Rajiv Gandhi University of Health Sciences s137

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME REGARDING KNOWLEDGE AND PRACTICE OF PERINEAL HYGIENE AMONG POSTNATAL MOTHERS IN A SELECTED HOSPITAL AT KOLAR DISTRICT.

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

Mrs.SHANTHI REBEKA.J

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

KOLAR-563101 (KARNATAKA)

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

1 SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 NAME OF THE CANDIDATE Mrs. SHANTHI REBEKA.J & ADDRESS I YEAR M.Sc NURSING A.E.&C.S.PAVAN COLLEGE OF NURSING. KOLAR-563101 (KARNATAKA) 2 NAME OF THE A.E.&C.S.PAVAN COLLEGE OF INSTITUTION NURSING KOLAR 3 COURSE OF STUDY AND M.Sc. NURSING (OBSTETRICS SUBJECT & GYNAECOLOGICAL NURSING) 4 DATE OF ADMISSION TO COURSE 4-06-2008

5 TITLE OF THE TOPIC:- A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME REGARDING KNOWLEDGE AND PRACTICE OF PERINEAL HYGIENE AMONG POSTNATAL MOTHERS IN A SELECTED HOSPITAL AT KOLAR DISTRICT.

6. BRIEF RESUME OF THE INTENDED WORK INTRODUCTION

2 “For she said within herself, If I may but touch his garment, I shall be whole. Mathew 9; 21

Perineal hygiene involves cleaning the external genitalia and surrounding area. The perineal area is condunsive to the growth of pathogenic organisms because it is moist and is not well ventilated. Since there are many orifices (urinary meatus, vaginal orifice and the anus) situated in this area, so the pathogenic organisms can enter into the body.1 In order to prevent infection and bad odor perineal hygiene is important. Perineal hygiene is also called as ‘peri care’.2

The most pertinent principle for the perineal care is to clean the perineum from cleanest to the less clean area. The urethral orifice is considered as the dirtiest area. Because the orifices in the perineal area are in proximity, cross contamination is a potential problem. The normal flora of the urinary system is different from that in the gastro-intestinal system. Entry of organisms from the anal orifice cans cause urinary tract infections, because these organisms are foreign to the urinary tract. During the perineal care, clean the area around the urinary meatus before cleaning the area around the anus. The perineal area also has hair follicles which tend to harbour organism .3

Lack of perineal hygiene May leads to some other complications like puerperal pyrexia (rise in temperature), puerperal infection by hemolytic streptococci and other infections affects the genital tract. Perineal hygiene is important to prevent these complications.4

3 One of the objective of health for all by 2000AD stated that maternal mortality rate should be less by 2/1000 live birth necessary steps are initiated to improve the quality of maternal services. It is difficulty to achieve the aim.

According to WHO maternal mortality is currently estimated (2007) to be 529,000 deaths per year, a global ratio of 400 maternal deaths per 1000,000 live births. Between 11% to 17% of maternal deaths happen daily child birth itself, and between 50 to 70% in post partum period. South East Asia region accounts for 170,000 maternal death annually.5

In India for every minutes one Indian women dies from complications related to pregnant and child birth, which adds up to approximately 1, 30,000 women per year. Indian maternal mortality rate is higher 400 maternal deaths per 100,000 live births. Which in itself is very high compared to the International scenario like Sweden 8, U.K 10, Grees 2 and even neighbouring countries like Srilanka 60, China 60 and Thailand 54, among this puerperal sepsis 16% of death occure due to the infection during postpartum period? The situation in Pakistan is that over 4 million women become pregnant each year, of whom 3.2 million (80%) deliver at home. Non-medical personnel conduct eighty two percent of all home deliveries. This is the reason that postpartum morbidities stay unrecognized by the health personnel. Although global estimated prevalence of perceived perineal infection was 5.1% in our study. Similar perceived prevalence of 2% and 3.9% have been reported.7

About 80percent of maternal deaths are due to direct cause that is obstetric complications of pregnancy, labor and pueperium to interventions or incorrect practices. The single most common cause accounting for a quarter of all maternal deaths occurring postpartum which can lead to death very rapidly in the absence of prompt life saving care? Puerperal infections often the consequent of

4 poor hygiene during delivery or untrained reproductive tract infection account for about 15% of maternal mortality. Such infection can be easily prevented by providing perineal hygiene. 5

Educating the mother while assisting her will encourage co-operation and ensure that necessary measures are continued upon discharge from hospital. The perineal wound is kept cleaned by sterile antiseptic swab after each of urination and defication.8

Simple comfort measures include encouraging the women to lie on her side or use pillow while sitting. Washing perineal area it provides comfort to postnatal mothers. Washing perineum with mild soap and water at least once daily each bath it provides comfort to the mother. Cleanse from symphysis pubis to anal area apply pad from frent to back protecting inner surface of the pad and place in covered waste container, washing hand before and after the procedure it prevent infection.9

The women may take care either tub bath or showers she should continue to apply ointment ordered for perineal area and cleanse her perineum from frent to back, any perineals stitches heal by washing perineal area. Perineal care should be taken to prevent infection.10

Promoting healing careful hygiene is important mother should be encouraged to bathe as frequently as she wishes in order to ensure a clean wound and relief discomfort. Care should be taked dry the perineum after bathing. Mothers should be encouraged to walk about as they feel able sitting is often uncomfortable and discomfort may be relieved by the use of air cushion mothers find that laying on one side in bed is the most comfortable position.11

5 Perineal hygiene involves some steps should be followed to perineal cleansing are always wash hand before using bathroom of changing pads, remove old pad and dispose properly after using the bathroom, spray or pour worm water over the vaginal area. Water mixed with an antiseptic soap or solution to be used. Squirt the water over the area between vagina and rectum in frent to back motion pat the dry with clean towel do not rub the area, do not touch the area with hands. Apply a clean pad often to maintain cleanliness. Continued to do the perineal care for one week after delivery.12

6 NEED FOR STUDY: Perineal hygiene is a procedure employed to clean the vulva, the perineum and the anal region are means of preventing infection. Promoting healing of the perineum and making mothers to comfortable. Careful hygiene is important; the mother should encouraged to ensure a clean wound and relief of discomfort. Care should be taken to dry the perineum after bathing. Mothers should be encouraged to walk about as they feel able.1

Perineal hygiene should be directed to the prevention of infection and promotion of healing. Lack of perineal hygiene leads infection during postnatal period like puerperral pyrexia and septic. In some cases of infection by haemolytic streptococci, localized infection occurs as a result of ascending spread of infection from the perineum, vagina or cervix to the uterine cavity. From there it may spread to fallopian tubes causing salpingitis. To overcome this infection perineal hygiene is important in order to prevent this complication.12

Puerperal infection after birth is common among postnatal mothers. Keeping the perineum clean will increase comfort and lower the risk of infection. Infection in postnatal period is 20% to 40% have been reported maternal morbidity.4

In developing countries, it is estimated that ¼ million women die each year during the ante-partum, partum, and postpartum periods, 61% of these deaths occur during the postpartum period.

Pregnancy and childbirth related complications are the leading causes of morbidity and mortality among women of reproductive age in developing countries.13 it is estimated that 18,000 to 25,000 mothers die each year in Pakistan due to pregnancy related causes, of those 13 to 16 % deaths occur during the

7 postpartum period and deaths from vagino-utero sepsis contribute 12.4%. These deaths are mostly preventable.7

In India the Average of MMR is 407 per 100,000 live births its increase compare to other country and Sri Lanka respectively21. Within the country in India the states above this average are Uthar Pradesh 70 per 100,000 live births, Rajasthan 670, Madhya Pradesh 498, Bihar 451, and Assam 408.15 In Karnataka at kolar district there are 25,846 population among 1015 delivers were conducted in that, there are 4 death due to cause of infection.

The millennium development goal 5 seeks to reduce maternal death below 100 by 2015. Current maternal mortality being quite high, our country needs to take up effective strategy of improvement of maternal mortality. In Karnataka, kolar district SNR hospital, there are 986 deliveries are conducted in the year 2007 and 4 death due to cause of postnatal infection.13

Some of the unhygienic practices like unhygienic bathing after 40 days and not frequently changing of pad. Unhygienic materials (soda, mud, leaves) to soak up the lochia, not drying under sunlight. Untrained daies conducting unhygienic practices during delivery and not using 5cleans by recommended by WHO, these leads to bad order. Infection sepsis, swelling fever vaginal infection. To prevent infection Maine steps to be taken by proper hands washing before and after the procedure. Remove old pad disposing properly and washing the perineum with water mixed antiseptic solution. Gently tap the perineum with toilet paper making sure to start at the front and end at the back to avoid spreading of germs from the rectum to vagina. After drying place a new clean pad and wash the hands after caring for perineum. These are the steps should followed during the postnatal period.14

8 Bathing perineum in plain clean water will aid the healing process and soothe. No special antiseptics are needed. If maternity unit or birth centre has policies in place, use complementary therapies, eg, adding essential oil of lavender to bath water or using vulvae compresses to aid healing and prevent infection will also smell delightful. In some Hospital maternity units in UK provides own supply of sanitary protection. Mothers will need to wear them for up to two weeks following the birth of baby.15 Change pads frequently throughout the day, as blood stained pads can encourage infection, and smell offensive. As loss becomes lighter, can change to pant protectors that are thinner and more comfortable to wear.11

A study Conducted on survey on postnatal perineal morbidity. 482 women responded to questionnaire, overall high level of perineal morbidity was reported 87% complaining of morbidity, Instrumental birth high level of perineal morbidity. So thee findings highlight the need for further research and provides a number of challenges for health care services and workers. Obstetric deaths are due to obstetric complications of puerperium infection maternal mortality rate is increase.16 A community based cross-sectional study was conducted in five squatter settlements of Karachi from July to October 2000. A total of 525 married women between the ages of 15-49 years. Interviews were conducted on post delivery. A sample size of 525 was considered. the prevalence of perceived vaginal infection within a 4% bound on the error estimation at 95% confidence level as well as having at least a power of 80% for identifying factors associated with perceived vaginal infection by detecting least 2.0 at 5% The unhygienic materials, defined as any material such as unwashed cloth, dirty cotton, washed cloth but not dried under the sun, stored cloth in a dirty place used to staunch lochia. All others including sanitary pads, new cotton, new cloth and washed cloths dried under sun are referred to as hygienic material.17

9 Based on personal experience of the investigator during her clinical posting, found that Perineal hygiene has significant to postnatal mothers. It requires teaching on hygienic practices.

Hence the investigator is interested to conduct the study on effectiveness of perineal hygiene.

“When I stayed in the nurse cleaned the perineum for me. When I came home I used some medicine from hospital. I healed well I used warm water with antiseptic lotion to clean it” (postnatal mother)

REVIEW OF LITRATURE

“A broad comprehensive, in depth, systematic and evitical review of scholarly publication, unpublished materials, audio visual materials and personal communication is called review of literature”.

Review of literature is a key step in research process. It refers to an extensive, exhaustive and systematic examination of publication relevant to the research project. According to polite and beck (2006).

The related literature is Organized and presented under the following headings. 1. Studies related to perineal hygiene.

2. Studies related to knowledge and practice of perineal hygiene.

3. Studies related to perineal hygiene on episiotomy woun

STUDIES RELATED TO PERINEAL HYGIENE; A study conducted a on prevalence and to identify the factors associated postpartum vaginal infection between the age group of 15to49years in Pakistan. Across sectional study was conducted by using random sampling by trained nurses. The descriptive multivariate analysis showed that the associated factores with vaginal infection were use of unhygienic materials to soak lochia( a OR =3.45,95% CI91.36, 8.75) , bathing after 40 days {a OR= 2.10,95% CI(1.55,3.14)] women did not receive antenatal care[OR=3.87,95% CI (1.23,5.06)] reported of vaginal infection in conclude this study that there is considerable need for health education among women and entire community for the maintenance of perineal

11 hygiene and safe delivery from medical person and importance of preventing infection.18

A study conducted on a randomized controlled trial study to investigate the usefulness of local application of procaine spirit versus cleansing with water for care of episiotomy wound after normal vaginal delivery was conducted in 100 women at Singapore general hospital, Singapore. They selected 50 women for experimental group and 50 women for control group. The study results showed that the pain scores on a verbal analogue scale was highest (score=2.5) on day 1 of the delivery, this was the same in women in both groups. By the fourteenth day of delivery, all the women were pain free and the wound had healed well and all the women maintained a high standard of perineal hygiene with a mean of 5 washes a day. The study concluded that women with normal vaginal delivery, local application of procaine spirit is unnecessary in the care of postnatal period.19

A study conducted on post delivery care after episiotomy in French by survey method between 1990 and 2005. The study results showed that considering local case, the best possible personal hygiene is key to healing. But no specific treatment has been accepted. The treatment of pain by non-medical means as well as topically is not very efficient. The study conducted that the medical staff must emphasize the importance of self care and personal hygiene. The study conducted that personal hygiene is very important for postnatal hygiene.20

A study conducted to assess the effectiveness of teaching on episiotomy and perineal care among primipara women of selected hospital in Karnataka. By using convenience sampling technique. The study was conducted in 2 phases. The phase 1 of the study, the data were collected from 30 primipara women to identify learning needs of primipara mothers in terms of knowledge and ability to

12 perform self perineal care. The phase 2 of the study consisted of 25 subjects in the experimental group. 30 subject in control group. The data was collected by using on interview method, observation checklist, and episiotomy healing. The planned teaching programme on episiotomy and self perineal care was given to experimental group. The study results showed that planned teaching programme was effective in increasing the knowledge (t=23) and ability (t=24.34) of the experimental group. The study suggested that nurse and midwives have a major role in identifying and providing necessary supportive educative care to postnatal mothers 21.

A study conducted on a cross-sectional from July 2000 to October 2000 in five in Karachi Pakistan. These squatter settlements were selected on the basis of an existing surveillance system run by female community health workers for maternal and child healthcare which identified women who had delivered prior to the date of interview. Vaginal infection was considered present when a mother perceived foul smelling vaginal discharge during the postpartum period. Mothers were interviewed on socio demographic variables; materials used to staunch lochia, unhygienic practices not changing pads frequently, personal and perineal hygiene and past obstetric history. A total of 525 women were interviewed. The estimated prevalence of perceived vaginal infection was 5.1%. Included, delivery conducted by a non-medical personnel (AOR 3.5, CI 1.3-9.5) and use of unhygienic cloth or cotton for staunch of lochia (AOR 2.7, CI 1.1-6.2). Among women who reported perceived vaginal infection, a higher proportion was delivered by non-medical personnel perceived vaginal infection. We recommend deliveries to be conducted by trained personnel and provision of health education for persons who conduct delivery and women to use hygienic material for soaking the lochia.22

13 A study conducted on demonstrated that the use of salt and salon solutions in bath water for postpartum women made no difference to the prevention of perineal infection (1988). A randomized controlled trial conducted by Keane and Thornton demonstrated that the use of water was as effective as chlorhexidine swabbing forperineal hygiene for intra-partum procedures during labour (1998). No other effective interventions appropriate to midwifery practice were identified and thus midwives should inform women of the need to keep the perineal area clean and dryad regular intervals through the day by rinsing with water only and gentle patting dry of the area.23

A study conducted on postpartum care, the postpartum period is a time of significant emotional, social and physical changes for women. This review focuses on recent evidence supported by systematic randomized; perineal healing, bathing and changing pad, some recommendation can be made for evidence based postpartum care.24

A study conducted on the women can experience stitches after birth as being uncomfortable to very painful. Pain can interfere with caring for a new baby. There are some simple steps that heal reduce any pain or discomfort and promote healing. The first important thing is good hygiene practices. Having a shower or perineal are every 6to 8 hours is a good idea. Salt is not necessary to add to water, research has found that salt has no benefit for stitches or the healing process. Perineal pads should be changed frequently. To heal reduce pain and swelling applying ice to effected area 12 to 20 minutes every two to four hours. Maintaining cleanliness will reduce the risk of infection.25

A study conducted on Exposure to urine and feces leads to perineal skin infection.. Sgadari et al reported the prevalence of incontinence in nursing home

14 residences using a minimum seta set –derived from a cross national database. In this sample of 279,191 residents, the prevalence of urinary incontinence was 46.4% fecal incontinence was 29.5% and combined was 25.6%. Fecal incontinence is estimated to affect 16%to66% of hospitalized elderly. Perineal skin damage secondary to incontinence ranges in severity include erythema; swelling oozing vesicultion; scaling potentially harmful variables. Moisture from incontinence alters the skin protective ph and increases permeability of stratum corneum. An intense irritant such as feces contains bacteria that can permeate the stratum corneum, allowing secondary infection. Additional problems associated with perineal skin damage include skin damage include diminished quality of life.26 A study conducted on the association of skin infection due to urinary incontinence. in postnatal mothers. prevention and treatment perineal dermatitis ; establish a bowel and bladder programme for patients with incontinence- avoiding excess friction on the skin, cleanse skin gently at each time of soiling with PH – balanced cleansers, select under pads, diapers, or briefs that are the absorbent moisture away from the skin, consider utilizing a pouching system or collection device. Panel of expert from various clinical setting reviewed scientific evidence to develop the recommendations. The panel used provisional guidelines that wound ostomy continence nurses and wound healing society developed by expanding, updating, and elaborating on the work done by the two society the product usage is more likely to occur in the user of the product accepts or likes the product safety, therapeutic activity and convenience are key aspects of high quality product. Recent Studies also suggest that perineal cleaning and protection may be more consistent when regimens are simplified and one-step products are available.27

A study conducted on the association among perineal outcomes, selected risk factors, intrapartum nurse midwives. This nonrandomized cohort study analyzed

15 all vaginal birth (n=1211) by midwives in hospital over 2 years period. Calculated relative between two. Study related with parity ethnicity, birth use 2 techniques (hot compresses and lubrication) were associated with laceration and made performance of perineal laceration son episiotomy. Episiotomy inverse relationship with perineal hot compresses was noted, and perineal lubricant is not effective lack of perineal support was 66% rise in the risk of episiotomy. The other concluded that selected care measures to protect the perineum may reduce intrapartum perineal care.28

A study conducted on hygiene and comfort are really important after birth mothers need to change pad frequently to stay fresh and help prevent infection. Mothers should remember to wash their hands before and after changing pad. using bidet can heal or washing down with a jug of water or shower spray after using the toilet. Bathing at least once a day is also a good idea. Bath water shows to be most effective, although some aromatherapy will advice on oils that can be used. Effective perineal hygiene should be maintained to minimize the infection.29

A study conducted the designed to verify the effective of aromatherapy on postnatal mother perineal healing .the researcher design was a clinical trial. The subject of thie experiment was postpartum mothers who delivered vaginally with an episiotomy. The bacteria is found during postpartum 5th and 7th days (p=0.009) (p=0.003) respectively. Most observed few (5-10 bacteria per field) bacteria in the smears of episiotomy wound. One bacteria was identified in the 50.8% of subject in pretest and two bacteria in the 60.3% in post testin post test. In conclusion these findings indicate that postpartum aromatherapy for perineal care could be effective in healing the perineum.30

A study conducted on sutured damage to the perineum occurs in at least 39% of women being delivered in Australia and perineal wound breakdown is

16 associated with perineal odema. The available literature was reviewed to ascertain what might constitute best practices for postpartum perineal wound management. Classification of level of evidence was used to priorities the available evidence. Little evidence that might be considered scientifically robust was found. Recommended based on the available level of evidence include a careful emphasis on perineal hygiene.31

A study conducted on the aim women was to compare healing and perineal pain with the use of continuous and interrupted suture techniques in women after normal delivery. A randomized controlled trial was carried out at a hospital birth center in Itapecirica da Serra, Sao Paulo, Brazil. A total of 61 women participated with episiotomy or second degree perineal tear, allocated in two groups according to the continuous (n=31) or interrupted (n=30) suture techniques. In this study author stated that perineal hygiene of the perineum must be done with physiological solution. Topic Polivinil–iodine–pirrolidone was used for the antisepsis of the vulvar skin, perineum and internal face of labia majora.32

A Study conducted on perineal care. The major themes to emerge from the and be reviewed are the need for episiotomy, treatment of Local hygiene is important for good healing and lochia is a means of culture for bacteria. The women in this study were oriented to keep perineal hygiene with water and soap. However, during the first return visit, a statistically significant difference was observed between the two groups (p=0.024), with good conditions of perineal hygiene in all women with continuous suture. The knot on the skin left by the interrupted suture causes discomfort and fear of accidentally unfastening the suture, which can favor accumulation of dirt, predisposing to prevent infection frequent changing pad and using antiseptic solution.33

STATEMENT OF THE PROBLEM;

17 A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME REGARDING KNOWLEDGE AND PRACTICE OF PERINEAL HYGIENE AMONG POSTNATAL MOTHERS IN A SELECTED HOSPITAL AT KOLAR DISTRICT.

6.3 OBJECTIVE :

. 1. To assess the existing knowledge and practice regarding perineal hygiene Among the postnatal mother before Structure Teaching programme.

2. To evaluate the effectiveness of structured teaching programme on knowledge and practices regarding perineal hygiene among postnatal mothers. 3. To find out the association between post test knowledge level With their selected demographic variables. 4. To find out the association between post test practice level with their Seleted demographic variables.

OPERATIONAL DEFINITION EVALUATE: It refers to determine the effectiveness of teaching on perineal hygiene among postnatal mothers.

EFFECTVENESS; In this study it measure the improvement score in post test, when compare with the pre-test score after teaching programme which will be measured by the application of structure questionairs. KNOWLEDGE;

18 In this study, it refers to the written responses received from the patient to the knowledge item listed in the structured questionnaire.

PRACTICE: In this study, it referce to the written responses receieved from the patient to the practice item listed in the structured questionnaire.

STRUCTURED TEACHING PROGRAMME: Refers to a system of planned instructional design to impart information in order to bring the changes in knowledge and practice regarding perineal hygiene of postnatal mothers

PERINEAL HYGIENE: In this study it refers to the perineal cleanliness of postnatal mothers.

POSTNATAL MOTHERS; Refers to the mother who had delivered and admitted in postnatal ward till 6 weeks of child birth.

6.5 HYPOTHESIS: Ho; There will be no significant relationship between the pre and -post test knowledge and practice scores of postnatal mother. H1: There will be significant association between knowledge of postnatal mothers on perineal hygiene with selected variables.

6.6 VARIABLES

19 6.6.1 INDEPENDENT VARIABLES: Structured teaching programme on perineal hygiene.

6.6.2 DEPENDENT VARIABLES: Knowledge and practice regarding perineal hygiene . 6.6.3 ATTRIBUTE VARIABLES: Demographic variables [age, sex, education Occupation, area]

7. MATERIALS AND METHODS;

SOURCE OF DATA: Postnatal mothers who are admitted in the postnatal ward. In a selected hospital at kolar district.

7.2 METHOD OF DATA COLLECTION:

7.2.1 RESERCH DESIGN; Quasi Experimental research design.

7.2.2 SETTINGS: The study will be conducted in Sri Narasmha Raja hospital SNR Kolar, the incidence rate of deliveries in 2007 was 1015, which is 500 bed Strength, situated 2kms away from Pavan College of Nursing.

7.2.3 POPULATION:

20 The population for the present study comprises postnatal mother who are admitted in a selected hospital in kolar dist

7.2.4 SAMPLE: Postnatal mother who are admitted in postnatal ward in SNR Hospital. Kolar

7.2.5 SAMPLE SIZE: Postnatal mothers. Total sample size; 60

7.2.6; SAMPLING TECHNIQUE; Simple random technique

7.2.7 SAMPLING CRITERIA

INCLUSIVE CRITERIA: -Mother who are between the age group of 20to30yrs - Mother who are willing to participate in the study. - Mother who are able to understand Kannada. - Mother who are admitted in the postnatal ward.

EXCLUSIVE CRITERIA; - Mothers who are not willing to participate in the study - Mother who are not able to understand Kannada. - Mother who are not admitted in the postnatal ward.

7.2.8 TOOL FOR DATA COLLECTION

21 Structure interview schedule will be used for the assessment of knowledge and practice.

The tool consists of 2 sections.

Section 1; Questions related to demographic data like [age sex education, Occupation and income].

Section 2; Structured knowledge and practice questionnaires on perineal hygiene.

7.2.9 METHOD OF DATA COLLECTION; Prior to the study the purpose of the study will be explained to the subjects and consent of subject will be obtained to participate in the study. Tentative period of data collection will be done. Before that the pilot study will be conducted and then necessary modifications and further refinement of the practice of perineal hygiene data will be collected by the researcher herself.

7.2.10 DATA ANALYSIS AND INTERPRETATION; Data is planned to analyze on the basis of objectives and testing of hypothesis by using descriptive statistics like mean median, standard deviation, correlation, coefficient and chi square will be used for data analysis and inferential statistics presented in the form of tables, graphs and diagrams.

22 DOES THE STUDY REQUIRES ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED FROM OTHER CLIENTS OR ANIMALS, IF SO DESCRIBE BRIEFLY. Yes. The study is conducted on patients admitted in postnatal wards in selected SNR hospitals at Kolar. Since it is a quasi experimental study, it needs interventions.

HAS ETHICAL CLEARENCE BEEN OBTAINED FROM CONCERN AUTHORITIES? Yes. Prior to the study, written permission will be obtained from the concerned authorities to conduct the study and also from research committee of Pavan College of nursing, Kolar. The purpose of the study will be explained to the postnatal mothers who are admitted in the selected hospital.

23 REFERENCES;

1. Sr Nancy. Text book of “principles and practice of Nursining “Volume one. N.Rpuplishing house. Pp176 2. Recovery after Vaginal Birth. The Ohio state university university medical center www.google.com. 3. Bennett and brown. Myles text book for midwives. 12th Edition. Pp 486. 4. Park.,(2007) Park’s Text Book of Preventive and social medicine, (21st edition), Jabalpur, M/s. Banarsidas Bhanot Publishers, pp.442-443 5. The Nursing Journal of India, Nove 2006.vol XL no 5 6. Journal of Nepal Health research council Vole 4 No 2 may 2008 Pp38. Nightingale 7. 7. Nursing Times. The ministry of health and family welfare programme . Vole four. Issue 2 may 2008. pp38 . 8. Krishna tank deftary.” Pregncey at risk current concept. 4th Edition. Jaypee Brothers. Pp 40. 9. Bobak text Book of ‘meternity and gynecological care’. 4th edition. Pp 1230. 10.Pillitteri Adele. “Maternal and child health care of childbearing and children and family. 4th edition. 11. Ruth Bennett text book of midwives 12. Stephanie Brown ‘caring of perineum ‘. About. Com, www Google. Com. 13. Diana M. Fraser. Text book of midviews .14th edition. Pp; 1022. 14. Nursing Journal of India, 2008 Vol.XLIL No 11. 15 Mary Steen ‘Perineal care’ 26 mar 26 2007. 16. Williams. A. Herron, max S. knibb.r postnatal perineal morbidity. PMID:17335531 pubmed.com 17 Lyder c. cleames-lowerance c. Davis A. Sullivan l. “A structure skin care”. JET Nurs. 1992:12:12-16. 18 Ghani N. Rukanudeen R J. Ali TS asso 2007 Jul; 57(7):363-7. PMID: 17867261 [Pub med]

24 19 Tay S.K, Soong S.L, Choo B.M, ‘is routine sprit application necessary in the care of Episiotomy wound? 1999 Sep: 40(9): 581-3, Singapore. General hospital 20.Furssel –Fosse H ‘post deliver care after child birth’. 2006 Feb: 35(1): 15552- 15558 PMID: 16495827 [pubmad] 21.Judith’s Angelita Noronha ‘effectiveness of teaching on episiotomy and perineal care among primipara women of selected hospital’. Nursing gernal of India , May 2004 by Noronha Judith agencies .22 Herron-Marx S. William A. Hick C. “midwifery.” 2007 Sep: 23131:322. Pub med 2006 no 27. 23. Fikree FF, Ali T, Durochera JM, Rahbar MH. Health service utilization for percieved postpartum morbidity among poor women living in Karachi. Soc Sci Med 2004; 59:681-94. 24. Shaw E, Kaczorowski J. “Postnatal care”. PMID: 18007134 [Pubmed – indexed for MEDLI. 25.. Palmer Jane, Bgrelay, schemed A Becoming a mother- ans analysis of women’s experiences of early motherhood. Journal of Advanced Nursing 25, 719-728. 26. National Collaborating center for primary care. Postnatal care. Routine postnatal care of women and their babies. London; Royal College of general practioners: 2006jul. 392p. 27. Mr. Han SH. Aromatherapy on postnatal mothers perineal healing. English obstract research support, non U.S. govt PMID; 15314339 [ pubmed.] 28. Chiarelli P. Cockburn J Aust coll midwives Inc J.1999 mar; 12 (1); 14-8. Postpartum perineal management. PMID; 10222939 [pubmed] 29. Nix D. Prevention and treatment of perineal skin breakdown. In milene c, Corbett l.Dusuc D, wound ostomy, and continence nursing secrets continent society, Inc; 2002: 373-37 30. Brown DS, seams M, ‘perineal dermatitis a conceptual framework, ostomy wound manage 1993:39:2-26.

25 31. Lydon-Rocelle MT, Albers L, Teaf D. ‘perineal outcomes and nurse- midwifery management’.J Nurse Midwifery. 1995 jan-feb; 40(1);13-8. PMID; 7869144 [pubmed]. 32 ALi XF, Fortney JA, Kotelchuck M, Glover LH. The postpartum period: the key to Int J Gynaecol Obstet 1996;54:1-10.. 33 J nurse midwifery, ‘perineal outcome’ Sutport, non-U.S.Govt PMID 7869144 [pubmed

9 SIGNATURE OF THE

26 CANDIDATE 10 REMARKS OF THE GUIDE

11 NAME AND DESIGNATION

11.1 GUIDE 1.2 SIGNATURE

1.3 CO-GUIDE

1.4 SIGNATURE

11.5 HEAD OF THE

DEPARTMENT 1.5 SIGNATURE

12 12.1 REMARKS OF THE

PRINCIPAL 12.2 SIGNATURE