A Study To Assess The Knowledge And Practice Regarding Minor Disorders Of Pregnancy And The Incidence Among The Mothers Who At

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

A STUDY TO ASSESS THE KNOWLEDGE AND PRACTICE

REGARDING MINOR DISORDERS OF PREGNANCY AND THE

INCIDENCE AMONG THE MOTHERS WHO ATTEND OPD IN

SELECTED HOSPITAL, KOLAR, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

M.MARIE ROSY

A.E & C.S PAVAN COLLEGE OF NURSING, KOLAR.

1 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

Ms. M.MARIE ROSY 1. PAVAN COLLEGE OF NURSING, NAME OF THE CANDIDATE KOLAR – 563 101 , AND ADDRESS KARNATAKA.

A.E& C.S PAVAN COLLEGE OF NURSING, 2. NAME OF THE INSTITUTION KOLAR- 563101

1 YEAR M.Sc. NURSING OBSTETRICS COURSE OF STUDY AND 3. AND GYNAECOLOGICAL NURSING SUBJECT

4. DATE OF ADMISSION TO 30.05.2007 COURSE

A STUDY TO ASSESS THE 5. TITLE OF THE TOPIC KNOWLEDGE AND PRACTICE REGARDING MINOR DISORDERS OF PREGNANCY AND THE INCIDENCE AMONG THE MOTHERS WHO ATTEND OPD IN SELECTED HOSPITAL, KOLAR, KARNATAKA.

2 6: BRIEF RESUME OF INTENTED WORK

INTRODUCTION:-

‘Pregnancy is special, let make it as safe’

(- Who Theme on 1998)

Every pregnancy is a unique experience for the women and each pregnancy that the women experience will be new and uniquely different. (1)

Reproduction though considered to be an usual process in the life of a women, is stressful and can lead to the risk and threats in reproductive age group women unless, appropriate measures are taken in time, it may reach its peak and endanger the life of mothers. (2)

In any community, mothers and children constitute a Priority group. In India, women of the child bearing age (15- 44 years) constitute 19% and children under 15 years of age about 40% the total population of about 100 million. By virtue of their numbers, mothers and children are the major consumers of the health services of whatever form.

In recent years maternal and child health (MCH) service in India have been integrated into the basic health services with increased emphasis on risk approach in order to improve the maternal and child health.

Pregnancy is a period of great anabolic activity, when the most rapid rate of growth takes place. It is a condition in which the fatal growth is accompanied by extensive changes in the maternal body composition and metabolism (17) mothers and children not only constitute a large group, but they are also a “vulnerable” or special risk group, the risk is connected with child bearing in the case of women. (3)

Understanding the common disorders of pregnancy in order to advise the women on strategic that help her to cope with the condition and minimize the effects she experiences. Although such disorders are termed as “minor disorders” they are far from minor for the woman, who is experiencing them. (4)

3 The majority of discomforts experienced during pregnancy can be related to either hormonal changes or the physical changes related to the growing uterus.

Today, nurses and midwives have an important role in health promotion, bring the health care manufacturers. The midwife is posed to a unique function of identifying and providing huge standard of antenatal care that contributes to the maintenance of good health and minimize the severity of the disease. (5)

It also indicates that, it for those who have poor knowledge regarding minor disorders during pregnancy. It is to be estimated that most of the ailments com be controlled through proper education.

6.1 NEED FOR THE STUDY:-

Pregnancy is a biological function and an integral part of the social environmental, bringing joy to the mother and family. This can turns into a tragedy where a woman loses or suffers a catastrophic herself. (6)

It is the social injustice and discrimination against women for several countries, which have made us to believe, firmly and resolutely, that women’s plague from the womb of her mother till she bids “adieu” to this world – is only because she is woman. (4)

The vulnerability of her being a women’s life. To fight against these ends, ideas expanded from the confine s of pregnancy and child birth to looking after the health of her reproductive system as a whole and those of her partner. (2)

A woman who is pregnant for the first time enters pregnancy with certain beliefs, attitudes & knowledge towards child bearing. Some of which are unscientific and unhealthy like eating papaya will cause abortion, consuming plenty of food and water will make the baby oversize and make deliveries difficult. These misconceptions need to be corrected for the sake of the child as will as the mother, through proper information.

A study conducted in primary health centre at periyanaickenpalayam, Coimbatore district, [November – 1993- published master’s nursing thesis assessment of antenatal nursing services at PHC periyanaickenpalayam, Coimbatore]. This study has recalled that 60% of antenatal mother had the history of common discomforts during pregnancy, nausea – 47% , vomiting – 87%, fatigue – 70%, giddiness 89%, heartburn 55% back pain

4 24%.A minor disorder of pregnancy may bad to a serious complication like morning sickness that develops into the hyper emesis grand arum, a condition, which begins as a minor disorder and become a life threatening abnormality. So make the mother as alert as possible to any complication and referral is important for that she must always educate when the changes of pregnancy are understood and it is easier to tolerate and avoid unnecessary anxiety.(7) The healthy mother brings forth the healthy child. So many of the minor disorders can be controlled and prevented using existing knowledge and affordable tools to the primi gravid mothers. (1)Before providing the health education to the prim gravid mothers it is essential to know what they want to know certain aspects of self and child health such as:

a) Changes and effects of the changes in her own body. b) Protection of the baby in the uterus and how to keep him/her healthy. c) Adjustment to the expected motherhood and effects of pregnancy on her beauty and comfort is of grater concern in primi gravid.(3)

Investigator in her own experience in community found that the antenatal mothers had inadequate knowledge and the remedial measures for minor discomforts. So the investigator was interested in assessing the mother’s knowledge practice regarding the minor discomforts. Further, it facilitates birth of a normal healthy baby with healthy mother.

6.2 REVIEW OF LITERATURE: -

Literature review is one of the major components of the research process.

According to polite & Hungler (1997) , literature review is refer to the activities involved in identifying and searching for information on a topic and developing an understanding ,of the state of knowledge on the topic.

The literature review for this study is presented under the following sub-division:

Part I : Minor disorders of pregnancy

Part II : Causes of minor disorders

Part III : Remedial measures of minor disorders

5 Of pregnancy.

Part I : MINOR DISORDERS OF PREGNANCY :-

The anatomical and physiological changes in pregnancy are associated with what are perceived by many women as minor disorders or ‘nuisance’ problems of pregnancy. The majority of women will put up with these as normal ‘part and parcel’ of pregnancy, not wishing to appear to be making fuss. Professionals involved in the care of pregnant women have a role to offer advice and reassurance regarding the nature of these symptoms. The majorities of these complaints are trivial in medical terms but may be the cause of considerable discomfort and distress to many pregnant women. (7)

Providing empathetic and sound advice about measure to relive these discomforts helps promote the overall health and well being of a pregnant client. They may not seem minor to the women who wakes up each morning feeling nauseated, wondering, if she will ever feel like herself again. Also, each of these symptoms has the potential to lead to problems that are more serious. (8)

Minor disorders may occur due to hormonal changes, accommodation changes, metabolic changes and postural changes. Every system of the body is affected by pregnancy. The mother needs knowledge to cope with the experience of pregnancy. She also needs knowledge when she present with discomforting or worrying symptoms. (9)

Haubran (1979) studies have shown that discomforts among ante natal mothers are common and there is a need to develop and implement planned education in comfort measures specifically to each trimester. Assessment of the discomforts serves as the basis for instruction to initiate a change in patients’ behaviors to improve, maintain and restore equilibrium. (10)

Dines A .et. al .( 1999) has confirmed that , nurse can anticipate these discomforting symptoms and provide anticipatory guidance for women who have a knowledge of the physiological basis for discomforts of pregnancy are also apt to become overly anxious concerning their health . An understanding of the rationale for treatment promotes their own care. Nurse need to use common terminology that the women can understand and enabling people to be more autonomous in relation to their health by imparting knowledge about health risks. (7)

6 PART II - CAUSES OF MINOR DISORDERS OF PREGNANCY:-

The minor disorders during pregnancy can be classified according to the trimester, it is follows as in 1 st Trimester a. Nausea b. Vomiting c. Fatigue d. Frequency of micturation

2 nd Trimester a. Heart burn b. Constipation c. Vaginal discharge d. Back ache

3 rd Trimester:- a. Hemorrhoids b. Leg cramps c. Edema d. Varicosities

Above mentioned minor discomforts are explained below:

Nausea & Vomiting:-

Nausea & Vomiting are very common problems of early pregnancy and can be result in first trimester being viewed as a miserable time. (7)

As many as 50 % of pregnant women report nausea and vomiting.(8)

Vomiting may start as early as 6 weeks gestation and usually settles by 13- 14 weeks.(7)

Hormonal influences are thought to be the most likely cause.(9) The precise etiology is unknown, but it may be related to

7  Sensitivity to the high levels of chorionic Gonadotropin hormone produced by the Trophoblast.  High estrogen or progesterone levels.  Lowered maternal blood sugar caused by the needs of the developing embryo.  Lack of pyridoxine ( vitamin B6 )  Diminished gastric motility. (8)

Psychological factors may also have a role through their direct action on the emetic centre in the mid brain. Symptoms tend to recur in a quarter of women in a subsequent pregnancy. The smell of food cooking will often cause the mother to retch. (9)

Some authorities consider that morning sickness is a minor form of the toxemia of pregnancy, and that the reason why it is not so common in multi paral is that they have become immune to their first pregnancy. If the patient vomits food repeatedly the case becomes one of the neurotic vomiting or hyperemesis gravid arum. (11)

Snell .et all (1998) nausea and vomiting are said to affect over 50% of pregnancies. (5)

Fatigue:-

Flax man and Sherman 2000. Nausea and vomiting are aggravated by fatigue and may aggravate by emotional disturbance.

Bobak and Jenson (1993) have noted that, fatigue may cause by increased levels of estrogen and progesterone, HCG levels and increased metabolic rate. (8)

In early pregnancy fatigue may occur due to vasodilatation under the influence of progesterone. Later in pregnancy, a mother may feel fainting while lying flat on her back. This is because the weight of the uterine contents presses the inferior vena cava and slows down the return of the blood to the heart. (11)

Fatigue is probably due to increased metabolic requirement. They know that pregnancy is not an illness, and so they proceed as if nothing is happening to them. (12)

Frequency Of Micturation: -

8 It occurs in early pregnancy due to the pressure of the gravid uterus o the anterior bladder. The sensation may last for about 3 months, some times beginning as early as the first or second missed menstrual period, disappear in the mid pregnancy. (12) When the uterus rises into the abdominal cavity this pressure is relieved. During the last fortnight the uterus sinks and the pressing on the bladder, again causes frequency. (10) Frequency may also due to an increased secretion of urine, to the incontinence of retention occasionally a retroverted uterus may fail to become spontaneously ante-averted, and if remains retroverted after the 14th week may become incarcerated in the pouch of Douglas. This leads progressively to frequency and dysuria and eventually to urinary retention and overflow incontinence. It is important always to exclude urinary tract infections with any urinary symptoms. (13)

Valancogne G. et al (1993) has conducted a study on pregnant women relating to frequency of micturition. He has revealed hat 30- 40 % of women suffer due to his problem while 60 -80 % of women are resolved. He has also quoted that pernieo spincter exercises will improve the perineal tone. (14)

In a convenience sample of 50 pregnant women who have received care at a prenatal clinic in United States (2003) 62 % of came reported to have some degree of involuntary urine loss during pregnancy. (15)

HEART BURN:-

Heart burn starts towards the end of 2nd and 3rd trimester. (5)

Pyrosis or heart burn is a burning sensation along the esophagus caused by regurgitation of gastric contents into the lower esophagus. In pregnancy, it may accompany nausea, but it may persist beyond the resolution of nausea and even increase in severity as pregnancy advances. (8) Heart burn is most troublesome at about 30th to 40th week of gestation, because at this stage. The stomach is under pressure from the growing uterus. (9)

Heart burn is medicated by relaxation of the physiological sphincters of the stomach due to elevated progesterone levels. The resulting reflux of the acid gastric contents and bile irritates the lower esophagus and may also contribute to nausea and vomiting. The Problem is aggravated by smoking, and wearing tight clothing. (13)

9 Dianne Jo Moore (1999) has proved by the study, heart burn is a painful retro sternal burning sensation as a result of a growing uterus pressing on the stomach, raising progesterone levels and decreased gastric motility. Advise the mother to take little amount of frequent foods. Avoid bending and lying down after taking food. (5)

Constipation:-

Constipation is one of the most common problems encountered in pregnancy, (13) especially in the later months of pregnancy. (6)

It is due to the smooth muscle relevant effect of progesterone (13) pressure of the gravid uterus on the colon near term make it worse as the colon gets displaced. (16)

This is a frequent ailment of pregnancy. Delayed emptying of bowel is considered to be due to diminished tone intestinal muscles, restriction activity and improper diet.(11)

It also tends to produce hemorrhoids. Strong purgatives should be avoided, because they are apt to cause miscarriage (17) the reduced gut motility is also aggravated from iron supplementation. (13)

Mammen (1990) studies have depicted that, many women experience constipation during pregnancy, especially in the 2nd and 3rd trimester due to the sluggishness of the intestines. Increasing in take of fresh fruits and vegetable, whole grain cereals, fluids, especially adequate intake of water may offer relief. (7)

Vaginal Discharge:-

Leukorrhea is a profuse, thin or thick vaginal secretion that begins during the first trimester.(14) It is a whitish, an increase in the amount of normal vaginal secretions, occurs in response to the high estrogen levels and the increased blood supply to the vaginal epithelium and cervix in pregnancy.(8)

The secretion is acidic because of the conversion of an increased amount of glycogen in the vaginal epithelial cells into lactic acid by Doderlein’s Bacilli. This serves the function of protecting the mother and fetus against possible harmful infection; it does provide a medium that fosters the growth of the organisms responsible for virginities. The productivity of the cervical glands in secreting an increased amount of mucus plug may also contribute to leucorrhea.(18) Vaginal discharge is to be clinically differentiated from

10 pathological discharge and the latter needs laboratory examination of discharge. Pregnancy leucorrhoea needs no treatment but assurance.(11)

Broncoyn Mayden (1997) has found that, vaginal discharge is normal for the pregnant women to have increased vaginal discharge (leucorrhoea) resulting from increased estrogen levels. Irritation can be relieved by wearing loose cotton or cotton lined under garments. Instruct women to keep the perineal area clean and dry. (6

Backache:-

This is usually complained of even at early pregnancy being worse at later month back ache is mostly postural. (11)

It is due partly to the relaxation of ligaments and partly to the posture adopted by many women to balance the weight of the gravid uterus. (16)

As pregnancy advances, a lumber lordosis occurs and postural changes necessary to maintain balance may lead to backache. (8)

The problem is exaggerated if the women’s abdominal muscles are lan; they fail to give any support to the heavy enlarged uterus. Weakness of the abdominal muscle is more common in grand multi paras who have not exercised and regained their abdominal muscle bone after each pregnancy. Backache, thus generally increases in severity with parity. (16)

Backache may also result from excessive bending, walking without rest periods, and lifting, especially if any or all of these are done when the woman is tired. Such activities add strain to the back.(18 )

Backache can be an initial sign of a bladder or kidney infection. thus obtaining a detailed account of the women’s symptoms is crucial to ensure that she is describing only backache. (12)

J.Perkins, R.L.Hammer (1998) has estimated that 48.56% of all pregnant women had backache wearing low healed flat chapels offer some relief. Instruct mother with regard to good posture and explain body mechanisms. (10)

11 A study on backache, survey of 107 pregnant mothers 72% of respondents had significant backache and 53% reported the cause of working in her home situation the prevalence was not affected by gestational age. (19)

Hemorrhoids:-

Hemorrhoids (varicosities of the rectal veins) occur commonly in pregnancy because of pressure on these veins from the bulk if the growing uterus. (8)

Hemorrhoids develop or get aggravated during pregnancy due to relaxation of vascular smooth muscle by progesterone, and constipation. (16)

In addition, the enlarging uterus causes increasing pressure – specifically in the hemorrhoid veins as well as generally; the pressure interferes with venous circulation and causes congestion in the pelvic veins. (18)

Leg cramps:-

In the later weeks of pregnancy, the patient may complain of cramp on the muscles of the calf and the back of the thigh. The cramp is considered to be due to inefficient calcium metabolism with which the parathyroid glands are concerned. It may be partly due to pressure on the savor- sciatic plexus by the head of the child. (17)

Cramps have been attributed to deficiency of Vitamin B and decreased levels of calcium. Night Cramps may be related to ischemia of the leg muscles, and often relieved when the patient sleeps with the foot end of the led elevated by 20 to 25 cm. (16)

For a number of years, leg cramps were thought to be caused by inadequate or impaired calcium intake or an imbalance in the calcium phosphorous ratio in the body, but these causes are no longer stated in the current literature.

Another school of thought is that the enlarged uterus exerts pressure either on the pelvic blood vessels, thereby impairing circulation, or on the nerves as they course through the obturator foramen on their way to the lower extremities. (18)

In a study by Valbo and Bohmer (1999), 120 women were sent an questionnaire 3 days post delivery to assess the extent to which they had suffered leg cramps during

12 pregnancy. The results revealed that 45% had suffered leg cramps during pregnancy, 54% of the women had suffered leg cramps after the 25th week of pregnancy and 76% of the women had experienced the symptoms twice a week of less, which demonstrates that leg cramps are common disorders of pregnancy. Advice the women to do some leg stretching before retiring to bed, women should advise to flex the foot of in the opposite direction. (10)

Edema:-

Dependent pedal edema is the result of impaired venous circulation and increased venous pressure in the lower extremities. These circulatory disturbances are caused by pressure of the enlarging uterus on the pelvic veins when the women is sitting or standing and on the inferior vena cava when she is supine. Any constrictive clothing that inhibits venous return from the lower extremities adds to the ankles and feet and edema associated with pre -eclampsia / eclampsia. (18)

Swelling, which pits on pressure, of the feet, hands, face or eyelids may be due to cardiac or renal disease, to the toxaemia of pregnancy to pressure of the uterus on the veins of the pelvis, which is more probable if the blood is in a watery condition.

The midwife remembers that, while a rise of blood pressure is the earliest sign of toxaemia of pregnancy, edema, though it appears later, is an important symptom. (17)

Varicosities:-

These may develop on the vulva and the inferior endometriosis towards the end of the first trimester and get worse up to term most of the enlarged veins disappear after delivery, sometimes completely. (16)

Varicosities are common in pregnancy, because the weight of the distended uterus puts pressure on the veins returning blood from the lower extremities. This course pooling of blood in the vessels. The veins become engorged, inflamed, and painful.

Varicosities can extend to the vulva. They occur most frequently in women with a family history of varicose veins and those who have a large fetus or a multiple pregnancy. (8)

Progesterone relaxes the smooth muscles of the veins and results in sluggish circulation the values of the dilated veins become inefficient and varicosities results. Mothers with a

13 family history of varicose veins and those doing works which demands long periods of standing sitting usually, develop varicose veins. (20

PART –III REMEDIAL MEASURES OF MINOR DISCOMFORTS:-

NAUSEA AND VOMITTING:-

The midwife can explain the probable reasons and encourage the mother to look positively towards the resolution of the problem, which may happen between 12th and 16th week woman have found the following as helpful practices:-

1. Salads and light snacks are more tolerable than full meals 2. Carbohydrate snacks at bedtime can prevent hypoglycemia, which is often shown as a cause of nausea and vomiting. 3. Dry toast or biscuit on waking up and breakfast after half an hour. (9) 4. Eat small, frequent meals, even as often as every 2 hours, as these are more apt. to be retained than three large meals a day. 5. Do not brush your teeth immediately after eating to avoid stimulating the gag reflex. 6. Drink carbonated beverages- especially gingerly. 7. Avoid foods with strong or offensive odors. 8. Restrict fats in your diet. 9. Try acupressure wristband 10. Keep in mind that nausea will most likely and sometimes during the 2nd trimester. 11. Rest 12. Use medications. There are two issues with the use of drugs; teratogenicity and effectiveness; Phenothiazines, Prochlorperazine, meclizine and cyclizine are effective in controlling vomiting, not teratogenic when taken in doses recommended for pregnant woman. (16)

Vicky woman (1993), has said that nausea and vomiting are a combination of hormonal. Psychological they may have a casual effect during pregnancy. They occur in 50 to 80% of all pregnant women. They usually improve about the 10th gestational week. They are often relieved by taking dry crackers before arising in the morning others helpful

14 measures include eating small, frequency meals every 2 to 3 hours and avoiding fatty, freed foods. Sit up right after meals, to reduce the frequency of gastric reflux.(21)

Show et al (1989) has conducted a prospective study on dietary practices related to nausea and vomiting among urban blacks. This study has highlighted that relationship between dietary practices and pregnancy discomforts among fifty urban blacks. It shows that increase intake of cities fruits but low in take of vitamins and iron supplements co. related with constipation and heart burn and sleeping difficulty. Hence, this study show, the appropriate diet during antenatal period will reduce certain discomforts like nausea, vomiting, heart burn, constipation and insomnia. (25)

(Signorello et al 1998) to investigate the effect of pre pregnancy dietary fat intake on serve hyperemesis. They concluded that a high total fat intake and particularly one high in saturated fat increased the risk of serve hyperemesis. This study would suggest that a well balanced diet containing all the required food groups in adequate proportions prior to conception could reduce the incidence of this disorder. (2)

Diloria, E .et.al (1994) conducted a study on recommendation by clinicians for nausea and vomiting of pregnancy. The purpose of this study was to assess the current use of relief measures for nausea and vomiting of pregnancy among clinicians. The findings of the study indicate that clinicians generally recommended eating small frequent meals based on the severity of the symptoms. Clinicians perceive varying degrees of effectiveness of relief measures with no one measure being totally effective, and that clinicians look at patient as the primary resource for information about nausea an d vomiting of pregnancy. (23)

Frequency of Micturation:-

There are no solutions for decreasing the frequency of micturation suggesting a woman reduce the amount of caffeine she is drinking may be helpful. Doing legal exercises helps to strengthen urinary control, directly strengthen perineal muscles for birth and decreases the possibility of stress incontinence. (8) Decrease in fluid intake before bedtime so that the woman need not make many trips to the bathroom when she is trying to sleep. (18)

Wear perineal pad; refer to physician for pain or burning sensation. (12)

Heart burn:-

15 The following suggestion can be made:-

i) It may be relieved by eating small meals frequently and by not lying down immediately after eating, to help prevent reflux ii) Administer Aluminium hydroxide (Amphojel) or a combination of aluminium and magnesium hydroxide (Maalox) may be prescribed for relief. (8) iii) Eat small, frequent meals, to avoid overloading of your stomach. iv) Maintain good posture, to give more room for your stomach to function; slumped posture only adds to the problem by allowing further pressure on your stomach. v) Stretch your arms high over your head, to give room for your stomach to function. vi) Avoid fats with meals; fat depresses both motility of the stomach and the secretion of gastric juices needed for digestion. vii) Avoid beverages with meals, since liquids tend to inhibit gastric juices; a dry diet without bread stuffs has helped some woman. viii) Avoid very cold foods with meals. ix) Avoid spicy foods or other foods causing indigestion. x) Drink cultured milk rather than sweet milk, this has helped some woman. xi) Drink skim milk and or eat too fat ice cream; this has helped some woman. xii) Avoid healthy foods or a full meal just before bed time. (18)

Koniak Ciriffin D et al (1994) has revealed that aerobics exercise will reduce major discomforts like heart burn. Health education can be an important aspect of prenatal self care for healthy pregnant woman. (19)

Constipation:-

The following remedial measures for constipation are most effectively:-

i) Encourage mother to evacuate her bowels regularly, ii) Encourage to increase the amount of roughage in her diet by eating raw fruits, bran, and vegetables; and to drink at least eight glasses of water daily. (8) iii) Adequate rest; this may require rest periods during the day. iv) Prunes or prune juice; prunes are a natural mild laxative. v) Warm liquids (e.g. water, tea) on rising, to stimulate peristalsis.

16 vi) Foods that contain roughage, bulk, and natural fibers (e.g. lettuce, celery, bran) vii) General exercises, a daily walk, good posture, good body mechanics, and daily exercise of contracting the lower abdominal muscles; all of these measures facilitate venous circulation, thereby preventing congestion in the large intestine. viii) Mild laxatives, stool softeners, and or glycerin suppositories if Indicated vaginal discharge (18)

A too centre study b y Anderson (1984), that included pregnant women from Israel and England demonstrated that 11% and 38% respectively of women in these countries identified themselves as being constipated. The lower rate in women from Israel is thought to be due to the higher amount is important that woman also has an adequate fluid intake which will keep the stool soft and easy to pass. (12)

Muller (1995) has highlighted certain issues constipation is a common problem during pregnancy. It is essential to relieve the condition without putting the developing child at risk or further stressing the mother. Administration of dry lactulose (Dupha lac dry) seems to be very effect in the case of chronic or occasional constipation. Results showed that the frequency of defecation was significantly increased after week. (7)

Vaginal discharge:-

The premedical measures are stated below:-

 A close attention to bodily cleanliness on the area and frequent changes of cotton gotch panties.  A woman should not douche or use feminine hygiene sprays (14)  Caution woman not to use tampons, however, because this could lead to stasis of secretions and subsequent infections.  Pantyhose may help prevent vulvar and vaginal infections, particularly yeast infections  Advise women to contact their physician or nurse. Midwife if there is a change in the color, odor, or character of this discharge which might suggest infection.

Back ache:-

17 Proper body mechanics for lifting are essential to avoid this type of muscular stain. There are two principles to be followed:-

(i) Stoop, rather than bend, to lift anything e.g. toddler groceries) so that the leg (thigs) rather than the back, bear the weight and strain. (ii) Spread the feet apart and place one foot slightly in front of the other when stooping so there is a broad base for balance when rising from the stooped position.

Relief measures for backache are as follows:-

1 ) Good posture’ 2 ) Proper body mechanics for lifting 3 ) Avoidance of excessive bending, lifting or waling without rest period 4 ) Pelvic rock / pelvic tilting exercises 5 ) Supportive low heeled shoes; high heals are unstable and further exaggerate the problem of the enter of gravity and lordosis. 6 ) If the problem is severe, external abdominal support is advisable (e.g. maternity girdle or supportive elastic “ Belly Band”) 7 ) Warmth (not too hot) on the back (e.g. heating pad, warm bath, sitting in a warm shower) 8 ) Ice packs on the back 9 ) Massage / back rub. 10 ) For resting or sleeping.

a) a supportive or mattress b) positioning with pillows to straighten the back and alleviate pulling & strain (18)

Backache is relieved by exercise and maintenance of good posture. When sitting and standing, taking short rest periods and wearing comfortable footwear during the periods of activity may be helpful (Francis, 1988). Maintaining correct posture also will be helpful. Experts have recommended the chair to those who suffer from mussels skeletal problems. (7)

Hemorrhoids:-

18 Preventive measures early in pregnancy may be effective in reducing their severity.

The following listing of relief measures for hemorrhoids:-

(a) Daily bowel evacuation helps to prevent the formation of hemorrhoids. (b) Resting in a modified Sims position daily also is helpful. (c) At day’s end, assuming a knee-chest position for 10 to 15 minutes at first, and then gradually increase the time until she can maintain the position comfort ably for about 15 minutes (d) Avoidance of staining during defecation (e) Sits baths, the heat of the water not only gives comfort but also increases circulations (f) Witch hazel compresses ( for reduction) (g) Ice bag ( for reduction) (h) Epson salt compresses ( for reduction) (i) Reinsertion of the hemorrhoids into the rectum (using lubrication) in conjunction with perineal tightening (kegel) exercises. (j) Bed rest with hips and lower extremities elevated (k) Analgesics Ointments and or topical anesthetics. (18)

Mukla Nadig (1988) has proved by the study that the hemorrhoids of mother can be managed mothers are advised to prevent constipation through dietary management, establishing regular bowel habits and limiting eh amount of standing and sitting cold or warm soaks, ointments and suppositories are also useful in treating pain and the edema associated with hemorrhoids mothers are asked to avoid chilies and all pungent spices, non-vegetarian diet, tea, coffee, betel leaf tobacco chewing and alcoholic drinks during the course of treatment.

Prot Care (2001) emphasized on treatment of hemorrhoids in pregnancy among mothers. He advised the mothers to take balanced diet with plenty of water and high fiber diet, cleanliness of the anal area is important. (21)

Leg Cramps:-

Relief measure as follows:-

19 1) Have the woman straighten her affected leg and point her heal (i.e. clorsiflem her foot). If the woman is in bed, she needs strong steady pressure against the bottom of her foot, either someone’s hand or the footboard of the bed, to floor serves this function. This measure is nearly guaranteed to instantly alleviate an acute leg cramp 2) Encourage general exercise and a habit of good body mechanics 3) Recommended leg elevation periodically through out the day 4) Recommend a diet that includes calcium and phosphorous. (24) 5) If the mother is having frequent leg cramps, she may need a prescription for aluminium hydroxide gel (Amphojel), which binds phosphorous in the intestinal bract and thereby lowers its circulating level. (8)

Katherine (1995) has suggested that muscle cramps could be relieved by forcing the toes upward by putting pressure on the knee straighten the legs and increased of calcium in the diet. (19)

Insomnia:-

The time honored relief measures for insomnia may or may not be effective for many women they are at least something to do.

i) Warm baths ii) Warm drink (milk, decaffeinated tea with milk) before going to bed iii) Non stimulating activity prior to going to bed iv) Use relaxation positions v) Use the techniques of progressive relaxation (18)

Mead Bennett E (1990) has given an article related to insomnia during pregnancy studies indicate that sleep is disturbed throughout the maternity cycle. The sleep disturbance leading to reduced sleep time has been associated with a variety of physical behaviors and psychological problems. It concludes that insomnia in pregnancy will affect their health. Nursing intervention is to identify sleep deficit and promote sleep as required al all stages of the maternity cycle. Knowledge of sleep structure and the role of each stage of sleep are prerequisite in understanding the value of sleep in health. (10)

Edema:-

20 Remedial measures include the following:-

 Edema can be relieved best by resting in a left side- lying position because this increases the kidneys glomerular filtration rate and allows good venous return.  Sitting for half and hour in the afternoon @ gain in the evening with the legs elevated is also helpful.  Women should avoid wearing constricting clothing such as panty girdles or knee high stocking because these impede lower extremity circulation and venous return  Some women need reassurances that ankle edema is normal during pregnancy otherwise they worry that it is a beginning sign of PIH (8)

Judith. A Me line (1993) has found that, physiological edema is common during pregnancy. For managing this problem the mother has to adopt certain comfort measures like bed rest. Elevate her legs, while sitting, restrict salt, restricted food or to take more fluids, and avoid wearing tight clothing that cause pressure on pelvic and leg blood vessels. (7)

Varicosities:-

Varicosities during pregnancy are most pronounced in the legs and or valve. Remedial measures specific to vulvar varicosities are so noted in the following list of suggestion to a woman:-

1) Use support hose, Ace bandages, or elastic stockings; whichever is used should be put on after elevating your legs and before arising 2) Avoid cons tribute clothing (e.g. knee high or ankle hose, round garters) 3) Avoid long periods of standing 4) Have rest periods, with your legs elevated, periodically throughout the day 5) Lie in the right ankle position several times daily 6) Assumes the incline position several times daily ( for vulvar varicosities) 7) Keep your legs uncrossed when sitting 8) Sit whenever possible, preferably with your legs elevated, rather them Provide physical support for vulvar varicosities with a foam rubber pad held in place with a sanitary belt 9) Wear a maternity abdominal support or griddle to relieve pressure on your pelvic veins

21 10) Do Kegel exercise for valvar varicosities or hemorrhoids, to increase circulation. 11) Take warm, soothing baths (18)

Marhie C (2002) has suggested that varicosities can be relieved by taking rest or lying flat. Advise the woman to raise her legs for abrit 5 to 10 meters several times a day. Rotate the ankle about 10 times to the left and right while the legs are elevated.

Mrs.C.Josephine.R Little Flower (1996) conducted a study on nursing comfort measures to antenatal mothers on discomforts, which revealed mean knowledge score in the pretest (0.95) and the significant increase in the post test mean score (4.1).(7)

Discomforts are experienced by most of the pregnancy mothers and affect their health and the health of growing fetus.(25) The above literature and study finding reinforce the need to develop appropriate measures to be performed by mother in order to overcome the discomforts by adopting comfort measures to antenatal mothers.

Statement of the problem:-

The study to assess the knowledge and practice regarding minor disorders of pregnancy and the incidence among the mother who attend OPD in selected hospital Kolar, Karnataka.

6.3 Objectives of the study:-

1) To determine the incidence and prevalence of minor disorders during pregnancy. 2) To assess the knowledge of the mother on the discomforts during pregnancy. 3) To assess the practices taken for the minor discomforts by the mothers during pregnancy.

To compare the knowledge and practices regarding minor disorders of pregnancy with selected demographical variable

6.4 OPERATIONAL DEFINITIONS:-

Knowledge:-

It refers to imparting the information to the mothers on the knowledge minor disorders of pregnancy, at selected hospitals by the investigators through formal teaching and later assess by using a questionnaire.

22 Practice:-

It refers to the mothers, are taking a remedies for minor discomforts experience during pregnancy.

Minor disorders:

It is a discomfort which is experienced by the mother during pregnancy

Mothers: It refers to the women who are pregnant.

Incidence:-

It refers to mothers in what way they are experiencing the discomforts during pregnancy.

Selected Hospitals:-

It refers to the conduction of this study in the Sri Narasimma Raj Hospital, kolar, settings, mainly the mothers who are attending the obstetric OPD clinics of Kolar, Karnataka.

6.5 HYPOTHESIS:-

H1 There will be significant association between the knowledge score and practices score of mothers regarding the minor disorders of pregnancy.

H2 There will be association between the knowledge score of mothers about minor discomforts and the selected variables.

H3 Association between the measures / practice score of mother and selected variables regarding minor discomforts of pregnancy.

ASSUMPTION:-

23 1) There is no specific antenatal education facilities provided in SNR hospitals regarding the minor disorders of pregnancy among mothers. 2) Primi and multi gravid a mothers differ in their knowledge related to discomforts occurring during pregnancy

6.6 Variables:-

6.6.1 Independent variables:-

Minor disorders of pregnancy.

6.6.2 Dependent variables:-

Antenatal mother

6.6.3 Extra neous variables:-

Demographic variables like age, occupation, education, income, marital status etc.

7. MATERIALS AND METHODS :

7.1Sources of Data :

The population includes mothers who are pregnant.

7.2 Method OF DATA COLLECTION :-

This study design is explorative method to asses the knowledge and the incidence among the mothers who attend the antenatal OPD in selected hospitals of kolar, at Karnataka.

7.2.1 Research Design:-

A explorative study approach is adopted in this study.

7.2.2 Setting:-

24 This study will conduct in the outpatient department of obstetrics and gynecology department in Sri Narasimma Raj Hospital, kolar Hospitals, and Kolar. This Hospital is 3 km from Pavan College of Nursing, Kolar. This area consist of 12, 1650 Population and 1217 no’s of floating population. It has female population of 55847.

In Sri Narasimma Raj Hospital, bed strength is 365. Where 200 antenatal mothers attend this clinic daily between 9 am and 1 pm and the antenatal ward bed strength is 20. Out of these 50% attend the outpatient department with minor discomfort occurring during pregnancy. Antenatal clinic is managed by the qualified obstetricians and Gynecological, and assistant consultants. Biochemistry laboratory, ultra sonography, and pharmacy are available in the antenatal clinic.

7.2.3 Population:-

The population for this, study includes all the pregnant mothers who are attending the antenatal outpatient at SNR Hospital, Kolar.

7.2.4. Sampling Techniques:-

Samples will be selected by convenient sampling method.

7.2.5 Sample Size:-

Samples size is 150.

7.2.6 CRITERIA FOR SAMPLE SELECTION:-

Inclusion Criteria:-

1) Pregnant mothers below 38 weeks of gestation 2) Pregnant mothers of all the age groups

Exclusion Criteria:-

1) Above 38 weeks of gestation 2) Pregnant mothers at high risk

7.2.7 Tools of data collection:-

Structured questionnaire consists of three parts.

25 Part – 1 It Consist of interview schedule related to demographical data.

Part – 2 It consists of check list of minor disorders of pregnancy.

Part – 3 It consists of objective questions regarding practices of minor disorders of pregnancy.

7.2.8 Methods of data collection:-

The structural questionnaire will be distributed among subject to educated ones and others (uneducated) are interviewed by investigator. Prior to the study, the purpose of the study will be obtained to involve in the study tentative period of data collection will be sep 2008, before that pilot study will be conduct and then necessary modification and further refinement of the tool will be done. Researcher himself will collect data.

7.2.9 Data analysis & interpretation:-

Inferential statistics will be used for data analysis and will present in the form of tables, diagrams & graphs.

7.3. Ethical clearance been obtained from your institution:-

Prior to the study the permission will be obtained from the concerned authorities to conduct the study in urban area of kolar and also from research committee of Pavan College of nursing, kolar. The purpose of the study will be explained to the mothers those who attending in the obstetrics and Gynecologic OPD of the Sri Narasimma Raj Hospital, Kolar.

7.4. Do the studies require any investigation or interventions to be conducted on patients / samples population / other humans or animals?

It does not require any treatment / intervention, since it is an explorative study.

26 Bibliography: -

Books: -

1) . Park‘s.k, “Text Book of Preventive and Social Medicine”, 17th edition, 2003, by M/S. Banarsidas Bhanot Publishers, Jabalpur, Pg. No -359 - 364. 2) The NSG Journal of India Volume XCVI No. 4, April 2005, WHO. Pg.No. 73. 3) The NSG Journal of India Volume LXXXXI, No. 3, March 2000, WHO. Pg.No.50-52 4) Usha B Sarauja , Kamini A Rao Alokendu Chatterjee , “Principles & Practices of obstetrics and gynecology for Postgraduates ”, 2nd Edition , 2003 , by Jayapee Medical brothers publishers ltd , NewDelhi , Pg .no . 7- 11. 5) Diane M. Faser M Margaret A Cooper, Myles, “Text Book for Midwives”, 14th Edition, 2003, by Churchill living stone, London, Pg no. 216-219. 6) Dutta D.C., “Text Book of Obstetrics Including Perinatalogy & Contraception”, , 6th Edition, 2004, by central book Publisher, Calcutta, Pg.No.102 - 103. 7) www.medlar.com.

27 8) Bo back Jenson, “Maternity And Child Health Nursing”, 5th edition, 1993, Mosby, London, Pg.No. 283- 325 9) Arthur.T. Evans, Wolters Kluwer “Manual of obstetrics”, , Lippincott, Villiams and Wilkins, Philadelphia, 7th edition, 2007, Pg.No. 12-13 10) www.google.com 11) C.S.Dawn, “Textbook of Obstetrics”, 14 th edition ,2003, Dawn books, Calcutta, Pg.No. 73-75 12) Adele Pillitleri ,“Maternity And Child Health Nursing ”, care of the child bearing and child rearing family, , 4th edition, 2003, by Lippincott Williams and wilkins , Philadelphia, Pg. no. 266-269. 13) Sabaratnam Arul Kumaran , v. Sivanessaratnam Alokendu Chatterjee , Pratap Kumar , “Essential of obstetrics” , by Shirish S Sheth , 1st edition , 2004 , Jaypee medical brothers Publishers , Pg. no. 115 -117 14) www.pubmed.com 15) An Exploratory study to assess the knowledge and attitude of primi gravida mothers regarding minor disorders of pregnancy with view to develop health education pamphlet, at Karnataka. 16) Dr. Rashmi patil, “Manual of Midwifery”, (Practical & Theory), Byvora medical publications, Mumbai, First Edition, 2004, Pg.no.60-63. 17) C.Berkeley, “A Handbook of midwifery” (for nurses & midwives, published by N.R.Brothers, Indore, First Edition, 1991, Pg.No. 85-88. 18) Varney’s “Textbook of Midwifery “, Carolyn, L.Gregor, Helen Varney, Jan M. Kriebs, All India Publishers and Distributors Reg. Medical Book Publisher, NewDelhi 4th Edition, 2005, Pg.No.591- 599. 19) www.medline.com

28 20) Annamma Jacob “ A comprehensive Text Book of Midwifery”, , Jaypee Brothers Medical publishers (p) Ltd., New Delhi, Foist Edition, 2005 Pg.No. 98- 101. 21) A study to assess the knowledge and practice of antenatal mothers regarding minor ailments and their remedies in selected hospitals of Dakshina Kannada 22) The NSG Journal of India Volume XCV No. 7, July 2004, Pg.No. 155-158. 23) The NSG Journal of India Volume LXXXX1I, No.2, February 2001, Pg.No. 33-34 24) The NSG Journal of India Volume LXXXX1I, January 1995, Pg.No. 4-8. 25) Pamela.S.Miles, William F.Rayburn, J. Christopher Carey, “Obstetrics and Gynecology,” by Japee Brothers P.B. New Delhi, First Edition, 1994, Pg.No.20-21

29 9 SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE

11. NAME AND DESIGNATION OF

11.1 GUIDE

11.2 SIGNATURE

11.3 CO- GUIDE

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT

11.6 SIGNATURE

12. 12.1 REMARKS OF THE PRINCIPAL

12.2 SIGNATURE