The Umbilical Cord Is a Unique Tissue, Consisting of Two Arteries and One Vein Covered
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1. INTRODUCTION
The umbilical cord is a unique tissue, consisting of two arteries and one vein covered by a mucoid connective tissue called Wharton`s jelly and a thin mucus membrane. During pregnancy, the placenta supplies all material for fetal growth and removes waste products.
Blood flowing through the cord provides nutrition and oxygen to the fetus and carries carbon dioxide and metabolic waste products away from the fetus. Umbilical cord function is essential for growth and development before birth. The devitalized tissue of the cord stump can be an excellent medium for bacterial growth, especially if the stump is kept moist and unclean substance are applied to it. Keeping the stump clean and dry is therefore very important in order to prevent infection. There are a number of different ways to clean the cord stump. The cord clean with sterilized bowl cooled boiled water, cotton wool, clean towel.
The umbilical cord can be cleaned immediately after birth. The timing of cord clamping may have effects on both mother and infant. Which helps to protect the birth attendant in area which where HIV infection is common. Plastic cords clamp effectively close all vessels in the umbilical cord and are easy to use. Sterile and sharp instruments are usually recommended for cutting the cord. Using blunt instrument could possibly result in an increased incidence of infection due to more traumas to the tissue. A long stump could possibly increase risk of infections because it is harder to keep clean and dry. A recommended length of the stump after cutting is usually 2-3cm.
Clean cord care at birth and in the days following birth is effective in preventing cord infections and Tetanus neonaterum. Clean cord is accomplished by the maintenance of aseptic techniques. So that the umbilical cord remains uncontaminated by pathogens. A birth hands should be washed with clean water with soap before delivery after any vaginal examination and again before tying and cutting the cord. Early and frequent breast feeding will provide the newborn with antibodies to help fight infections. Clean with alcohol is not recommended as it delay healing and drying of wound. While there is general consensus that clean cord care decrease the risk of cord infection, the application of topical antimicrobials to the cord stump is more controversial. It was unable to conclude that application of topical antimicrobials is superior to just keeping the cord clean. Applying antiseptics to the cord stump reduces staphylococcal infections.
According to available studies, chlorhexidine, tincture of iodine, povidine iodine, silver sulphadiazine and triple dye appear to be of most value in controlling umbilical colonization. 1
NEED FOR STUDY
The umbilical cord is very important anatomical part for the unborn babies. It is considered the lifeline that supplies all nutrients and oxygen needed to survive. Properly caring for it after birth is of prime importantance2. Good cord care practices reduce the incidence of neonatal infections. While cord care practices vary from place to place, some of can be harmful to the new born3. Studies have showed that most neonatal Tetanus is caused by infection originating from the umbilical cord. Here are some do`s don`ts when taking good care of the umbilical cord.
1. Do watch out for umbilical cord infection. Common signs are yellow and foul
smelling discharge, tenderness and redness of the skin around the cord. At alert the
parents to call the doctor as soon as possible. 2. Call a doctor immediately if the cord is bleeding profusely. This usually happens when
the cord is accidently pulled while changing diapers.
3. If the stump doesn`t naturally fall off until the baby reach two months, this suggests
that immunological or anatomical abnormality problem. When this happens,
immediately get medical assistance.
4. When cleaning the umbilical cord, use topical antiseptic instead of alcohol. This is
proven to greatly reduce if not eliminate infection.
5. For first time mothers, experts suggest to get advice about cord care from their doctor.
Remember to follow all the tips, write them down and keep handy for reference.2
Care of umbilical cord includes taking precautions like
A diaper should not be rubbed against the belly button stump. For that the diaper
curved in the middle front can be used. If such diapers are not found, they can be fold
down on the front. So it won`t be touching the babies belly button. This gives the
stump a chance to breath and won`t get contaminated by the babies urine.
Clean the belly button at least once or twice a day using a little rubbing alcohol on the
cotton ball.
Do not full off the umbilical cord stump.
Certain things are to be looked out for baby`s umbilical cord that is pus around the
stump, redness or baby has a fever.
The child should be taken to the doctor immediately if the above said signs are found.4
The incidence of cord infections among neonates in developing countries is unknown but may be under appreciated. Some studies have reported infection rates among hospitalized babies before discharge, infection is rare. Morever, no population based studies of rates of cord infection in the community have been reported. There is wide variation in rates of umbilical cord infections among neonates in developing countries with rates ranging from 2 per 1000 to 54 per 1000 live births and case fatality rates ranging from 0 to 15%.A 2 year hospital based study of neonatal omphalitis in Estarn Turkey reported an even higher omphalitis incidence rate of 7.7 per 1000 in patient newborns per year. Gram positive bacteria
(mainly S.aureus) were more commonly isolated from the cord than gram negative bacteria(mainly E.coli). Anaerobic bacteria, including bacterial Spores, were also isolated from 32% of cultures. Among infants hospitalized for sepsis in Uttar Pradesh, India, cord infection was the source of illness in 47% of cases and Omphalitis, especially among those delivered at home.
The world health organization (WHO) estimated that 4 million children die during the neonatal period each year with most deaths occurring in developing countries. Infections are the single most important cause of neonatal mortality. It is estimated that 3,00,000 infants die annually from Tetanus and a further 4,60,000 die because of severe bacterial infections, of which umbilical cord infections are an important precursor. Although increasing access to tetanus toxide immunization during pregnancy must remain a priority, high rates of umbilical cord infections and sepsis can occur in areas free from tetanus, attributable to unhygienic delivery or immediate post partum practices that lead to contamination of the umbilical cord stump.5
A study was conducted to compare the risk of mortality between infants with and without signs of umbilical cord infection during a community based trial of chlorhexidine interventions in Southern Nepal. It concluded that common local signs of cord infections are associated with increased risk of mortality. Where exposure of the umbilical cord to potentially invasive pathogens is high, interventions to increase hygiene care of the cord should be promoted, including hand washing, avoiding harmful topical applications and topical cord antisepsis.6
Nearly 4 million neonatal deaths every year are in low-income and middle income countries. Infection accounts for an estimated 1.44 million (36%) deaths, and about half neonatal mortality rates. Contamination of the umbilical cord can lead to omphalitis, characterized by pus, abdominal erythma, or swelling. Pathogens can enter the bloodstream through the patent vessels of the newly cut cord and lead to rapid demise, even in the absence of overt signs of cord infection. Hygiene delivery and postnatal care practices are widely promoted as important interventions to reduce risk of omphalitis and deaths.7
The Auxiliary nurse midwives students are potential health care professionals who work as a primary care givers in the community setting. Caring the umbilical cord at birth is given top most priority, since the uncared umbilical cord may result into infection and in severe case it may result into the death of the neonate. Umbilical cord sepsis is one among the major causes of neonatal mortality .The umbilical sepsis is preventable if proper care of the cord is taken in time.
Hence the investigator felt the need to improve the knowledge of Auxiliary nurse midwife students regarding umbilical cord care. So that they can provide not only better umbilical cord care but also they can educate other primary care givers like mothers, care providers etc regarding care of umbilical cord. 2. OBJECTIVES
This chapter deals with the statement of the problem, objectives of the study, operational definitions, hypotheses and conceptual framework, which provides a frame of reference.
STATEMENT OF THE PROBLEM
“ A study to evaluate the effectiveness of video assisted teaching programme on knowledge regarding umbilical cord care of neonates at birth among auxiliary nurse midwife students at B.V.V. Sangha’s sajjalashree ANM training centre, Navanagar
Bagalkot.”
OBJECTIVES OF THE STUDY
Objectives are the guiding forces for a researcher throughout his study. The explicit description of objectives is essential to come out with meaningful research. With this background the objectives for the current study are as follows:
1. To assess the knowledge regarding umbilical cord care of neonates at birth among
Auxiliary nurse midwife students.
2. To develop and implement a video assisted teaching programme on knowledge
regarding umbilical cord care of neonates at birth.
3. To evaluate the effectiveness of video assisted teaching programme on knowledge
regarding umbilical cord care of neonates at birth.
4. To find out association between knowledge score and selected socio demographic variables regarding umbilical cord care of neonates at birth.
HYPOTHESIS
H1: More than 50 percent of Auxiliary nurse midwives students will not have a high knowledge regarding umbilical cord care of neonates at birth.
H2: There will be no significant difference between the pretest knowledge and post knowledge scores of Auxiliary nurse midwife students regarding umbilical cord care of neonates at birth.
H3: There is no significant association between the knowledge of Auxiliary nurse midwife students regarding umbilical cord care of neonates at birth and selected socio demographic variables, at 0.05 level of significance.
VARIABLES
1. Dependent variable: Knowledge of Auxiliary nurse midwives students regarding
umbilical cord care of neonates at birth.
2. Independent variable: Video assisted teaching programme on umbilical cord care
of neonates at birth.
3. Socio demographic variable: It includes Age, Gender, Educational status of
parents, occupation of parents & source of information regarding health etc.
OPERATIONAL DEFINATION EVALUATE: In this study it is the process used to signify the difference between pre tests and post test knowledge scores of Auxiliary nurse midwife students regarding umbilical cord care.
EFFECTIVENESS: In this study it is the extent to which the planned teaching programme prepared by the researcher will be successful in manipulating the knowledge of Auxiliary nurse midwife students regarding umbilical cord care.
VIDEO ASSISTED TEACHING PROGRAMME: In this study video assisted teaching programme is a systematic plan of teaching and learning process between the investigator and study subjects regarding umbilical cord care with the assistance of video clips.
KNOWLEDGE: In this study knowledge refers to awareness of ANM students regarding umbilical cord care.
UMBILICAL CORD: In this study the cord which connects the fetus and the placenta, and more prone to acquire infection and place the neonates at stage of fatal life threatening condition.
NEONATES: It refers to the period until 28 days after birth, who have umbilical cord upto 5-
7 days after birth and needs special care to prevent infection.
UMBILICAL CORD CARE: In this study the umbilical cord care refers to the care given to the umbilicus of neonates at birth like cutting, tying.
ANM STUDENTS: In this study Auxiliary nurse midwife students refers to the student studying Auxiliary nurse midwife programme/ course at B.V.V.Sangha’s sajjalashree ANM training centre , Bagalkot. ASSUMPTIONS
1. Neonates are at risk for omphalitis and umbilical cord sepsis if proper umbilical
cord is not provided.
2. Umbilical sepsis is one of cause of the neonatal mortality.
3. ANM students will show interest to participate in study.
DELIMITATION
The study is delimited to the Auxiliary nurse midwife students who are studying at
B.V.V.Sangha’s Sajjalashree ANM training centre, Navanagar Bagalkot.
PROJECTED OUTCOME
The video assisted teaching programme will help the Auxiliary nurse midwife students to improve their knowledge regarding umbilical cord care of neonates at birth.
CONCEPTUAL FRAME WORK
Conceptual frame work act as a building block for the research study. The overall purpose of frame work is to make scientific findings meaningful and generalized. It provides a certain frame work of reference for clinical practice, education and research. Frame work can guide the researcher’s undertaking of not only ‘What’ of natural phenomena but also ‘Why’ of their occurrence. They also give direction for relevant question to practical problem.
(Pilot and Hunglar).
This study is intended to assess the effectiveness of video assisted teaching programme on knowledge regarding umbilical cord care of neonates at birth among auxiliary nurse midwife students. Conceptual frame work selected for this study was based on general system theory as capsulated by Von Ludwig Bertalanfly; in this theory main focus is on the discrete parts and their interrelationship (Marcia Stanhope).
‘System’ as a complex interaction which means that system consists of two or more converted elements, which forms an organized whole and interact with each other.
In this study ‘Input’ is considered to be the information related knowledge regarding umbilical cord care of neonates at birth it includes,
Structured knowledge questionnaire regarding umbilical cord care
Video assisted teaching programme prepared on
Socio demographic data of the auxiliary nurse midwife students.
According to Von Ludwig Bertalanffy, ‘Through put’ refers to the process by which the
system processes input and release an output. In this study the through put considered for
processing the input are,
-Pretest by using structured knowledge questionnaire on umbilical cord care
-Group teaching by using lecture cum discussion method.
-Post test will be implemented by using the same knowledge questionnaire used for pretest to assess the effectiveness of Video assisted teaching programme on umbilical cord care.
According to system theory ‘Out put’ refers to energy, matter and information that leave a system, in the pretest study .Output consider the gain in knowledge obtained through the comparison of the pre and post test.
According to his ‘Feedback’ refers to output that is returned to the system that allows it to monitor itself over time in an attempt move closer to a steady state known as equilibrium or homeostasis, feedback may be positive, negative or neutral. For the present study Feedback related to the video assisted teaching programme on knowledge regarding umbilical cord care
will be obtained by testing of hypothesis.
-Relationship between pretest and post test knowledge scores.
-Association between the post test knowledge and the selected demographic variables of auxiliary nurse midwife students.
According to Von Ludwig Bertanlaffy the system act as a whole dysfunction of a part causes a systems disturbance rather than loss of a single function, in all system activity can be resolved in to an aggregation of feedback circuits such as inputs, throughput and output.
In this study effectiveness of video assisted teaching programme is tested by interrelated elements such as input, throughput and output from the feedback. Efficiency of the input such as video assisted teaching programme regarding umbilical cord care will be assessed in terms of its effectiveness.
REVIEW OF LITERATURE
The review of literature is a summary of current knowledge about a particular problem, which includes what is known and not known about the problem. The literature is reviewed to summarize knowledge for use in practice or to provide a basis for conducting research study.
Review of literature for the present study has been organized under the following sections:
Section I: Review related to risk factors of umbilical cord infections
Section II: Review related to knowledge on umbilical cord care
Section III: Review related to a effectiveness of video assisted teaching programme Section I: Review related to risk factors of umbilical cord infections
A study was conducted to know the incidence and risk factors for infection over a range of severity among neonates in Pemba, Infants' umbilical stump was assessed on days 1, 3, 5, 7,
10, and 14 after birth for presence of pus, redness, swelling, and foul odor. Infection incidence and proportion of affected infants was estimated for 6 separate combinations of these signs.
Two definitions were examined for associations between infections and selected potential risk factors using multivariate analysis. Nine thousand five hundred fifty cord assessments (in
1653 infants) were conducted. The proportion of affected infants ranged from 16 (1.0%, moderate to severe redness with pus discharge) to 199 (12.0%, pus and foul odor), while single signs were observed in >20% of infants. Median time to onset of infection was 3 to 4 days; 90% of infections occurred by age 7 days. The study was concluded that Signs of omphalitis occur frequently and predominantly in the first week of life among newborns in
Pemba.8
Umbilical cord infection contributes to neonatal mortality and morbidity and risk can be reduced with topical chlorhexidine, behavioral or other factors associated with cord infection in low-resource settings have not been examined. Data on potential risk factors for omphalitis were collected during a community-based, umbilical cord care trial in Nepal during 2002-
2005. Newborns were evaluated in the home for signs of umbilical cord infection (pus, redness, and swelling). Omphalitis was defined as either pus discharge with erythema of the abdominal skin or severe redness (>2 cm extension from the cord stump) with or without pus.
Multivariable regression modeling was used to examine associations between omphalitis and maternal, newborn, and household variables. Omphalitis was identified in 954 of 17,198 newborns (5.5%). Infection risk was 29% and 62% higher in infants receiving topical cord applications of mustard oil and other potentially unclean substances, respectively. , unhygienic newborn-care practices lead to continued high risk for omphalitis. In addition to topical antiseptics, simple, low-cost interventions such as hand washing, skin-to-skin contact, and avoiding unclean cord applications should be promoted by community-based health workers.9
Case-control approach was used to estimate the odds of mortality between infants with and without umbilical cord infection; compared the risk of mortality between infants with and without signs of umbilical cord infection during a community-based trial of chlorhexidine interventions in southern Nepal.The results showed Among 23,246 assessed infants, there were 392 deaths. Odds of all-cause mortality were 46% (8-98%) higher among infants with redness extending onto the abdominal skin. A nonsignificant increased odds of mortality
[odds ratio (OR): 2.31; 95% confidence interval (CI): 0.66-8.10] was observed among infants with severe redness and pus. Infections occurring after the third day of life were associated with subsequent risk of all-cause (OR: 3.11; 95% CI: 1.68-5.74) and sepsis-specific (OR:
4.63; 95% CI: 2.15-9.96) mortality. The study was concluded that common local signs of cord infection are associated with increased risk of mortality. Where exposure of the umbilical cord to potentially invasive pathogens is high, interventions to increase hygienic care of the cord should be promoted and including hand washing, avoiding harmful topical applications, and topical cord antisepsis.10
A community-based, cluster-randomised trial, 413 communities in Sarlahi, Nepal, was randomly assigned to one of three cord-care regimens. 4934 infants were assigned to 4.0% chlorhexidine, 5107 to cleansing with soap and water, and 5082 to dry cord care. In intervention clusters, the newborn cord was cleansed in the home on days 1-4, 6, 8, and 10. In all clusters, the cord was examined for signs of infection (pus, redness, or swelling) on these visits and in follow-up visits on days 12, 14, 21, and 28. Incidence of omphalitis was defined under three sign-based algorithms, with increasing severity. Infant vital status was recorded for 28 completed days. The primary outcomes were incidence of neonatal omphalitis and neonatal mortality. Analysis was by intention-to-treat. The findings reveled Frequency of omphalitis by all three definitions was reduced significantly in the chlorhexidine group.
Severe omphalitis in chlorhexidine clusters was reduced by 75% (incidence rate ratio 0.25,
95% CI 0.12-0.53; 13 infections/4839 neonatal periods) compared with dry cord-care clusters
(52/4930). Neonatal mortality was 24% lower in the chlorhexidine group. The study gave the recommendation for dry cord care should be reconsidered on the basis of these findings that early antisepsis with chlorhexidine of the umbilical cord reduces local cord infections and overall neonatal mortality.11
A nested case-control approach was used to estimate the odds of mortality between infants with and without umbilical cord infection as defined by various levels of severity,
Among 23,246 assessed infants, there were 392 deaths. Odds of all-cause mortality were 46%
(8-98%) higher among infants with redness extending onto the abdominal skin. A nonsignificant increased odds of mortality [odds ratio (OR): 2.31; 95% confidence interval
(CI): 0.66-8.10] was observed among infants with severe redness and pus. Infections occurring after the third day of life were associated with subsequent risk of all-cause (OR:
3.11; 95% CI: 1.68-5.74) and sepsis-specific (OR: 4.63; 95% CI: 2.15-9.96) mortality. This study provides evidence that common local signs of cord infection are associated with increased risk of mortality. Where exposure of the umbilical cord to potentially invasive pathogens is high, interventions to increase hygienic care of the cord should be promoted and including hand washing, avoiding harmful topical applications, and topical cord antisepsis.12
Owing to a high incidence of superficial infection in the newborn period the existing cord care treatment of Iodosan 10% in surgical spirit was compared with 4% chlorhexidine detergent solution. A prospective crossover study was performed between two comparable maternity units. Cord bacteriology was assessed at the time of discharge from hospital and the day of cord separation recorded. The number of infections involving skin, eyes and umbilical cord occurring in hospital and at home were recorded. Chlorhexidine treatment of the cord was associated with an overall reduction in bacterial colonisation of the cord. This was most marked for coagulase positive staphylococci and was not associated with an increase in gram negative organisms. Cord separation occurred at a mean of 10 days with Iodosan and 20 days with chlorhexidine. Chlorhexidine treatment was associated with fewer infections overall;
21% of babies v 38% of babies treated with Iodosan. Conjunctival infection was most commonly recorded; 48 babies being affected in the Iodosan group and 20 in the chlorhexidine group. The use of 4% chlorhexidine detergent solution is supported, but the length of treatment may have to be limited in order to encourage cord separation.13
In an article it has stated that Umbilical cord care is a common practice after birth.
Although most hospitals routinely use alcohol in the administration of cord care to newborns in Taiwan, the literature suggests that other different cord-care regimens may also be as or more effective. The purpose of this paper is to compare the effect of different cord-care regimens on cord separation time, colonization, omphalitis occurrence, and maternal satisfaction. Findings are hoped to provide nurses information essential to consider and select an optimal approach to umbilical cord care.14 Randomized and quasi-randomized trials of topical cord care compared with no topical care, and comparisons between different forms of care. Twenty-one studies (8959 participants) were included, the majority of which were from high-income countries. No systemic infections or deaths were observed in any of the studies reviewed. No difference was demonstrated between cords treated with antiseptics compared with dry cord care or placebo.
There was a trend to reduced colonization with antibiotics compared to topical antiseptics and no treatment. Antiseptics prolonged the time to cord separation. Use of antiseptics was associated with a reduction in maternal concern about the cord. Good trials in low-income settings are warranted. In high-income settings, there is limited research which has not shown an advantage of antibiotics or antiseptics over simply keeping the cord clean. Quality of evidence is low.15
A case controlled study was conducted to compare the incidence of omphalitis among three groups, each using a different type of newborn care-povidone- iodine, dry care and topical human milk in Turkey.150 healthy, full term newborns and their mothers were taken as sample. There was no significant deference between the three groups. Two cases of omphalitis were observed (one in human milk, one in the povidone-iodine group). Babies in the dry care or topical human milk group had shorter cord separation times than those in the povidone-iodine group. The culture practice of applying human milk to the umbilical cord stump appears to have no adverse effects and associated with shorter cord separation times than are seen with the use of antiseptics.16
Community-based data exist on the frequency of cord infection signs in low resource settings, especially in Sub-Saharan Africa. We developed simple sign-based definitions of omphalitis and estimated incidence and risk factors for infection over a range of severity among neonates in Pemba, Zanzibar, Tanzania. Infants' umbilical stump was assessed on days
1, 3, 5, 7, 10, and 14 after birth for presence of pus, redness, swelling, and foul odor. Infection incidence and proportion of affected infants was estimated for 6 separate combinations of these signs. The study was concluded that Signs of omphalitis occur frequently and predominantly in the first week of life among newborns in Pemba, Tanzania. Infection definitions relying on single signs without classifying severity level may overestimate burden.
Redness with pus or redness at the moderate or severe level if pus is absent is more appropriate for estimating burden or during evaluation of interventions to reduce infection.17
Umbilical cord infection contributes to neonatal mortality and morbidity and risk can be reduced with topical chlorhexidine, behavioral or other factors associated with cord infection in low-resource settings have not been examined. Data on potential risk factors for omphalitis were collected during a community-based, umbilical cord care trial in Nepal during 2002-
2005. Newborns were evaluated in the home for signs of umbilical cord infection (pus, redness, and swelling). Omphalitis was defined as either pus discharge with erythema of the abdominal skin or severe redness (>2 cm extension from the cord stump) with or without pus.
Multivariable regression modeling was used to examine associations between omphalitis and maternal, newborn, and household variables. Omphalitis was identified in 954 of 17,198 newborns (5.5%). Infection risk was 29% and 62% higher in infants receiving topical cord applications of mustard oil and other potentially unclean substances, respectively. Skin-to- skin contact (relative risk (RR) = 0.64, 95% confidence interval (CI): 0.43, 0.95) and hand washing by birth attendants (RR = 0.73, 95% CI: 0.64, 0.84) and caretakers (RR = 0.76, 95%
CI: 0.60, 0.95) were associated with fewer infections.18 Aseptic cord care, in conjunction with antibacterial skin care, has reduced the incidence of omphalitis specifically caused by Staphylococcus aureus. However, this practice has resulted in the emergence of resistant organisms that may pose a greater risk for newborn infections.
Subsequently, many institutions have changed to dry cord care and nonantiseptic whole-body baths, a practice that has not been adequately studied to determine potential infectious risks.
Three cases of omphalitis occurring after an institutional change to nonantiseptic whole-body baths are presented. Clinical diagnosis and treatment of omphalitis are reviewed.
Recommendations for surveillance of omphalitis are offered.19
Section II: Review related to knowledge on umbilical cord care
A study was conducted to provide information about home care practices of households for newborns, in order to improve neonatal home care through preventive measures and prompt recognition of danger signs. Survey of the newborn home care practices was done during the first few week of life in 217 households. Results revealed that many practices met women neonatal care standards, particularly umbilical cord care, prompt initial breast feeding, feeding of colostrums and conducted breast feeding and most bathing practices. Supplemental substances were given to 44% of newborns as pre-lacteal feeds, and to more than half during the first week. Nearly half(43%) of mother reported that they did not wash their hands before neonatal care, and only 7% washed hands after diaper change. Thermal control was not practiced, although mothers perceived 22% of newborns to be hypothermic. The study considered that the practices could be improved with minor modifications.20
A comparative study was conducted to evaluate the knowledge and practices of trained and untrained traditional birth attendants in Bodinga, Nigeria. 74 birth attendants; 43 trained and 31 untrained attendants were interviewed. Statistically significant difference were observed in the knowledge and practices of both groups. The Trained Birth Attendants were more likely to use new razor blades to cut the umbilical cord and untrained birth attendants uses sterilized razor blade (58 percent Vs 32 percent). The finding showed that Birth attendants need training programme to improve their knowledge and practices.21
A descriptive study was conducted to assess the knowledge and practices regarding care of neonates in Bangladesh. The cluster randomized trial of 520 subjects on the impact of topical chlorhexidine cord cleansing on neonatal mortality and omphalitis was done. Subjects behaviors regarding newborn cord and skin care practices were assessed by unstructured interviews, structured observations, rating and ranking exercises, and by household surveys.
The result showed that umbilical cord was almost always(98%) cut after delivery of the placenta, and cut by mother in more then half the cases(57%).Substances were commonly(52%) applied to the stump after cord cutting, the turmeric was the most common application(83%). 40% of the newborns were bathed on the day of birth. 91% of the subjects reported umbilical infections in their infants. The study recommended that education should be provided to the care givers regarding hand washing , cutting cord with clean instruments and avoiding un cleaned home applications to the cord, so that omphalitis and neonatal mortality can be reduced to some extent.22
A prospective randomized controlled trial was conducted to evaluate the effects of two cord care regimens(salicylic sugar powder versus chlorhexidine as a 4% detergent water solution) on cord separation time and other outcomes in preterm Italy. 244 preterm newborns with a gestational age of <34 weeks and a birth weight of <2500g were taken as sample. The cord separation time was significantly lower in infants who were treated with salicylic sugar powder (6+-2days) then in infants who were treated with chlorhexidine (9+-2days). A significantly higher percentage of nurses were satisfied with the salicylic sugar powder treatment(98%) then with chlorhexidine(67%), scar bleeding in the salicylic group(78%),chlorhexidine group(41%) and rate of negative umbilical swabs was higher in infants treated with salicylic sugar powder(73%),then with chlorhexidine.23
A study was conducted to find the characteristics and practices of traditional midwives in rural Bangladesh. They analyzed data set collected by Christian commission for
Development in Bangladesh about 242 traditional midwives. Result shows that a large majority of midwives were married or widowes and 79.7% were illiterate. The midwives learned their midwifery from informal sources, that is 41% from mother to mother-in-law,
16.5% followed their sister or cousin, 15.7% from grand mother, 11.9% from neighbors, 7.5% from other relatives and 7.4% were self-taught. The devices used in cutting the umbilical cord were not properly sterilized, and may use bamboo sheath. The study reveals that the midwives lacked basic knowledge about physiological processes during labour and child birth and the basics of the sterilization of umbilical cord cutting devices.24
This cross-sectional cohort study explored the impact of the use of clean delivery-kit on morbidity due to newborn umbilical cord and maternal puerperal infections. Kits were distributed from primary-care facilities, and birth attendants received training on kit-use. A nurse visited 334 women during the first week postpartum to administer a structured questionnaire and conduct a physical examination of the neonate and the mother. Results of bivariate analysis showed that neonates of mothers who used a of clean delivery-kit were less likely to develop cord infection (p = 0.025), and mothers who used a of clean delivery-kit were less likely to develop puerperal sepsis (p = 0.024). Results of multiple logistic regression analysis showed an independent association between decreased cord infection and kit-use
[odds ratio (OR) = 0.42, 95% confidence interval (CI) 0.18-0.97, p = 0.041)]. Mothers who used a CDK also had considerably lower rates of puerperal infection (OR = 0.11, 95% CI
0.01-1.06), although the statistical strength of the association was of borderline significance (p
= 0.057). The use of clean delivery-kit was associated with reductions in umbilical cord and puerperal infections.25
Cross-sectional survey was conducted to determine the knowledge, attitudes and practices
(KAP) of mothers and the knowledge of health workers regarding care of the newborn umbilical cord. Mothers with infants less than three months of age were the subjects, total Of the 307 mothers interviewed. The study findings revealed that 91% and 28% of mothers knew of the need for hygiene whilst cutting and tying the cord, respectively. Regarding postnatal cord care, 40% had good knowledge and 66% good practice. Fifty-one percent of mothers knew and 54% practised postnatal cord care for the appropriate duration of time. Seventy-nine percent of mothers were afraid of handling an unhealed cord. After multivariate analysis, the following variables showed significant independent association with good maternal KAP; increased level of education (OR 2.3, p < 0.001), living in middle class areas rather than slums
(OR 1.5, p < 0.03), increased maternal age (OR 1.8, p < 0.001), acquisition of knowledge from a HW rather than from other sources (OR 1.5, p < 0.001), and living in stone/brick houses rather than mud houses (p = 0.01). Fifty per cent of HW had correct knowledge on type of postnatal cord care, and 79% had correct knowledge on duration required for the same.
The study was concluded that Mothers had good knowledge on the need for hygiene when cutting the cord, had poor knowledge and practice in other aspects of cord care, and were afraid of handling the cord. Poor KAP was associated with young, poor mothers of low education, who had acquired their knowledge from sources other than health worker.26
A population-based study to determine obstetric risk factors and prenatal outcomes of pregnancies complicated by umbilical cord prolapse. The study findings showed Prolapse of the umbilical cord complicated 0.4% (n=456) of all deliveries included in the study
(n=121,227). Independent risk factors for cord prolapse identified by a backward, stepwise multivariate logistic regression model were: malpresentation (OR=5.1; 95% CI 4.1-6.3), hydramnios (OR=3.0; 95% CI 2.3-3.9), true knot of the umbilical cord (OR=3.0; 95% CI 1.8-
5.1), preterm delivery (OR=2.1; 95% CI 1.6-2.8), induction of labor (OR=2.2; 95% CI 1.7-
2.8), grandmultiparity (>five deliveries, OR=1.9; 95% CI 1.5-2.3), lack of prenatal care
(OR=1.4; 95% CI 1.02-1.8), and male gender (OR=1.3; 95% CI 1.1-1.6). Newborns delivered after umbilical cord prolapse graded lower Apgar scores, less than 7, at 5 min (OR=11.9, 95%
CI 7.9-17.9), and had longer hospitalizations (mean 5.4+/-3.5 days vs. 2.9+/-2.1 days;
P<0.001). Study was concluded that Prolapse of the umbilical cord is an independent risk factor for perinatal mortality.27
Population-based case-control study was conducted to identify risk factors and outcomes associated with a short umbilical cord. Results showed short cord was associated with increased risk for maternal labor and delivery complications, including retained placenta (RR
1.6; 95% CI 1.2, 2.3) and operative vaginal delivery (RR 1.4; 95% CI 1.3, 1.5). Adverse fetal and infant outcomes in cases included fetal distress (RR 1.8; 95% CI 1.6, 2.1) and death within the first year of life among term infants (RR 2.4; 95% CI 1.2, 4.6). Study was concluded saying Modifiable risk factors associated with the development of a short cord were not identified. Case mothers and infants are more likely to experience labor and delivery complications. Term case infants had a 2-fold increased risk of death, which suggests closer postpartum monitoring of this infants.28
Case control to compare the incidence of omphalitis among three groups, each using a different type of newborn cord care: povidone-iodine, dry care, and topical human milk. 150 healthy, full-term newborns and their mothers were the participants. The results showed There were no significant differences between the three groups in terms of omphalitis occurrence.
Two cases of omphalitis were observed (one in the human milk group, one in the povidone- iodine group). Interestingly, babies in the dry care or topical human milk group had shorter cord separation times than those in the povidone-iodine group. Study concluded that cultural practice of applying human milk to the umbilical cord stump appears to have no adverse effects and is associated with shorter cord separation times than are seen with the use of antiseptics.29
A study was conducted to compare the effect of topical application of human milk, ethyl alcohol 96%, and silver sulfadiazine on umbilical cord separation time in newborn infants.
Newborns from birth were randomized to either: 1) mother's milk group, 2) alcohol group, 3) silver sulfadiazine group, and 4) control (no treatment) group. Mother's milk for group 1, ethyl alcohol for group 2, and silver sulfadiazine ointment for group 3 were applied to the umbilical stump three hours after birth and continued every eight hours until two days after umbilical cord separation. It was observed a significant difference in the mean cord separation time among the four groups. No significant complications were observed in any group. Breast milk could be substituted for other topical agents for umbilical cord care, but a multicenter study is required in order to advise it for routine umbilical cord care.30 A prospective, randomized, controlled trial was conducted on 244 preterm newborns with a gestational age of <34 weeks to evaluate the effect of 2 cord-care regimens (salicylic sugar powder vs chlorhexidine as a 4% detergent water solution) on cord separation time and other outcomes in preterm infants. The results showed A significantly higher percentage of nurses were satisfied with the salicylic sugar powder treatment (98%) than with the chlorhexidine treatment (67%), notwithstanding a more frequent occurrence of slight cord scar bleeding in the salicylic sugar group (7.8%) than in the chlorhexidine group (4%). The rate of negative umbilical swabs was significantly higher in infants treated with salicylic sugar powder
(73.1%) than with chlorhexidine (53%). On conclusions In neonatal intensive care units and neonatal special care units of developed countries, salicylic sugar powder can be used effectively and safely for umbilical cord care of preterm infants.31
Newborn cord care practices may directly contribute to infections, which account for a large proportion of the four million annual global neonatal deaths. This formative research study assessed current umbilical and skin care knowledge and practices for neonates in Sylhet
District, Bangladesh. The umbilical cord was almost always (98%) cut after delivery of the placenta, and cut by mothers in more than half the cases (57%). Substances were commonly
(52%) applied to the stump after cord cutting; turmeric was the most common application
(83%). Umbilical stump care revolved around bathing, skin massage with mustard oil and heat massage on the umbilical stump. Overall 40% of newborns were bathed on the day of birth.
Mothers were the principal provider for skin and cord care during the neonatal period and 9% of them reported umbilical infections in their infants. Unhygienic cord care practices are prevalent in the study area. Efforts to promote hand-washing, cord cutting with clean instruments and avoiding unclean home applications to the cord may reduce exposure and improve neonatal outcomes. Such efforts should broadly target a range of caregivers, including mothers and other female household members.32
A prospective randomized trial using antiseptic applied directly to the umbilical stump to determine which antiseptic is appropriate for preventing omphalitis in the newborn infants.
Four hundred and twenty-seven infants were enrolled. Birth weight, gestational age and gender of the infants in both groups were not different. There were no known maternal risk factors for omphalitis. Omphalitis was observed in 9/213 (4.2%) infants in group A and
23/214 (10.7%) infants in group B. The relative incidence rate between each group was statistically significant (p<0.01). The study was concluded that during an epidemic outbreak of omphalitis, Triple dye was the most appropriate and effective antiseptic to prevent omphalitis but could delay cord separation.33
Studies related to effectiveness of video assisted teaching
A multi method study was conducted to determine the effectiveness of, and student attitudes to, online instructional videos for teaching clinical nursing skills in 2009 among student nurses in Netherlands. The results suggested that the students view the flexible and self management aspects of this method of learning positively, with some attitudinal differences between male and female students, mature and non mature students. The researcher concluded that this method can be best used to complement rather than substitute classroom teaching or lecture demonstration, lending support to a blended model.34
A study was conducted to determine the effectiveness of interventions for family care- givers of older adults through meta- analysis to determine the effects of 78 caregiver intervention studies for six outcome variables and six types of interventions. The combined interventions produced a significant improvement of 0.14 to 0.41 standard deviation units, on average, for caregiver burden, depression, subjective well-being, perceived caregiver satisfaction, ability/knowledge and care receiver symptoms. Intervention effects were larger for increasing caregivers` ability/ knowledge than for caregiver burden and depression.
Psycho educational and psychotherapeutic interventions showed the most consistent short term effects on all outcome measures. The researchers concluded that a Professional Training manual and video should be produced for an audience of physical and occupational therapists as well as other rehabilitation-oriented health care professionals. These materials explain the importance of a thorough seating assessment, how to conduct an assessment, and how to prescribe appropriate products that meet the persons` identified needs and a report on policy, resource, and cost implications of individualized seating was produced. The report is intended for policy makers, funding agencies, and nursing home administrators.35
A Interventional study is being done for comparison of impact of Breast Feeding
Counseling of Mothers And Use of Audio-Visual aids on Breast Feeding Rates at Six Weeks
Postnatal age at Deen Dayal Upadhyay Hospital, from September 2009 with a purpose that counseling of mothers will increase exclusive breast feeding rates at 6 weeks postnatal age. In developing countries like India, there is shortage of staff and the number of new born cared is huge. So counseling of mothers for breast feeding becomes difficult. In such situation using audio-visual aids may be a more practical option to increase breast feeding rates. Therefore the investigators will compare the use of video module with counseling for exclusive breast feeding. The principal investigator will visit the postnatal wards daily except on holidays and look for eligible mothers who will be asked for written and informed consent. Those who give the consent will be enrolled and randomized to counseling group, video group and control groups. The mothers in the intervention group will be counseled along with the husband and mother/mother-in-law/female caretaker. The mothers in the video group will be shown a video on breast feeding. The baseline characteristics of the three groups will be recorded. The mothers in the control group will receive standard care.36
A study was conducted wit a mission to develop a multi media educational module for a broad audience of medical professionals, focusing primarily on improving module user’s skills in interacting with patients with developmental and intellectual disabilities by a team of nursing faculty, medical faculty and social workers at the University of Kentucky in 2006.
The results suggested that CD-ROMS provided a better vehicle for high quality video modules than did web based applications and they concluded that CD-ROMS could serve as a future reference tool for primary care provider students as they entered into clinical practice.37
A study was conducted with a purpose to find out the effectiveness of instructional methods on the performance of students having different cognitive styles among 80 students,
40 in control group and 40 in experimental group in 2003. The results showed that the students in experimental group showed significantly higher performance than control group in achievement test. The study concluded that students who participated in discussion based group work scored high than students who were conveniently taught also and it is certain that some other factors and cognitive styles have also effect in student’s performance in any topic that is learnt.38
A study was done to assess the effectiveness of nosocomial infection control training in improving knowledge in patient hired attendants and outsourced workers among 1467 samples in Taiwan in the year 2003. A training model including nosocomial infection control guidelines, a training CD, training program, evaluation form and descriptive procedures was built and evaluated training effectiveness in terms of improved knowledge. The results suggest that the model could positively influence clinical practice, improve patient safety and reduce hospital nosocomial infection rates. The researcher concluded that this type of program is worth promoting in hospitals and other healthcare institutions.39
A prospective study was conducted to compare the clinical outcomes of two groups of patients undergoing laser transurethral resection of prostate (TURP) at a metropolitan hospital in Melbourne in 1998. The study compared the effects of two different patient
Education methods used prior to discharge. Results indicated that patients who received video based post-operative education had significantly greater knowledge, lower frustration and higher acceptance levels than a matched group of controls. There was no difference between the groups in a psychomotor performance index or in the rates of microbial contamination at five days post-operatively. The findings suggest that video based education methods may be effective in positively influencing cognitive and affective domains, however, where a patient needs to learn a new manual skill, it may be more effective for nurses to concentrate their efforts on demonstration, supervision and support.40
A study was conducted to assess the effectiveness of video modeling in 2008 to educate patients based on computer search of the electronic databases of Medline and
CINAHL between 1990 and 1999 with a total of 40 research studies on video instruction for patients and found that the use of video modeling has potential benefits for clinical practice in facilitating knowledge acquisition, reducing preparatory anxiety, and improving self care and it offered the benefit of videotaped procedures.41