1

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

NAME OF THE CANDIDATE AND Mrs. STUTY MOSES KALE

ADDRESS

1ST YEAR M.SC. NURSING,

NAME OF THE INSTITUTION

COURSE OF THE STUDY AND 1st YEAR M.Sc NURSING

SUBJECT

OBSTETRICAL AND
GYNECOLOGICAL NURSING

DATE OF ADMISSION

TITLE OF THE TOPIC

A
STUDY
TO
ASSESS
THE
EFFECTIVENESS
OF
SELF
INSTRUCTION
MODULE
ON
KNOWLEDGE
REGARDING
POSTNATAL PERINEAL PROBLEMS
AMONG MOTHERS IN SELECTED
COMMUNITIES, BANGALORE

6.1. Introduction
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The health of the women actually represents the health of the country she comes from. Women are
the primary care takers, first educators, bearers of the next generations. Approximately one million women
give birth vaginally each year in India. As per the estimation of 2008, 22.22% of normal deliveries take
place for every 1,000 population.1
Traditionally, the postpartum period has been defined as beginning 1 hour after delivery of the
placenta and lasting 6 weeks, at which time the uterus has regained its prepregnant size.
Morbidity is the degree or severity of a health condition or incidence of a disease in a particular
population during a particular period. Perineal morbidity is the occurrence of disease caused due to
episiotomy, instrumental deliveries, prolonged second stage of labor, poor surgical techniques , increased
number of births and old maternal age which can lead to genital tract trauma, perineal pain, perineal
infections, lacerations and very high rate of urinary incontinence and dyspareunia or sexual dysfunction.2
Perineal pain from childbirth lacerations is a common symptom reported by mothers and if
protracted, the pain may interfere with activities of daily living and family functioning. Perineal pain occurs
in 42% of mothers immediately after delivery but significantly may reduce to 22% and 10% even after
postpartum period. Perineal pain may be due to soft tissue trauma with or without suturing. If persisting it
can lead to cellulites and abscess formation.3
Most of the mother complaints of urinary problems such as difficulty in voiding, incontinence that result
in urinary tract infection. About 1-18% of mothers have residual volume even after puerperial period. About
20% to 34% of mothers having complaints of urinary incontinence. This is due to first vaginal delivery,
epidural anesthesia caesarean section, and prolonged labour and large head circumference.3
Bowel incontinence is also strongly associated with child birth especially following forceps delivery. Its
prevalence, usually including fecal urgency and soiling, estimated at 3% to 5% with incontinence of flatus
being much more common mainly due to defect in anal sphincter . Constipation is one of the problems seen
during pregnancy because of hormonal changes; this persists even after postnatal period about 36% of
mothers having clinical features of constipation.3
World Health Organization, reported that the number of health problems in the first months after
delivery is high. In India prevalence of perineal morbidity after 6 weeks of delivery is 23percentage and in
3

Bangladesh this ranges to 50 percentage, where as in England it is about 47 percentage. Some symptoms are
more typically present in the immediate postpartum period and usually resolve quickly while others often
become chronic.4
A study was conducted on womens perception regarding maternal morbidity in developing countries
such as Bangladesh, Egypt, India, and Indonesia. (Fortney and smith 1996). Women were asked about their
experiences for obtaining information about postpartum morbidity. The result showed that in India 4.4
percentage of women reported lower abdominal pain, 5.3 percentage higher fevers, and 0.5 percentage foul
discharges as symptoms of genital infections. Women who had spontaneous vaginal delivery had better
health in postpartum as compared to the women who gave birth by assisted delivery. Such women had the
fewest hospital readmissions for post delivery morbidity, less perineal pain , stronger pelvic floors, better
sexual function , less depression and optimum functional status.4
From various studies it is concluded that the postnatal mothers experience variety of perineal problems
during the postnatal period. The problems range from a mild perineal pain to perineal trauma, eliminatory
problems like incontinence and retention to sexual dysfunction. Well being of newborn infants is so
dependent on the health and functional abilities of their mothers. Thus the overall health status of postnatal a
mother is a priority concern for all who work in maternity care.

6.2. Need for the study

Healthy mothers have healthy babies only if the mother receives regular and proper care during
perinatal period. After delivery mothers are at risk for developing certain morbidity related to the perineum
such as perineal pain, lacerations, perineal trauma, sexual dysfunction, incontinence of urine and feces.
A study conducted among postpartum mothers to identify the perineal problems after delivery reported
that about 22 % of mothers had perineal pain after 8 weeks and 10 % after 2-18 months of delivery. The
study suggested avoidance of unnecessary episiotomies.4
Stress incontinence is one of the common symptoms seen during 3 months after delivery. The
prevalence was reported to be 8-11% among women in the United Kingdom. It was associated with long
second stage labor, big babies and forceps delivery. Sleep (1984) revealed in his study that about 19% of
4

involuntary loss of urine was seen in mothers after 3 months of delivery, with a slightly higher incidence in
multipara than in primi mothers.4
Urinary incontinence among postnatal mothers was mainly caused by vesicovaginal fistula. It is one
of the serious problems in many developing countries. This problem is seen among 0.3% of post natal
women in India. In Pakistan 12% of postnatal mothers reported with hemorrhoids within 3 months of
delivery, 15% at 2-18 months. Deliveries with a long second stage of labor, with heavier babies, and forceps
deliveries resulted in higher rates of hemorrhoids.4
Postpartum urinary retention continues to be a not very well understood clinical condition. The
incidence varies between 0.05 to 14.1%, after vaginal delivery, and between 3.3 to 24.1% after cesarean
section, depending on the criteria used and reflecting differences in obstetrical practice.5
A study conducted among 2,062 women to assess the impact of pregnancy upon continence and
constipation. The study shows that the incidence of incontinence before pregnancy was 31% in the
multiparous women with 24 months of gestation, 44% in the multiparous with above 5 months of gestation
and 11% in the primiparous group. Of the total women questioned 35% suffered from constipation, the
incidence of which also significantly increased with parity.6
Puerperium traditionally lasts for six weeks, when involution is supposedly complete. The postnatal
check occurs at that time, but it is now clear that most mothers have not returned to normal health by then
and some may never do so. Health professionals should increase their vigilance towards postnatal problems
and might consider extending the duration of routine postnatal care or individualizing to meet variation in
needs.
The researcher has come across many mothers with complaints of perineal morbidity during her
clinical experience. After delivery many women doesnt visit hospital and even do not contact health care
providers till any gross problem occurs. Lack of care during postnatal period may lead to several postnatal
morbidity, which are the most common problems women faced by a women during her postnatal period.
This is mainly because of negligence, hiding the problems, improper hygiene, and lack of knowledge related
to common postnatal problems.

Postnatal mothers experience certain physical health problems that may affect their quality of life,
future health and the health of their children. Yet, the physical health of the postnatal mothers is relatively
neglected in both practice and research. Educating mother regarding perineal morbidity will certainly help
the mother to identify and report the problem early and promptly. With all this view researcher is interested
to undertake the present study among postnatal mothers.
Thus the researcher felt the need to conduct the present study on the mothers after puerperium and
explores the knowledge of mothers related to problems which the mothers may experience in postnatal
period and their prevention. Thereby it leads to early detection and prevention of further complications.

6.3. Review of related literature

A review of research and non research literature relevant to the study was undertaken which will help
the investigator to develop deeper insight into the problem and gain information on what has been done in
the past.

A Study was conducted with an objective to investigate the prevalence of enduring postnatal perineal
morbidity and its relationship to perineal trauma. Total samples of 2100 women were surveyed from two
maternity units using a self-administered postal questionnaire 12 months after birth. The questionnaire
included self-assessment of perineal pain, perineal healing, urinary incontinence, flatus incontinence, faecal
incontinence, sexual morbidity and dyspareunia. The study reported a high level of perineal morbidity
(53.8% stress urinary incontinence, 36.6% urge urinary incontinence, 9.9% liquid faecal incontinence,
54.5% with at least one index of sexual morbidity). The study concluded that postnatal perineal morbidity
was common in women with all types and grades of perineal trauma as well aswith intact perineum after
childbirth. The study also highlighted the need for further debate and research into the prevalence and
experience of postnatal morbidity.7
With the aim of identifying the incidence and types of postpartum perineal morbidity and the factors
associated with it, a study was conducted up to 42 days postpartum with a minimum of three visits. The first
visit was within 14 days of delivery and subsequent visits were every 14 days. On the first visit 211 women
6

were identified and 174 (82.46%) completed the study. The findings of the study revealed that 74 percent
reported at least one morbidity, and there were 1.75 reported morbidities per woman per postpartum period.
Common problems reported were: weakness, lower abdominal pain, perineal pain, abnormal vaginal
discharge, high fever, breast problems, excessive vaginal bleeding, etc. There was greater morbidity among
women of lower socioeconomic status, parity greater than 4, birth interval more than 36 months, having a
breech or caesarean delivery or a delivery assisted by relatives or neighbors.5
A study to determine the prevalence of dyspareunia and perineal pain using validated pain scores
following accurate classification of perineal trauma according to the guidelines of the Royal College of
Obstetricians and Gynecologists was carried out. Pain was assessed with a 4-point Verbal Rating Score and
an 11-point visual analogue scale on day 1, day 5 and 2 months after delivery. 254 women were invited and
95% participated. Ninety-two percent experienced perineal pain on day one, resolving in 88% (p<0.001) at 2
months. Compared to an intact perineum or first degree tears significantly more women experienced
perineal pain after a second, third or fourth degree tear. Although perineal pain affected 92% of mothers, it
resolved in the majority within 2 months of delivery. Obstetric anal sphincter injury was associated with
more perineal pain than other perineal trauma. Spontaneous second degree tears caused less perineal pain
than episiotomies.8
A Study carried out on Symptoms of anal and urinary incontinence following caesarean section or
spontaneous vaginal delivery. The objective of the study was to compare the prevalence of incontinence
disorders in relation with spontaneous vaginal delivery or cesarean section. This study revealed that when
compared with cesarean section, vaginal delivery was associated with an increased frequency of stress
urinary incontinence (P = .006) and an increased use of protective pads (P = .008) as well as an increased
frequency of fecal urgency (P = .048) and gas incontinence (P = .01).17
A Study of women who delivered by cesarean section have an increased risk of urinary incontinence as
compared with nulliparous women and whether women who deliver vaginally have an even higher risk. The
prevalence of any incontinence was 10.1 percent in the nulliparous group; age-standardized prevalence was
15.9 percent in the cesarean-section group and 21.0 percent in the vaginal-delivery group. The moderate or
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severe incontinence were 3.7 percent in the nulliparous group, 6.2 percent age-standardized prevalence, and
8.7 percent cesarean-section group. Stress incontinence were 4.7 percent, 6.9 percent, and 12.2 percent, in
nulliparous group, age-standardized prevalence, and cesarean-section group respectively; urge incontinence
were 1.6 percent, 2.2 percent, and 1.8 percent, in nulliparous group, age-standardized prevalence, and
cesarean-section group respectively ; and mixed-type incontinence were 3.1 percent, 5.3 percent, and 6.1
percent, in nulliparous group, age-standardized prevalence, and cesarean-section group respectively. Study
revealed that the risk of urinary incontinence was higher among women who had cesarean sections than
among nulliparous women and is even higher among women who had vaginal deliveries.9
A Study to investigate the prevalence of persistent and long term postpartum urinary incontinence
and associations with mode of first and subsequent delivery was carried out. About (4214) women were
selected who returned postal questionnaires three months and six years after the index birth. Symptom data
was obtained from both questionnaires and obstetric data from case-notes for the index birth and the second
questionnaire for subsequent births. Urinary incontinence-persistent (at three months and six years after
index birth), and long term (at six years after index birth) was assessed. The prevalence of persistent urinary
incontinence was 24%. Delivering exclusively by caesarean section was associated with both less persistent
(OR=0.46, 95% CI 0.32-0.68) and long term urinary incontinence (OR=0.50, 95% CI 0.40-0.63). Caesarean
section birth in addition to vaginal delivery, however, was not associated with significantly less persistent
incontinence (OR 0.93, 95% CI 0.67-1.29). The Study concluded that there is some significant associations
between persistent or long term urinary incontinence and forceps or vacuum extraction delivery. Other
significantly associated factors were increasing number of births and older maternal age. The risk of
persistent and long term urinary incontinence is significantly lower following caesarean section deliveries
but not if there is another vaginal birth. Even when delivering exclusively by caesarean section, the
prevalence of persistent symptoms (14%) is still high.10
A retrospective case-controlled study was conducted to determine the incidence of clinically overt
postpartum urinary retention after vaginal delivery and to examine what maternal, fetal, and obstetric factors
are associated with this problem. The study included women who had overt postpartum urinary retention
8

after vaginal delivery from August 1992 through April 2000; Fifty-one of 11,332 (0.45%) vaginal deliveries
were complicated by clinically overt postpartum urinary retention. In most cases (80.4%), the problem had
resolved before hospital dismissal. Mothers with urinary retention were more likely than control subjects to
be primiparous (66.7% vs 40.0%; P <.001), to have had an instrument-assisted delivery (47.1% vs 12.4%; P
<.001), to have received regional analgesia (98.0% vs 68.8%; P <.001), and to have had a mediolateral
episiotomy (39.2% vs 12.5%; P <.001). On multivariate logistic regression analysis, of these 4 variables,
only instrument-assisted delivery and regional analgesia were significant independent risk factors. Clinically
overt postpartum urinary retention complicates approximately 1 in 200 vaginal deliveries, with most
resolving before hospital dismissal. Factors that are independently associated with its occurrence include
instrument-assisted delivery and regional analgesia.11
A study conducted to assess the impact of pregnancy upon incontinence and constipation. A total of
2,062 women (858 primigravidae, 1, 057 multigravidae [24], and 147 multigravidae [5+] participated were
involved. Questionnaire was administered on the maternity wards of the Rotunda Hospital, Dublin, two or
three days after delivery and a follow-up questionnaire were mailed at three months to a cluster sample of
women who gave birth during a randomly selected month. A further follow-up questionnaire was mailed
nine months after the birth to a random sample of the multiparous (24) group who indicated leaking on the
first questionnaire. Of the total number of women questioned initially, 59% experienced some degree of
leaking, the incidence of which significantly increased with parity (x 2 = 56.26; p= 0.0001). The incidence of
incontinence before pregnancy was 31% in the multiparous (24), 44% in the multiparous (5+) and 11% in
the primiparous group. Of the total women questioned 35% suffered from constipation, the incidence of
which also significantly increased with parity (x2 = 6.034; p = 0.049).6
The study was conducted to assess the prevalence of constipation throughout and after pregnancy
using a prospective 4- to 7-day weighed food diary, International Physical Activity Questionnaire and 7-day
bowel habit diary, dietary factors, physical activity levels and bowel habit parameters were assessed and
examined concurrently at weeks 13, 25, 35 of pregnancy and 6 weeks post-partum. Ninety-four primiparous
pregnant women were initially recruited, and 72, 59, 62 and 55 completed the first, second, third trimester
9

and post-partum study stages, respectively. Key dietary factors and physical activity levels were compared
between the constipated and non-constipated groups from each of the three trimesters and after parturition.
Compared with non-constipated mothers-to-be, constipated participants consumed statistically significantly
less water in the first trimester (P = 0.04), more food in the second trimester (P = 0.04), and less iron
(P = 0.02) and food (P = 0.04) in the third trimester and after birth, respectively. No statistically significant
differences were identified between light, moderate and vigorous physical activity levels when groups were
compared. This study demonstrates that dietary factors may play a role in terms of preventing, or alleviating,
bowel habit perturbations both throughout and after pregnancy. Further research is required to investigate
the interrelationship between physical activity and constipation during and after pregnancy.12
A study was conducted to assess the prevalence and severity of urinary incontinence in the 12-month
postpartum period and to relate this incontinence to several potential risk factors including body mass index,
smoking, oral contraceptives, breast-feeding, and pelvic floor muscle exercise. Total 523 women included in
this study, aged 14 to 42 years, who had obstetrical deliveries. The women were interviewed in their rooms
on postpartum day 2 or 3 and by telephone 6 weeks, 3 months, 6 months, and 12 months postpartum. Chart
abstraction was conducted to obtain obstetrical data from the index delivery. The study reported at 6 weeks
postpartum, 11.36% of women reported some degree of urinary incontinence since the index delivery.
Although the rate of incontinence did not change significantly over the postpartum year, frequency of
accidents decreased over time. In the generalized estimating equation, postpartum incontinence was
significantly associated with seven variables: baseline report of smoking (odds ratio [OR] 2.934; P = .002),
incontinence during pregnancy (OR 2.002; P = .007), length of breast-feeding (OR 1.169; P = .023), vaginal
delivery (OR 2.360; P = .002), use of forceps (OR 1.870; P = .024), and two time-varying covariates:
frequency of urination (OR 1.123; P = < .001) and body mass index (OR 1.055; P = .005). Factors not
associated with postpartum incontinence included age, race, education, episiotomy, number of vaginal
deliveries, attendance at childbirth preparation classes, and performing pelvic floor muscle exercises during
the postpartum period. Study concluded that ,Postpartum incontinence is associated with several risk factors,

10

some of which are potentially modifiable and others that can help target at-risk women for early
intervention.13

Statement of the problem

A Study To Assess The Effectiveness of Self Instruction Module On Knowledge Regarding
Postnatal Perineal Problems Among Mothers In Selected Communities, Bangalore.
6.4. Objectives of the study
1) To assess the pretest knowledge about postnatal perineal problems among mothers.
2) To assess the effectiveness of Self Instruction Module on postnatal perineal problems among
mothers.
3) To determine the association between knowledge of mothers regarding postnatal perineal problems
and selected demographic variables.
6.5. Operational definitions
1)

Assess: it refers to the response of subjects to knowledge questions regarding postnatal perineal
problems, by using an investigator developed questionnaire.

2)

Effectiveness: Refers to differences in the post test knowledge score with that of pre test knowledge
score.

3)

Self Instruction Module: Refers to systematically organized written material developed to provide
information about post natal perineal problems and their management which includes perineal pain,

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perineal trauma, urinary retension, urinary incontinence, bowel incontinence constipation and sexual
dysfunction.
4)

Postnatal Perineal problems: it refers to the health problems developed during post partum period
due to the process of labour such as perineal pain, perineal trauma, urinary retension, urinary
incontinence, bowel incontinence constipation and sexual dysfunction that persists even after
puerperium.

5)

Mothers: It refers to primi and multiparous women in the postnatal period after delivery till 12
months post delivery.

6.6. Sampling criteria

(a) Inclusion criteria
1) Mothers available during the period of data collection.
2) Who are willing to participate in the study.
(b) Exclusion criteria
1. Mothers who are health professionals
6.7. Assumption
It is assumed that postnatal mothers may have limited knowledge regarding postnatal perineal
problems.
6.8. Hypothesis
H1: There will be significant increase in the knowledge level among mothers

after

administration of STP
H2: There is significant association between knowledge and selected

demographic variables.

6.9. Variables
Dependent variable of this study is knowledge of mothers regarding postnatal

perineal problems.

Independent variables of this study are Self Instruction Module postnatal

perineal problems.

Demographic variables of this study are

Age, education, occupation, religion, Family income, Type of family and Source of information
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7. MATERIALS AND METHODS

The study is designed to determine the effectiveness of structured teaching programme on postnatal
perineal problems among the mothers in selected communities, Bangalore.

7.1. source of data

Data will be collected from mothers in

selected communities, Bangalore.

7.1.1. research design

Research design adopted for the present

study is quasi experimental, one group
pre test- post test design
The research approach used in this

7.1.2. research approach

study is Evaluative approach

7.1.3. Setting Of The Study

Selected communities, Bangalore.

7.1.4. Population

Postnatal Mothers
The proposed sample size of the study

7.1.5. Sample size

is 40 postnatal mothers.

7.1.6. Sampling technique

Sampling technique using in this study

is convenient sampling.
SAMPLING CRITERIA
1) Mothers available during the period of

7.1.7. Inclusion criteria

data collection.
2) Who are willing to participate in the
7.1.8. Exclusion criteria

study.
1. Mothers who are health professionals

7.2. METHOD OF DATA COLLECTION

7.2.1. Tool for data collection
Structured questionnaire.
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7.2.2. Method of data Collection

7.2.3.
procedure
collection

for

data

Self administered questionnaire

The data will be collected with the prescribed time
period.
Permission will be obtained from concerned
authorities.
Purpose of the study will be explained to the
respondents.
Pre test will be conducted using structured
knowledge questionnaire. Subsequently self
instruction module will be given on the day.
On the seventh day post test will be
conducted.
Proposed data collection period will be 30

7.2.4. data analysis method

days.
The data analysis through descriptive and inferential
statistics

descriptive statistics

Frequency, mean, mean percentage, and standard

deviation of described demographic variables.
Paired t test to compare pre and post test

Inferential statistics

knowledge score.
Chi square test will be used to find out association
between selected

7.2.5. Projected outcome

The structured teaching programme will enhance mothers knowledge regarding postnatal perineal
problems.
7.3. Does the study require any investigation to be conducted on the patient or other
animals?
No
7.4. ETHICAL CLEARANCE
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human beings or

The main study will be conducted after approval of the research committee. Permission will be
obtained from the concern head of the institution. The purpose and after details of the study will be
explained to the study subjects and as informed concerned will be obtained from them. Assurance will be
given to the study subject on the confidentiality of the data selected from them.

9. BIBLIOGRAPHY
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3. Cathryn M G and Christine M. Postnatal morbidity. Obstret Gynaec [online] Oct 2001; 3(4). 179182. Available from URL: http://www.google.co.in
4. .Maternal and newborn health. World health organization.[serial online]. 1998: available from
URL: http://www.who.int/reproductive-health/publications/msm_ 98_3/msm_98_3_3.html
5. Glazener CM Sexual function after childbirth: women's experiences, persistent morbidity and lack
of professional recognition University of Aberdeen, Health Services Research Unit, Foresterhill,

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Urinary Incontinence and Constipation During Pregnancy and After Childbirth Received 1 August
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associated with clinically overt postpartum urinary retention after vaginal delivery. Am J Obstet
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12. Black W. Maternal & Child Nutrition . Journal compilation 2006 Blackwell Publishing Ltd.
Volume 2 Issue 3, Pages 127 134 Published Online: 1 Jun 2006 2010 Original Article
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2003 Dec; 102(6): 1291-8. Available from URL:http://www.ncbi.nlm.nih.gov/sites/entrez?Db

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