RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,KARNATAKA, BANGALORE

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FORDISSERTATION

1Name of the candidate and address (in block letters)REEMA JACQUELINE ANDRADE

I YEAR M.Sc, NURSING

FATHER MULLER COLLEGE OF NURSING

MANGALORE-575002

2Name of the Institution FATHER MULLER COLLEGE OF NURSING

KANKANADY

MANGALORE-575002.

3Course of study and subjectM.Sc. NURSING

OBSTERTRICS AND GYNAECOLOGICAL NURSING

4Date of admission to the course29-5-2008

5Title of the topic:

A STUDY TO ASSESS THE IMPACT OF EARLY AND LATE

AMBULATION ON MATERNAL OUTCOME OF MOTHERS WITH CAESAREAN BIRTH IN A SELECTED HOSPITAL IN MANGALORE.

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8Brief resume of the intended work 6.1 Need for the study Early ambulation is a key factor in helping the patient to re-establish thenormal physiology and preventing or minimizing postoperative complications.Ambulation hastens muscle redevelopment and wound healing. Besides the positive effects of prevention of venous thrombosis, some other beneficial effects of early ambulation are more rapid involution of the uterus and genitals, less fever, less pneumonia, less blood in the lochia and a better state of mind1. The number of caesarean sections performed each year is increasing at a dramatic rate all around the world. Postoperative care of these women is an important aspect and demands due attention. Caesarean delivery poses a barrier to breast-feeding initiation related to delay in maternal-infant contact, maternal pain and exhaustion, less satisfaction with the birth experience, and even loss of self-esteem7. Breastfeeding is the healthiest, safest, and most nutritious method for feeding infants, with multiple benefits for mothers, including reduced postpartum bleeding and menstrual flow; improved blood sugar levels; faster postpartum weight loss and return of the uterus to its prepregnancy size; a facilitation of mother-infant bonding; reduced fertility, which facilitates family planning; and a reduced risk of osteoporosis, breast cancer, and ovarian

cancer8. Thromboembolism is one of the common and major complications during puerperium. Therefore women should be advised to get out of bed as early as possible in order to prevent thrombosis. However, many patients cannot be fully ambulatory early after surgery2. Early ambulation after caesarean birth is considered to be important for mother child interaction. The mother should be encouraged to get up and try to go the bathroom within the first 24 hours after surgery. This will help start the healing process5. An observational study assessed the quantity of upright mobilization performed following upper abdominal surgery in 50 patients in Australia. The study particularly assessed how much upright mobilization is performed in the first four days following upper abdominal surgery. An activity logger recorded the uptime continuously for the first four days. The results showed that the quantity of early upright mobilization performed was low10. The investigator through her experience has observed that the time of maternal ambulation after caesarean delivery varied in every hospital. Even though the advantages of early ambulation outweigh its limitations, its not been practiced in many of the hospitals in India. No much research is done in this particular area. Addressing the specific needs of the post caesarean woman, facilitating early ambulation may help to overcome the challenges and barriers facing post caesarean women. This motivated the investigator to compare the impact of different ambulation time on maternal outcome in post caesarean mothers. 6.2 Review of literature A literature search was being performed to understand the tortuous history of the implementation of early ambulation after delivery using MEDLINE, EMBASE, Web of Science, Scopus, Index Medicus, Dutch Central Catalogue, consecutive editions of generally used British, American and Dutch obstetrics and gynaecology textbooks, old volumes of The Lancet and the Dutch Nederlands Tijdschrift voor Geneeskunde. No negative effects of implementation of early ambulation were found. As most of the research were mostly performed before the Second World War, it is possible that the researchers may have missed some studies concerning this topic. The relevant references in articles and handbooks were checked. Researchers accepted that early mobilisation has mainly advantages. Besides the positive effects of prevention of venous thrombosis, some other beneficial effects of early ambulation on general morbidity are more rapid involution of the uterus and genitals, fewer uterine prolapses and retroflexions, less fever, less pneumonia, less blood in the lochia and a better state of mind. It showed that it is not

justified to keep healthy women in bed after giving birth to a child. Small increased risks of venous thrombosis of extended bed rest have been found in the literature search1. A retrospective study to investigate venous thromboembolism during pregnancy and the post-partum period of 6987 women delivering between March 1999 and June 2006 was done in Australia. Case notes of women with confirmed venous thromboembolism during this period were subjected to detailed analysis. The data were analysed for possible risk factors, the timing of thromboembolism in relation to the pregnancy and any correlation with thromboprophylaxis, if administered. The study showed that the rate of venous thromboembolism was 1.14 per 1000 deliveries, with risk factors of age>30 (100%), obesity (75%), previous history of thromboembolism (62.5%) and caesarean section (37.5%). Majority of cases were diagnosed in first trimester (62.5%), and in the right lower limb (75%). None of the patients had been given thromboprophylaxis2. A study assessed if the women were less likely to breast feed after pregnancy complications in California. A retrospective cohort study of 26,781 women was conducted. Potential confounding variables were controlled with maternal, neonatal and obstetric characteristics. The result of the study showed that caesarean or operative vaginal deliveries both predicted a lower rate of breastfeeding3. An observational study compared the breast feeding patterns of mothers who delivered their babies per vagina and via caesarean section in a private hospital in Istanabul. 118 mothers delivered by caesarean and 82 mothers who delivered vaginally were selected for the study. Data was obtained using introductory information form and LATCH breast feeding charting system. The result showed that pattern of delivery affected breast feeding and that the mothers who underwent caesarean delivery required more support and help by the professionals4. A study assessed womens experience of post operative pain and pain relief after caesarean birth and birth experience in central Swedish county hospital. Descriptive patient survey design was used. Assessment of pain was done using visual analog scale and birth experience was measured on a seven point likert scale. 60 participants were included in the study. Results showed that high level of pain was experienced during first 24 hours of delivery and women were pleased with the pain relief. It also showed that post operative pain negatively affected breast feeding and infant care. The researchers recommended that early mobilization after caesarean birth is important for the mother child interaction5. A study assessed breast-feeding initiation among postcaesarean women of the Negev, Israel. The study was a prospective population-based, nonrandomized evaluation of a breast-feeding intervention for healthy 570 Jewish and Muslim post-caesarean women and their term infants. A culturally appropriate breast-feeding intervention facilitating early post-caesarean mother-infant contact within 4 hours was adopted. Breast-feeding support, guidance and education, usually within 2 hours of delivery was provided. Breast-feeding initiation rates of the intervention groups were significantly higher than those of the control groups. Likewise, intervention groups initiated maternal-infant contact and breast-feeding significantly earlier than the control groups6.6.3 Statement of the problemA STUDY TO ASSESS THE IMPACT OF EARLY AND LATE AMBULATION ON MATERNAL OUTCOME OF MOTHERS WITH CAESAREAN BIRTH IN A SELECTED HOSPITAL IN MANGALORE. 6.4 Objectives of the study

1. Determine the impact of early ambulation on maternal outcome of mothers with caesarean birth (group I). 2. Determine the impact of late ambulation on maternal outcome of mothers with caesarean birth (group II). 3. To compare the maternal outcome among group I and group II.

4. Determine the association between maternal outcome and selected variables in group I and group II.6.5 Operational definitionsImpact: In this study it refers to the extent to which early and late maternal ambulation after caesarean birth helps in improving maternal outcome.

Maternal outcome:

In this study, it refers to incidence of deep vein thrombosis, volume of lochia, involution of the uterus and infant caring behaviour.Deep vein thrombosis: It refers to the thrombosis of the leg veins of the mother within 7 days of delivery as assessed by homans sign in the observation checklist.( homans sign is exhibited by the presence of calf muscle pain during the dorsiflexion of the foot 9 ).Lochia:

It refers to the uterine flow after the delivery, consisting of blood, fragments of decidua, white blood cells and mucus. In this study, it refers to the volume of the uterine flow from the day of delivery to the seventh day of delivery as measured by weighing of the pads (1mililitre = 1gram11).Involution of the uterus: It refers to the reduction in size of the uterus after birth as it returns to its pre-pregnancy size and condition.9 It this study it refers to the reduction in size of the uterus after birth as it returns to its pre- pregnancy size and condition as measured by an inch tape every day at the same time ( uterus decreases in height by 1.25 centimetres every 24 hours9 ).Infant caring behaviour: In this study it refers to frequency and duration of breast feeding and rooming in as measured by a questionnaire.Postnatal mothers : In this study it refers to women in the age group of 20-40 years who have undergone caesarean section from the first day of surgery to the seventh day of surgery and has no major illness or complications of pregnancy and childbirth. Early ambulation : In this study it refers to giving the mothers upright position and making them walk between 16-24 hours of delivery for mothers who were given general anaesthesia and spinal anaesthesia. The mothers are made to sit on the bed after 16 hours of delivery for 5 minutes. They are checked for headache, uneasiness and nausea. Those who do not exhibit the above symptoms are made to stand with support for 2-3 minutes and then ambulated in the ward with support for 15 minutes for every two hours. Mothers with headache, nausea and uneasiness will be given complete rest until 24 hours of delivery.Late ambulation: In this study it refers to follow the policy of Father Muller Medical College Hospital where the mothers are ambulated after 24 hours of caesarean delivery. 6.6 Assumptions

1. Early ambulation may help in minimizing maternal complications after childbirth.

2. Mothers will co-operate with the investigator in the study.

6.7 Delimitations

The study will be delimited to mothers after 16-24 hours of caesarean delivery, admitted in Father Muller Medical College Hospital, Mangalore.

6.8 Hypotheses (projected outcome)H1: There will be a significant relationship between early ambulation and maternal outcome in group I.

H2: There will be a significant relationship between late ambulation and maternal outcome in group II.

H3: There will be a significant difference between mean scores of maternal outcome of group I and group II.

H4: There will be a significant association between maternal outcome and selected variables like age, parity, educational status and occupation in group I and group II.Material and methods7.1 source of data

Postnatal caesarean mothers admitted in Father Muller Medical College

Hospital, Mangalore. 7.1.1 Research design

Exploratory comparative study design.

7.1.2 Setting

Study will be conducted in post operative room in Father Muller Medical College Hospital, Mangalore. It is a teaching hospital with 1050 bed strength and obstetric and gynaecological unit has got 60 beds. Nearly 40-50 caesarean deliveries are conducted per month and mothers are kept in the postnatal wards for 7 days after delivery.

7.1.3 Population

Mothers admitted in the post operative (recovery) room in Father Muller Medical College Hospital, Mangalore.

7.2 Method of data collection

7.2.1 Sampling procedure

Purposive sampling

7.2.2 Sample size

40 postnatal caesarean mothers7.2.3 Inclusion criteria Mothers willing to participate in the study.

Mothers in the age group of 20-40 years. Mothers who are able to read and write Kannada, English and Malayalam.

7.2.4 Exclusion criteria

Mothers who develop headache, uneasiness and nausea within 24 hours of surgery. Mothers previously diagnosed to have major illness. Mothers with major complications of pregnancy and child birth. 7.2.5 Instruments intended to be used Demographic profile

Questionnaire Observational checklist7.2.6 Data collection method

The investigator will obtain permission and ethical consent from the concerned authority of the hospital and obstetric and gynaecologic department of Father Muller medical college hospital. Informed consent will be taken from all the participants. The investigator will assign the participants into group I and group II. Group I participants will be given upright position and will be ambulated within 16-24 hours of delivery. Group II mothers will be subjected to the routine care as per the hospital policy and will be given upright position and ambulated after 24 hours of caesarean delivery. From the second day of delivery, maternal outcome of group I will be assessed by administering

questionnaires to the mothers and by observation checklist till the seventh day of delivery. Maternal outcome of the group II caesarean mothers will be assessed by administering the same questionnaire and by checklists from the second postnatal day up to the seventh postnatal day. 7.2.7 Data analysis planCollected data will be analysed by descriptive statistics such as mean, standard deviation, frequencies and percentages. Categorised data related to the maternal outcome can be compared in two groups. Qualitative data can be compared by chi-square test and qualitative data can be compared by unpaired t test. To determine the association between maternal outcome and selected variables chi-square test will be used. Collected data will be presented by tables and diagrams.7.3 Does this study require any investigations/interventions to be conducted on patients or the humans or animals. If so please describe briefly. Yes, the investigator will ambulate the mothers after caesarean section within 24 hours of delivery. 7.4 Has ethical clearance been obtained from your institution in case of 7.3.

Yes, ethical clearance has been obtained.List of references1. Stralen KJ , Terveer EM, Doggen CJM, Helmerhorst FM, Vandenbroucke JP. Tortuous history of the implementation of early ambulation. J R Soc Med 2007 Feb; 100(2):90-96.2. Sharma S, Monga D. Venous thromboembolism during pregnancy and the post-partum period: Incidence and risk factors in a large Victorian health service. Aust N Z J Obstet Gynaecol 2008;48(1):44-49.3. Lamar R, Court M, Robertson P, Weiner S, Caughey A. Are women less likely to breast feed after pregnancy complications. Am J Obstet Gynaecol 2007 Dec;197(6): S954. Cakmak H, Kuguoglu S. Comparison of breast feeding patterns of mothers who delivered their babies per vagina and via caesarean section: an observational study using the LATCH breastfeeding charting system. Int J Nurs Stud 2007;44:1128-37.5. Karlstrom A, Engstrom-Olofsson R, Norbergh K, Sjoling M, Hildingsson I. Postoperative pain after caesarean birth affects breast feeding and infant care. J Obstet Gynaecol Neonatal Nurs 2007 Sep; 36(5):430-40.6. Chertok LR. Breast-feeding initiation among postcaesarean women of Negev, Israel. Br J Nurs 2006; 15(4):205-08.7. DiMatteo MR, Morton SC, Lepper HS, Teresa M, Camey MF, Pearson M et al. Caesarean childbirth and psychosocial outcomes: a metaanalysis. Health Psychol1996 Jul; 1(4):303-314.

8. Centers for Disease Control and Prevention. Breastfeeding: Data and statistics: Breastfeeding practices. [Online]. [2007?] [cited 2008 Oct 15]; available from:

URL:http://www.cdc.gov/breastfeeding/data/NIS_data/data_2004.htm 9. Dutta DC. Textbook of obstetrics. 6th ed. New Delhi: new central book agency; 2004.10. Browning L, Denehy L, Scholes RL. The quantity of early upright mobilization performed following upper abdominal surgery is low: an observational study. Aust J Physiother 2007;53(1):47-52.11. Pillitteri A. Maternal and child health nursing. 2nd ed. Philadelphia: J B Lippincott company; 1995.

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