PROFORMA FOR REGISTRATION OF SUBJECT
FOR DISSERTATION
SR.LISSY PHILIPPOSE
1stYEAR M.Sc. (NURSING)
OBSTETRICS & GYNAECOLOGICAL NURSING
YEAR 2011-2013
ST. PHILOMENA’S COLLEGE OF NURSING
#4 CAMPBELL ROAD, VIVEKNAGAR P. O
BANGALORE 560047
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE. KARNATAKA
1 PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. NAME OF THE CANDIDATE AND LISSY. PHILIPPOSE (SR.LISMARY), ADDRESS 1ST YEAR M.SC (NURSING), ST. PHILOMENA’S COLLEGE OF NURSING, #NO.4 CAMPBELL ROAD, VIVEK NAGAR P.O. BANGALORE 560047
2. NAME OF THE INSTITUTION ST. PHILOMENA’S COLLEGE OF NURSING.
3. COURSE OF THE STUDY AND 1 ST YEAR M.SC ( NURSING) SUBJECT OBSTETRIC AND GYNAECOLOGICAL NURSING.
4. DATE OF ADMISSION 3RD MAY 2011 TO THE COURSE
5. TITLE OF THE STUDY A STUDY TO ASSESS THE EFFECTIVENESS OF REFLEXOLOGY ON PAIN AMONG POST CAESAREAN MOTHERS IN SELECTED HOSPITAL AT BANGALORE.
6. BRIEF RESUME OF THE INTENDED WORK
6. 1 NEED FOR THE STUDY
“ Nobody can go back and start a new beginning, but anyone can start today and make a new ending.”
2 -Maria Robinson
The incidence of caesarean section is steadily rising. The incidence and the indications for Caesarean section in the Obstetric Clinic of the University Hospital of
Obstetrics and Gynaecology were analysed and compared to a study carried out 20 years ago. In 2003 - 2004 there were 2700 pregnant women treated in the clinic and 558 had
Caesarean section (incidence 20.7%). For comparison, the incidence of Caesarean section in 1985 was 6.67% (160 Caesarean sections for 2096 patients) and in 1986 the incidence was 7.63% (131 Caesarean Sections for 1865 patients). While leading indication for both studies was "previous Caesarean section", the second indication was
"contracted pelvis" and infertility and breech presentation were on the third and fourth place. There was no change in the indications for Caesarean section in the present study and in the study carried out 20 years ago. There was a relative increase of the indications
'contracted pelvis' and 'increased age in a nulli parous patient' compared to the previous years1.
In the last few decades, the caesarean rates have increased dramatically in the developed world. Amongst developing counties like Brazil and China also, the caesarean section rates have sky-rocketed2. Currently 1 out of every 10 American women delivered by caesarean section each year. In United States more than 825,000 women are delivered by caesarean in 19983.
A descriptive study was conducted on critical appraisal of caesarean section rates at teaching hospitals in India by Kambo I, Bedi N, Dhillon BS & Saxena NC in 2002 at
3 New Delhi. The study revealed that the overall rate of caesarean section increased from
21.8% in 1993-1994 to 25.4% in1998-19999. From this study we can conclude that there is an increased caesarean rate in India also. Though the estimates of CS rates in India was
7.1% in the year 1998, there is 16.7% change in the annual rates in India and this is one of the highest among countries. A new report from survey, which was published online in the medical journal ‘The Lancet’ found that in Asia – in both developed
& developing nations - caesarean section births only reduced risk of major complication for mother & child if they were medically recommended4 .
A non pharmacological intervention, ‘foot reflexology, was studied on pain & physiological parameters after caesarean section by nurses’ conducted by Kevin
Kunz & Barbara at Alzabra hospital, Rasht city in Iran. 62 women were randomly assigned to a reflexology or control group. Experimental group received two 30 minute session within 24 hours interval. In case group, severity of pain after 1st stage of foot reflexology was lower than control group. They concluded that reflexology will decrease the pain.5
According to an August 2010 article from “applied nursing research”, reflexology can help with post operative pain. Dr. N.Degirmen & colleagues evaluated pain levels in patients who had undergone caesarean section. Somewhere given reflexology treatments while others were given standard care. They discovered that those women who received reflexology had less post operative pain. These women also had stronger vital signs than the control group.6
The Cesarean delivery rate has increased throughout the world, but rates in certain parts of the world are still substantially lower than in the United States. The caesarean delivery rate is
4 approximately 21.1% for the most developed regions of the globe, 14.3% for the less developed regions, and 2% for the least developed regions The estimates of caesarean section rates in
India is 7.1% in the year 1998 and 16.7% change in the rates annually in India which is one of the highest among countries. The WHO report mentions that in India overall, the caesarean section rate is 18%. The rate of caesarean section is relatively higher in Goa
(15.3%) and Kerala (13.7%). The researcher during her experience in maternity ward observed that mothers who underwent caesarean section experienced discomfort and pain during their post operative period. Pain affects the appetite, sleep, energy and inability to do things. So the researcher intended to do Reflexology to reduce pain and thereby promote comfort to post operative caesarean section mothers.
6.2. REVIEW OF LITERATURE
The literature review related to this study was discussed under the following domains.
6.2.1 Literature related to caesarean section.
6.2.2 Literature related to reflexology in reducing pain on caesarean mothers.
6.2.3. Literature related to effectiveness of reflexology on pain.
6.2.1. Literature related to caesarean section
Guise JM & co conducted a study on vaginal birth after caesarean: new insights on maternal & neonatal outcomes at USA in 2009. Objective of the study was to systematically review the evidence about maternal and neonatal outcomes related to vaginal birth after caesarean (VBAC). We identified 3,134 citations and reviewed 963
5 articles for inclusion; 203 articles met the inclusion criteria and were quality rated.
Overall rates of maternal harms were low for both trial of labour and elective repeat caesarean delivery. Evidence suggests that VBAC is a reasonable choice for the majority of women. Adverse outcomes were rare for both elective repeat caesarean delivery and trial of labor7.
A prospective study was conducted by Fyfe EM, Anderson, Chan EH and Tylor to estimate in a cohort of nulliparous women in labour at term whether caesarean delivery rates are increased in first and second stages of labour in overweight and obese women and whether being overweight or obese is an independent risk factor for caesarean delivery. Nulliparous woman who went into labour after 37 weeks of gestation were categorised according to ethnicity – specific body mass index criteria as normal, overweight or obese. 2,629 participants were included in the study. Risks of caesarean delivery were similar regardless of whether ethnicity-specific or World Health
Organization (WHO), BMI criteria were used. They concluded that among nulliparous women in labour at term, being overweight or obese by either WHO or ethnicity-specific
BMI criteria is an independent risk factor for caesarean delivery in the first stage but not the second stage of labor.8
A Comparative study conducted in Iran by Khadem. N, Khadivzadh T to assess the intelligence quotient of school aged children delivered by caesarean section & vaginal delivery. Study conducted in 2 stages: a cross sectional in which 5000 randomly selected children, who were 6-7 years old attended at 10 cognitive examination Posts in Mashhad. The examination was performed by the exceptional education & training institute affiliated to ministry of education for all 6 -7 years old
6 children at the entry to the primary school. At the second stage, we selected two matched groups of 189 children who delivered by caesarean or spontaneous vaginal delivery & then compared their IQ scores. The caesarean delivery group had significantly higher
IQ test score. Based on findings, the association between caesarean deliveries with better cognitive development in children cannot be supported.9
A study was conducted by Dr. Mary E. Hannah to find out whether a planned caesarean delivery will be more beneficial or harmful to a woman and her baby compared with a planned vaginal birth. 2088 women with a singleton foetus in breech presentation at term randomly selected as samples. The result revealed that compared with planned vaginal birth, the policy of planned caesarean delivery reduced the risk of perinatal or neonatal death or serious neonatal morbidity10.
A comparative study conducted by M P Fansawe regarding a comparison of patient controlled epidural pethidine versus single dose epidural morphine for analgesia after caesarean section. In a randomized, double-blind study, conducted in 60 patients after caesarean section, we compared epidural morphine (5 mg) with intravenous morphine patient-controlled analgesia (PCA). Efficacy of pain relief (visual analogue scale), comfort, satisfaction and side-effects were studied. Overall satisfaction for the first 24 postoperative hours was higher in the epidural group when assessed on a graded scale from 0 to 10, but equal when assessed using qualitative terms. Haemodynamic and respiratory tolerance were identical without any episodes of respiratory depression or oxygen desaturation in either group. The epidural morphine group showed a higher incidence of pruritus requiring specific treatment (P < 0.005). Nausea was reported to be equal in the two groups. Consumption of morphine was higher in the PCA group. From
7 this we conclude that epidural morphine analgesia, though of good quality, was associated with more pruritus. Morphine PCA, although producing a lesser degree of analgesia compared to epidural morphine, gave good satisfaction.11
6.2.2. Literature related to reflexology in reducing pain on caesarean mothers
An experimental study was conducted to determine the efficiency of foot and hand massage on reducing postoperative pain in patients who had caesarean operation.
This pre-test–post test design study was planned as a randomized controlled experimental study. In the light of the results, it was reported that the reduction in pain intensity was significantly meaningful in both intervention groups when compared to the control group. It was also noted that vital findings were measured comparatively higher before the massage in the test groups, and they were found to be relatively lower in the measurements conducted right before and after the massage, which was considered to be statistically meaningful. Foot and hand massage proved useful as an effective nursing intervention in controlling postoperative pain.12
A comparative study was conducted by Jamileh Mokhtani & co. to compare the impact of foot reflexology massage & Bensone relaxation on severity of pain after caesarean section. A quasi-experimental time series design and clinical trial was used. Non probability convenient method of sampling was used. Samples were placed in two groups: foot reflexology massage and Bensone relaxation and a control group. Pain was measured using a standard numerical pain scale. Comparison of the mean of pain severity was separately significant between two groups and measured group (P<0.05).
Difference between the mean of pain severity also was significant between foot
8 reflexology massage and Bensone relaxation (P=0.0001). They concluded that foot reflexology massage and Bensone relaxation were effective on decreasing pain severity after women abdominal surgical operation and the impact of foot reflexology massage was superior. 13
An experimental study was conducted to investigate the effect of foot reflexology on pain in caesarean section patients. This clinical trial study was carried out on 62 women who were referred to for caesarean section in Alzahra Hospital (Rasht city). They were randomly divided into two groups of case and control. The reflexology group received a 30-minute foot massage in two sessions, with 24-hours interval. Data gathering tool included a demographic form, step-visual analogue scale and pain score form. They found out that there was no demographical difference between two groups and they were matched completely. In case group, severity of pain after first stage of foot reflexology was significantly lower than before reflexology session and also in control group respectively (p<0.001, p<0.0001). The severity of pain after second stage was significantly reduced in case group as compared with control group. In general, foot reflexology appears to be a useful method of reducing pain.14
6.2.3. Literature related to effectiveness of reflexology on pain
A study was conducted by National Board of Health Council in Denmark on 1995 to ascertain the effectiveness reflexology on migraine and tension headache. 220 samples were participated in the study. Questionnaire was given to the patient at the beginning and end of the series of treatment and three month after the series. Qualitative interviews were conducted at the end of treatment. Result showed that 16% reported that they were cured, 65% said that reflexology had helped and 18% were unchanged. They concluded
9 that reflexology is able to cure or help both tension and migraine head ache in a significant number of patients15.
A study was conducted by F.M. Kovacs and V. Abraira to find out the effectiveness of neuro- reflex therapy intervention in the treatment on non specified low back pain. 48 sample were assigned to a treatment group and 43 to control group. The treatment group received neuro reflex therapic intervention, the control group underwent a similar procedure in which inappropriate zones were stimulated. The result shows that the treatment group showed immediate clinical improvement in pain, muscular contracture and mobility. They concluded that neuro –reflex therapic intervention is an effective method for treating non specific back pain16.
A study was conducted by Terry Oleson and William Flocco in 1993 to determine whether reflexology treatment can significantly reduce pre menstrual symptoms compared with which monitored 38 pre menstrual symptoms on a four point scale.
Somatic and psychological indicators of pre menstrual distress were recorded each day for two months before treatment, for two months during reflexology and two months afterward. The reflexology sessions for both groups were provided by trained reflexology therapist once a week for 8 weeks, and lasted for 30 minutes each. Result shows that analysis of variance for repeated measures demonstrated a significantly greater decrease in pre menstrual symptoms for the women given true reflexology than for the women in the placebo group. They concluded that ear; hand and foot reflexology is an appropriate therapy for the treatment of pre menstrual symptoms17.
10 A study was conducted by Margaret Berker, at the Cardiac Unit of the Queen
Elizabeth hospital , Birmingham, UK, into the effects of reflexology on a group of four patients suffering from chest pain. The patients were obtained from a consultant; all had all experienced pain for periods ranging between 18 months and 13 years and, cardiac catheterizations revealed that none of the patients had any identifiable disease of the cardiac arteries. Reflexology treatments were given weekly over a period of eight weeks and the patients were asked to keep a diary to record their chest pain before and after treatments which specified (a) the number of episodes, (b) the intensity of the pain and
(c) the duration of the pain. Analysis of the data revealed that all of the patients recorded positive results; three of the four experienced a complete relief from their original symptoms after nine months and the remaining patients reported a reduction in pain18.
A study was conducted at Glostrop hospital, Copenhagen, to demonstrate that reflexology can help to relieve the acute pain suffered by patients with kidney stones. 30 patients participated in the study and were divided equally into three groups: one group received reflexology treatment, one group received placebo treatment and the remaining group was used as controls. If no pain relief was experienced within 5 minutes, the treatment would end for analgesic medications, but those who experienced a benefit within 5 minutes, treatment was continued for a further 10 minutes. The results showed that 9 out of the 10 patients in the reflexology group experienced complete pain relief after the treatment which lasted for over an hour and in 5 of the patients pain was relieved for 4 hours19.
11 6.3. STATEMENT OF THE PROBLEM:
A STUDY TO ASSESS THE EFFECTIVENESS OF REFLEXOLOGY ON
PAIN AMONG POST CAESAREAN MOTHERS IN SELECTED HOSPITAL AT
BANGALORE
6.4 OBJECTIVES
6.4.1 To assess the level of pain among post caesarean mothers.
12 6.4.2 To evaluate the effectiveness of reflexology on pain among post caesarean mothers.
6.4.3 To find out the association between the effectiveness of reflexology on pain &
selected demographic variables.
6.5 HYPOTHESIS
H1: There will be a statistically significant difference in pain perception before and after reflexology as measured by Visual Analogue scale at P <0.05.
H2: There will be a statistically significant association between pain perception and selected demographic variables such as age, education, and parity among post caesarean mothers at P < 0.05.
6.6 RESEARCH VARIABLES
Variable is a concept that is measurable and varies.16 Two types of variables were identified in this study. They are independent variable & and dependent variable.
6.6.1 Independent variable
Reflexology.
6.6.2 Dependent variable
13 Level of pain.
6.7 OPERATIONAL DEFINITIONS
EFFECTIVENESS
In this study effectiveness refers to the extent to which reflexology has achieved desirable change in pain level as measured by visual analogue scale.
REFLEXOLOGY
It is an alternative medicine involving the physical act of applying pressure to the feet with specific thumb, finger and hand technique without the use of oil or lotion.
PAIN
In this study pain is the feeling of discomfort at the surgical site experienced by the post caesarean mother and is evidenced by visual analogue scale.
POST CAESAREAN MOTHERS
14 In this study post caesarean mothers are those mothers who have undergone caesarean section during 1st to 3rd postoperative days and those who have the pain scores between 3-8.
6.8 ASSUMPTION
6.8.1 Caesarean mothers may experience pain following surgery.
6.8.2 Complementary therapy like reflexology may help to reduce the pain.
6.9 DELIMITATION.
The study is limited to women who had undergone caesarean section in selected hospital during the time of data collection.
7. MATERIALS AND METHODS
7.1 SOURCES OF DATA
Women who had undergone caesarean section and admitted in a selected hospital at Bangalore.
15 7.1.1 Research design
The research design for the present study is quasi experimental design. (pre test and post test control group)
Study subjects Pre test Intervention Post test Experimental group 01 X 02 Control group 01 - 02
In this study 01- Pre test
X- Intervention
02- Post test
7.1.2 Research setting
This study will be conducted in St. Philomena’s hospital, which is 500 bedded hospital, with 2 labour wards and 5 labour tables. The approximate number of caesarean sections are 70 per month.
7.1.3 Population
Women who have undergone caesarean section and who are during 1 - 3 post operative days in selected hospital at Bangalore.
16 7.2 METHODS OF DATA COLLECTION
7.2.1 Sampling procedure
Non probability purposive sampling technique.
7.2.2 Sample size
60 samples who meet the inclusion criteria.
Experimental group-30
Control group - 30
7.2.3 Inclusion criteria
7.2.3.1 Post caesarean mothers who are suffering with moderate to severe pain.
7.2.3.2 Conscious and oriented post caesarean mothers.
7.2.3.3 1st to 3rd post operative day mothers.
7.2.3.4 Mothers who are able to speak Kannada, Tamil and English.
7.2.4 Exclusion criteria
7.2.4.1Post caesarean mothers who are suffering from mild pain.
7.2.4.2 Patients who are not willing to participate in the study.
17 7.2.5 Tools used for the study
The tool consists of following sections.
Section A: To assess socio demographic data of the caesarean mothers; such as age, religion and parity.
Section B : Visual Analogue Scale. It is a simple assessment tool consisting of a 10 cm line with 0 on one end, representing no pain, and 10 on the other, representing the worst pain ever experienced, which a patient marks to indicate the severity of his or her pain.
No pain -0
Mild pain 1-3
Moderate 4-6
Severe 7-10
7.2.6 Data collection method
Formal permission will be obtained from the head of the institution.
• Informed consent from patient will be obtained assuring the confidentiality.
• Pre test will be administered with Visual Analogue Scale to experimental and
control group on 1st day.
• The researcher will undergo certificate course training on reflexology for 2 days.
18 • Reflexology will be administered for 5 minutes twice a day for 3 consecutive
days to experimental group.
• Post test will be administered with Visual Analogue Scale for experimental and
control group on the 3rd day .
7.2.7 Data analysis plan
The data will be analyzed by using descriptive and inferential statistics.
Descriptive statistics
• Frequency and percentage distribution to assess the demographic variables
• Mean and standard deviation to assess the post operative pain.
Inferential statistics
• Statistical t- test is used to compare the pre test and post test scores of pain
among experimental and control group for statistical analysis.
• Chi-square is used to bring out association between demographic variables post
operative pain.
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION
TO THE PATIENT OR OTHER HUMAN BEINGS?
Yes, intervention will be in the form of reflexology.
7.3 HAS ETHICAL CLEARENCE OBTAINED FROM THE INSTITUTION
19 Yes. Permission is obtained from the institutional ethical review board of St.
Philomena’s hospital, Bangalore. (Enclosed)
8. LIST OF REFERENCES
1. Asenova D, Stambolov B. Incidence and indications for cesarean section in the
Obstetrics Clinic in the University Hospital of Obstetrics and Gynecology.
20 Maichin Dom in Sofia. 2005;[cited 2006 Jun];44(3): Available from: pubmed
http://www.childbirthconnection.org/article.asp?ck=10166.
2. Kambo I, Bedi N, Dhillon BS, Saxena NC. A critical appraisal of cesarean
section rates at teaching hospitals in India. Int J Obstet Gynaecol.[cited 2002
May];79(5).Available from http://www.bmj.com/content/341/bmj.c5065.
3. F. Gary Cunningham.William Obstetrics. 21st ed, New York: Mc Graw-Hill
medical publishing division; 1997.
4. Kambo I, Bedi N, Dhillon BS, Saxena NC.A critical appraisal of cesarean section
rates at teaching hospitals in India. Int J Gynaecol Obstet.[cited 2002 Nov];79(2)
Available from http://emedicine.medscape.com/article/272187-overview.
5. Heller H. Elective –caesarean-section-are-too-risky.studJ Fam Pract.
[abstract].2002;[cited2010 Jan 11];51(2): Available
from:pubmed.http://blogs.scientificamerican.com/observations.
6. Barbara and Kevin Kunz. Caesarean section and reflexology.[cited2010 June
22nd]. Available from://www. Reflexology- research.com/control.htm.
7. Barbara and Kevin Kunz. Caesarean section and reflexology.[cited2010 June
22nd].Available from http://www.livestrong.com.
8. Guise JM. Vaginal birth after caesarean: new insights on maternal & neoutcomes.
Obstetric gynaecology, 2010[cited 2010 June11];5(6). Available from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595216/.
21 9. Fyfe EM, Anderson NH, North RA, Chan EH, Taylor RS, Dekker GA, McCowan
LM; Consortium Risk of first-stage and second-stage cesarean delivery by
maternal body mass index among nulliparous women in labor at term. . Obstet
Gynecol.[abstract].2008;[cited 2011 Jun];117(6). Available from:
http://www.childbirthconnection.org/article.asp?ck=10166.
10. Khadem N, Khadivzadeh T. The intelligence quotient of school aged children
delivered by cesarean section and vaginal delivery. . Obstet Gynecol.[abstract]
2002;[cited2005April];2000;[cited2005Jun];37(11):Available from
http://en.wikipedia.org/wiki/Caesarean_section.
11. Dr. Mary E. Hannah, Director, University of Toronto Maternal Infant and
Reproductive Health Research Unit, Centre for Research in Women’s
Health2004;[cited 2009Jan];79(15):751–790. Available from
http://www.reflexology-research.com/howto.html
12. Cherkin DC, Sherman KJ, Kahn J, Wellman R, Cook AJ, Johnson E, Erro J, et al.
Obstet Gynecol [abstract].1998;[cited2002];25(14):Available from
www.ncbi.nlm.nih.gov.
13. Jamileh Mokhtari , Masoud Sirati Nir , Mehdi Sadeghi Sherme , Zahra Ghanbari ,
Hossein Babatabar Darzi , Hossein Mahmoodi. Foot Reflexology massage: a clinical
study.1998[cited1999Feb];22[6]:3840.Availablefromhttp://www.quackwatch.org/01Qua
ckeryRelatedTopics/reflex.html.
14. Khoshtrash Mehrnoosh. Survey the effect of foot reflexology on pain &
physiological parameters after caesarean section. The journal of nursing and
22 midwifery.2010:
[cited2011Jan];20(64).Availablefromhttp://www.mntnr.com/articles/Effects%20of
%20reflexology.pdf .
15. National board of health council. Effectiveness of reflexology on pain.1995;
[cited2000].Availablefromhttp://www.pacificreflexology.com/abstract/Headaches
. Accessed on 28th November 2011.
16. F.M.Kovacs, V.Abraira. Effectiveness of reflexology on pain.1995;
[cited2000]Availablefromhttp://www.pacificreflexology.com/abstract/Headaches.
Accessed on 28th November 2011.
17. Terry Oleson , William Flocco. American Journal of Obstetrics and
Gynecology.1993;[cited1993Dec];82,
(6).Availablefromhttp://foothealth.about.com/od/womensfoothealth/a/massreflexa
cup.htm.
18. Hattan J, King L, Griffiths P. The impact of foot massage and guided relaxation
following cardiac surgery: a randomized controlled trial. J Adv Nurs.2002;
[cited2002Jan];37(2):199207Availablefromhttp://www.internethealthlibrary.com/
Therapies/Reflexology-Research%20.htm.
19. Margaret Berker. . The impact of foot massages 0n kidney stone: a randomized
controlled trial. J Adv Nurs.2002;[cited2002Jan];37(6):199207Available from
http://www.internet healthlibrary.com/Therapies/Reflexology-Research%20.htm.
23 9. Signature of the candidate :
10. Remark of the Guide :
11. Name and designation of
11.1 Guide :SR.GALI MARIAMMA
11.2 Signature :
11.3 Co-Guide :MS.BLAZE ASHEETHA MARIA
ROSARIO
11.4 Signature :
11.5 Head of Department :
24 11.6 Signature :SR.GALI MARIAMMA
12. 12.1 Remark of the Principal :
12.2 Signature :
25