In this study it refers to in the episiotomy wound healing process and pain
reduction measured by REEDA scale and Numerical pain rating scale.

HOT APPLICATION
In this study it refers to the immersion of perineal area and buttocks in 4 litres of
warm water at 110 degree F. mixed with 1 gram of potassium permanganate 3 times a
day for 15 minutes.

PAIN
In this study it refers to unpleasant feeling caused by episiotomy wound and its
measured by numerical pain rating scale

EPISIOTOMY WOUND
In this study it refers to the incision made to the perineum it is a area between the
vagina and anus during the process of child birth.

POSTNATAL MOTHERS
In this study it refers to the women who delivered by normal vaginal delivery with
Episiotomy.

ASSUMPTION
 Hot application may fasten the episiotomy wound healing process and
simultaneously reduce the pain.
 Hot application helps to reduce the infection.

DELIMITATION

 The study will be limited to the postnatal mothers with episiotomy wound.
 The study will be limited to the mothers who have delivered in selected hospitals.
  Data collection period will be limited to 6 weeks

CONCEPTUAL FRAMEWORK - KINGS GOAL ATTAINMENT THEORY

The study is based on Imogen king's goal attainment theory (1997) which would
be relavant for hot application on episiotomy. It is an open system. In this system human
are in contact with their environment. The main concept in Imogene kings open system
are perception a process of organizing , interpretating and transforming from sense data
and memory that drives meaning to ones experience represent ones image of reality and
influence ones behavior.
Perception
In this study the researcher perceives that most postnatal mothers had poor wound
healing and pain reduction on episiotomy.
Judgement
In this study researcher judge that the hot application is effective in improving
wound healing and pain reduction on episiotomy. It provide confidence to tackle the
subsequent pregnancy.
Action
In this study the researcher prepare the hot application is effective in improving
the wound healing and pain reduction on episiotomy among the postnatal mothers.
Mutual goal setting
In this study it is an activity that includes the postnatal mothers when appropriate
in prioritizing the goal and in developing the plan of action to achievethose goals. Here in
this study both the researcher and mothers accept to undergone with the research study.
Reaction
The researcher plan is together moves towards goal attainment. Here the
researcher plan to give hot application on episiotomy to experimental group.
Interaction
The act of two or more pesons in mutual presence and sequence of verbal non
verbal behaviours that are directed towards goal. In this study the interaction includes
administration of hot application and assessed wound healing and pain in experimental
group and no intervention to samples of control group.
Transaction
In this study the transaction includes post test on the assessment of wound healing
and pain on episiotomy among the postnatal mothers. In this study the researcher and the
subject come together for an interaction. A different set of perception to exchange. The
researcher perceives the subject need to give hot application on episiotomy wound
healing and pain to manage the emergency situation confidently in hospital and in
community setting. The researcher communicates the subject by implementing the hot
applicaion on episiotomy. Transction takes place. The goal is said to be achieved is an
increased level of wound healing and pain in experimental group when compared to the
control group.

RESEARCH METHODOLOGY

Research methodology is a way to systematically solve the research problem. In

this chapter the investigator discusses the Research approach, Research design, Variables,
Setting, Population, Sample, Sample size, Sampling technique, Criteria for data
collection, Description of the tool, Plan for data analysis and production of human rights.

RESEARCH APPROACH
An evaluative research approach was used in this study.

RESEARCH DESIGN
True experimental research design ( post test only design) was used in this study.

E R X O2

C R - O2

E -Experimental group
C-Control group
R-Randomization
X-Treatment [Hot application by potassium permanganate]
O2-Post test for both group

VARIABLES

Independent variable: Hot application.

Dependent variable: Episiotomy wound healing and pain
Demographic variables: Age of the mother, parity, educational status, occupation, body
built, type of family, history of present medical illness, indication of episiotomy and types
of episiotomy.
SETTING OF THE STUDY

The location for conducting the research is referred to as setting (Burns and
Groove 2002) . The research settings are the specific places of research where data
collection is made. The selection of the setting was done on the basis of the feasibility for
conducting the study, availability of the subjects and geographical proximity. Setting for
the present study will the postnatal ward at Erode government hospital, Erode. Though
many hospitals are there in the private sector, people residing in and around Erode prefer
government hospital to meet their health care needs. This is because of economical
reasons as well as availability of health care facilities and infrastructure in this institution.
This was selected because of the investigator’s acquaintance with the setting, easy
accessibility and co-operation of the authorities

POPULATION
The population consisted of postnatal mothers at government rajaji hospital, Erode.

SAMPLE
In this study the postnatal mothers who had delivered by normal vaginal deliveries with
episiotomy.

SAMPLE SIZE
The sample consists of 60 postnatal mothers. [Experimental group – 30 samples and
Control group-30 samples]

CRITERIA FOR SAMPLE SELECTION

INCLUSION CRITERIA
􀁸 Postnatal mothers who are willing to participate in the study.
􀁸 Postnatal mothers who can understand the Tamil.

EXCLUSION CRITERIA
􀁸 Postnatal mothers who have done L.S.C.S and assisted vaginal delivery.
􀁸 Postnatal mothers who have received analgesics and antibiotics.

DEVELOPMENT AND DESCRIPTION OF THE TOOL

Tool comprised of 3 parts
Part-I: Demographic variables such as age of the mother, parity, educational status,
occupation, body built, type of family, history of present medical illness, indication of
episiotomy and types of episiotomy.
Part-II: REEDA scale to assess the episiotomy wound healing.

Part-III: Numerical pain rating scale to assess the pain reduction.

SCORING AND INTERPRETATION PROCEDURE

(A) DESCRIPTION OF THE TOOLS

TOOL consisted of III parts,
Part I: Demographic variables.
Part-II: It consisted of REEDA scale to assess the episiotomy wound healing.
Part-III: It consisted of Numerical pain rating scale to assess the pain reduction.
(B) SCORING
PART- II
Part-II: It consisted of REEDA scale to assess the episiotomy wound
healing.

LEVEL HEALING SCORE PERCENTGE

OF WOUND

Good wound healing 0 100%

Mild wound healing 1-5 90-70%
Moderate wound healing 6-10 60-40%
Severe wound healing 11-15 30-0%

PART III
Part-III: It consisted of Numerical pain scale to assess the pain reduction.

LEVEL OF PAIN SCORE PERCENTAGE

No pain 0 100%
Mild pain 1-3 90-70%
Moderate pain 4-6 60-40%
Severe pain 7-10 30-0%

RELIABILITY AND VALIDITY OF THE TOOL

 The validity of the tool will establish with obstetrical and gynaecological
experts. The tool will modified according to the suggestions and recommendations
of experts and the tool will finalize. The reliability of the tool will establish by
standard error of measurement method for Numerical pain scale and kappa
correlation co efficient formula for REEDA Scale

EHICAL CONSIDERATION
The research proposal will approve by the dissertation committee prior to conduct pilot
study. Formal permission will obtain from the hospital authorities. After the clear
explanation about the study, oral consent will obtain from each participant before started
the data collection. Assurance will provid to the subject that the anonymity,
confidentiality and subject privacy will be guarded

PILOT STUDY
Pilot study will conduct to test the reliability, practicability, validity, and
feasibility of the tool. Pilot study was conducted for a period of 6days. The investigator
will obtain a written permission from the head of the hospital authorities. The purpose of
the study will explain to the participants prior to the study. Pilot study will conduct for 3
postnatal mothers in government rajaji hospital for experimental group and 3 postnatal
mothers in government rajaji hospital for control group and simple random sampling
technique (lottery and table method ) will use to select the sample. The investigator will
obtain the oral permission from the participants prior to the study. The wound healing
and pain reduction was assessed by REEDA and Numerical pain scale respectively. By
using true experimental post test only design for experimental group hot application
given with potassium permanganate in sitz bath procedure for 3 days and control group
received routine care. Post test will conduct on 3rd day by using the same REEDA scale
and Numerical pain rating scale for each group. The result of the pilot study was analyzed
by the descriptive and inferential statistics
.
METHOD O F DATA COLLECTION

Written formal permission will obtain from hospital authorities and informed
oral consent obtain from each subjects. The samples will select by simple randomized
sampling technique and True experimental post test only design used. Hot application
will given to the postnatal mothers in experimental group. And routine treatment given
( Ice pack, moist or dry or topical applications, cleansing the perineum with cloth taking a
warm shower) in control group. After 3 days post test will conducted by using the
REEDA and Numerical pain rating scale for both experimental and control groups.

PLAN FOR DATA ANALYSIS

Collected data will tabulat and analyze by using descriptive and
inferential statistical methods.
represents the plan for data analysis
1. Descriptive statistics - Percentage, Frequency distribution, Mean, standard deviation
To assess the demographic variables of postnatal mothers wound healing and pain
in experimental group and control group. Correlation To determine the post test of wound
healing and pain of postnatal mothers in both experimental and control group.
2. Inferential statistics
 Correlation - To compare the post test of episiotomy wound healing and pain
among the postnatal mothers in experimental and control group.
 Chi-square test - To find the association between the post test score of wound
healing and pain among the postnatal mothers with selected demographic
variables.
.