RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCESBANGALORE , KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. NAME OF THE

CANDIDATE AND

ADDRESS

Ms. YUMKHAIBAM RENUBALA DEVI

GOUTHAM COLLEGE OF NURSING,

MANJUNATHANAGAR,

WEST OF CHORD ROAD,

RAJAJINAGAR,

BANGALORE – 10.

2. NAME OF THE

INSTITUTION

GOUTHAM COLLEGE OF NURSING,

MANJUNATHANAGAR,

WEST OF CHORD ROAD,

RAJAJINAGAR,

BANGALORE – 10.

3. COURSE OF STUDY

AND SUBJECT

M.Sc. NURSING I YEAR

OBSTETRIC AND GYNAECOLOGICAL

NURSING

4. DATE OF ADMISSION

TO COURSE

05.06.2008

.5 TITLE OF THE TOPIC A STUDY TO ASSESS THE

EFFECTIVENESS OF SELF

INSTRUCTIONAL MODULE ON

PREVENTION AND MANAGEMENT OF

EPISIOTOMY COMPLICATIONS

AMONG POST NATAL MOTHERS IN

SELECTED HOSPITAL,

BANGALORE.

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6. BRIEF RESUME OF THE INTENDED WORK:

6.1 NEED FOR STUDY:

Episiotomy refers to a surgical incision of the female perineum

performed by the accoucheur at the time of parturition. It is usually

performed with the scissors when the perineum is stretched and distended

just prior to crowing of the fetal head. The complications of episiotomy

are perineal pain, dyspareunia, incontinence of bowel and stool,

episiotomy dehiscence, infections, pelvic floor defect, sexual

dysfunction.1

According to report on 6, June 2008 the prevalence of episiotomy

procedure was 1.6 million in 1992 versus 7, 16,000 in 2003. The

prevalence of episiotomy is higher in Latin America and the United

States, approximately 40 percent of vaginal deliveries and lower in

Europe with reported rates varying widely from 1% in Swedan to 80 % in

Argentina.2

According to WHO the birth rate in India is 23.8 per thousand

births in 2005. In Karnataka crude birth rate is 22.5 per thousand live birth

while maternal mortality rate is 2 per thousand live birth 2007. In India

23% of women report health problem in first month after delivery related

to episiotomy as perineal tear, urinary incontinence, uterine prolapse. In

2004,29.1% of birth were delivered by ceasarean delivery and 60%

delivered per vaginal.3

A study was conducted on immediate and long term complication

of episiotomy, the main aim was to describe the complications of

episiotomy on 472 post natal mothers. When performed liberally,

episiotomy appears to increase the risk of post partum bleeding. More

restrictive use does not appear to increase the risk of serious perineal

injury. Patients who had an episiotomy complain of perineal pain more

than those with an intact perineum or first or second degree tears. Three

2

months after delivery, there was no difference. While episiotomy appears

to be a source of dyspareunia during the first weeks after delivery in

comparison with spontaneous tears. The study reveals that episiotomy

appears to be cause of more perineal pain and dyspareunia during the

early post partum week.4

A study was conducted on episiotomy to review the incidence and

complications associated with episiotomy and perineal tears among 1346

parturients. The prevalence of episiotomy was 46.6% over 90% of the

primigravid parturients had episiotomy. The incidence of episiotomy

decreased with increasing parity while the incidence of spontaneous

vaginal tears increased with parity. The study reveals that greater attention

needs to be paid to selection of women to undergo episiotomy, the

prevention of spontaneous perineal tears and care of episiotomy. 5

Since episiotomy is a surgical procedure care of the surgical site is

very essential to avoid any further complications. Many pharmacological

and non pharmacological treatment are available in the management of

episiotomy thereby prevent the complications.

A study was conducted on reducing post natal pain from perineal

tears by using Lignocaine gel.. The study was to investigate if typically

applied 2% Lignocaine gel was an effective treatment. The method of

study was experimental method. The sample size was 149 women. The

result was using Lignocaine gel had lower average pain scores statistical

significances at 48 hours after delivery. This study suggested that

Lignocaine gel is effective on the second postnatal day.6

A study was conducted on effectiveness of teaching on episiotomy

and perineal care among primipara women of selected Hospital in

Karnataka. The study reveals that knowledge deficit was found in 30

primipara women. The researcher concluded that nurses and midwives

have a major role in identifying and providing necessary supportive-

educative care to clients who have undergone episiotomy.7

3

In the view of above studies and from the investigator experience,

it is found that complication is more common among the post natal

mothers who undergone episiotomy. The researcher is thus interested in

imparting the knowledge to the postnatal mothers with episiotomy

regarding prevention and management of episiotomy complications. The

researcher personally felt that there is a need to study in this area and to

change the parental practices through educational intervention.

6.2 REVIEW OF LITERATURE:

Review of literature refers to as broad, comprehensive, in depth, systemic

and critical review of scholarly population and unpublished scholarly

print material ,audiovisual materials and personnel communication.18

The extensive review of literature has been done and it is organized

according to the following headings.

A) Studies related to the complications of episiotomy.

B) Studies related to the management of episiotomy complications.

C) Studies related to the self instructional module as teaching

module.

A) Studies Related to the Complications of Episiotomy:

A study was conducted on puerperal complications of episiotomy.

The objective was to establish the epidemiological variables associated

with episiotomy and their puerperal complications. The episiotomy rate

was 35.6% of all vaginal deliveries. Episiotomies were significantly

associated with primigravidity being performed in 88.5 percent of all

primigravidae. The mean delivery repair interval was 60.5 minutes. The

most common puerperal complications of episiotomy were perineal pain

that lasted an average of 5.5 days. Other complication included

asymmetry 32.9% infection 23.7%, partial dehiscence14.5%,skin tags

7.9%,haemorrhage 5.3% and extension of the incision 1.3%.The study

shows that episiotomy rate is very high among primigravidae and also

4

recommended that complications should be reduced by re-acquainting

accoucheurs with the indications for episiotomy.8

A study was conducted on late complications of episiotomy. The

study sample was 467 women. The objective was comparison between

median episiotomy, mediolateral episiotomy and no episiotomy regarding

perineal discomfort, wound healing and anal incontinence. Perineal pain

was reported by 30% of women with mediolateral episiotomy as

compared to19%of those with median episiotomy and 4.5% without

episiotomy.Involuntary passage of faeces in 7%, 9% and 1% respectively.

The study reveals that good healing of adequately reconstructed perineal

tears and the better outcomes of median episiotomy as compared to

mediolateral episiotomy.9

A study was conducted on causes for healing complications in

episiotomy. The aim of the study is to look the most probable causes of

distrubed healing of episiotomy. The study sample was 33 early puerperal

women without infection or risk factors like PPROM, vulvovaginitis,

chorioamnionitis, diabetes, obesity and others. The rate of entirely open

episiotomy is 1.07%. According to the study episiotomy healing is not

influence by age, parity, duration of labour and the weight of neonate. The

study concluded that the shorter time between rupture of membrane

during labour and delivery and used of catgut stitches on the skin of the

perineum shows tendency of poor healing of the episiotomy.10

A study was conducted on factors influencing the use of

episiotomy during vaginal delivery, the objective of the study was to

determine the prevalence of episiotomy to examine factors influencing the

performance of episiotomy and documents complications associated with

the procedure. January, 2001 to December 2005. The sample size was

4172 mothers. There were 1877 episiotomies 45%. 90% of primigravid

parturients had episiotomy. Women undergone episiotomy were younger

mean age 24.7 years, range 16-36 than women without episiotomy mean

age 28.5 year, range 20-43.When controlled for parity and maternal age,

other risk factors were occipito posterior position, vacuum extraction,

forceps delivery, vaginal breech delivery and a history of caesarean

5

section. The study shows that episiotomy rate is 45 per 100 vaginal

deliveries. Greater attention needs to be paid in order to avoid major

perineal lacerations and increased length of hospital stay.11

B) Studies related to the management of episiotomy

complications:

A study was conducted on Diclofenac pyrrolidine versus

Ketoprofen for the relief of episiotomy pain. The objective of the study

was to compare the effectiveness and side effect of two analgesics in the

management of post partum perineal pain. Sample size was 261 women

with vaginal delivery with episiotomy and /or a second to third degree

tear were randomly assigned, both received either Diclofenac

hydroxyethyl pyrrolidine 100mg, n=133 or Ketoprofen 100mg, n=128,

both given orally every 12hours upto 48hours as necessary. Side effects

and overall opinion on the two treatments were assessed at 24 hours. The

result was Diclofenac hydroxyethyl pyrrolidine and Ketoprofen had

similar analgesic properties in the first 24 hours postpartum, mean pain

rating 3.1±1.8 and 3.4 ±2.0, mean number of doses in 24 hours 1.4 and

1.3 ± 1.5, and proportion treatment failures 12.8% and 16.4%

respectively. Significantly fewer subjects in the Diclofenac hydroxyethyl

pyrrolidine group than in the Ketofrofen group experienced side effects

6.8% versus 15.6%; p=0.038 with an odd risk = 0.39,95% C1;16-0.95.

The study shows no main differences were found concerning the relief of

pain between the two treatments. Diclofenac Hydroxyethyl pyrrolidine is

preferred choice because it is associated with less adverse reaction,

together with a faster action in the relief of pain .12

A study was conducted on post episiotomy pain. Warm versus

cold sitz bath. The aim of the study was to assess the effectiveness of a

warm versus cold sitz bath in relieving post episiotomy pain. The

experiment was performed on 20 post vaginal delivery with episiotomy.

Sensation, distress, edema, and hematoma rating were obtained pre and

post treatments. The study obtained both therapies were found

comparable, with the exception that cold bath was significantly more

6

effective in reducing edema. Clinical research are presented

recommendation for practice in the patients should offered a choice of

therapies .13

A study was conducted on post delivery sex among 242 postnatal

mothers which reveals that 20% of mothers feel physically comfortable

during sex within six months, 57% of women were still having less

frequent sex after 12 months of childbirth. And they concluded, many

women do not desire sex after childbirth because of pain or fear due to

episiotomy.14

A study was conducted on episiotomy raises tear risk in next

delivery, among 600 women which reveals that 47.8% underwent

episiotomy during their first delivery. Moderate lacerations subsequently

occurred in 51.3% of these women during the second delivery,

significantly greater than 26.7% of women who had never had an

episiotomy. The study reveals that obstetric care providers should

encourage to restrict the use of routine episiotomy.15

C) Studies Related to Self Instructional Module (SIM) as

Teaching Module:

A study was conducted on stop the child labour before it stops the

child life. The aim of the study was to assess the effectiveness of self

instructional module on causes, hazards and prevention of child labour

among the mothers. The study sample was 40. The result of the study

shows that self instructional module was found to be effective in terms of

increasing the cognitive behaviour and developing a more favourable

attitude towards child labour. This indicates that self instructional module

was an effective method of imparting information to the mother on child

labour .16

A study was conducted on self care strategies of antenatal mother

attending OPD. The aim of the study was to assess the effectiveness of

self instructional module .The sample size was 60 antenatal mothers .The

7

study reveals that self instructional module was found effective in terms

of increasing knowledge of antenatal mothers regarding antenatal care.

The effectiveness was found by computing‘t’ test between the pre test

scores and post test scores. The mean post test knowledge was found to be

significantly higher than the mean pre test scores .17

6.3. STATEMENT OF THE PROBLEM:

A study to assess the effectiveness of Self Instructional Module on

prevention and management of episiotomy complications among the post

natal mother in selected hospital, Bangalore.

6.4. OBJECTIVES:

1. Assess the existing knowledge regarding the prevention and

management of episiotomy complications among the post natal

mothers in pre test scores.

2. Assess the effectiveness of Self Instructional Module regarding

prevention and management of episiotomy complications in

pretest and post test scores.

3. Determine the association of knowledge regarding prevention and

management of episiotomy complications with selected

demographic variables.

6.5. OPERATIONAL DEFINITIONS :

1. Knowledge: - Refers to the response of subjects on self administered

questionnaire on management and prevention of episiotomy

complications before and after the Self Instructional Module.

2. Effectiveness: - Refers to the gain in knowledge as determine by

significant difference in pre test scores and post test scores.

3. Self Instructional Module: - Refers to a booklet of contents prepared

by the investigator and validated by experts .It contains the meaning,

complications, management and prevention of episiotomy

complications, which will be provided to the subjects for self reading

and gaining information.

4. Episiotomy complications: - Refers to the complications that occurs

after vaginal delivery with episiotomy like perineal pain, episiotomy

8

dehiscence, dyspareunia, anal and bladder incontinence, edema, etc.

5. Management: - Refers to the methods of pharmacological and non

pharmacological therapies in treating the episiotomy wound thereby

preventing complications.

6. Prevention: - Refers to protecting the episiotomy and the perineum

from complications in the post natal mothers.

7. Postnatal mothers: - Refers to both primi and multi mothers after

childbirth with episiotomy from first day to 45 days.

6.6. HYPOTHESIS :

H1: There will be a significant difference between pre test and post test

knowledge scores on prevention and management of episiotomy

complications among the post natal mother at the level of P<0.05.

H2: There will be a significant association between the knowledge score

of post natal mother regarding prevention and management of episiotomy

complications with selected demographic variables.

6.7. DELIMITATIONS :

1. The study is delimited to post natal mother delivered per vaginally

only.

2. Post natal mothers who are available at the period of study.

3. Measurement of knowledge scores of post natal mothers once

before and after effectiveness of Self Instructional Module.

6.8. PROJECTED OUTCOME :

1. The study will enhance the knowledge of post natal mother on

management and prevention of episiotomy complications and help in

increasing autonomy and operate in a desirable manner to achieve

positive health.

2. The study will generate new knowledge on attitude of management

and prevention of episiotomy complications.

7. MATERIALS AND METHODS:

9

7.1 SOURCE OF DATA Post natal mothers with episiotomy

from selected hospital, Bangalore.

7.2. METHODS OF COLLECTION OF DATA

7.2.1 SAMPLING CRITERIA

INCLUSION CRITERIA 1. Post natal mother with

episiotomy in a selected

hospital.

2. Post natal mother available from

the first day of delivery.

3. Who understand the language

Kannada, English and Hindi.

EXCLUSION CRITERIA 1. Not willing to participate in the

study.

2. Mother who delivered else

where.

7.2.2. RESEARCH DESIGN Pre-experimental one group pretest

post test design will be adopted.

7.2.3. VARIABLE UNDER STUDY

INDEPENDENT VARIABLE

DEPENDENT VARIABLE

ATTRIBUTE VARIABLE

Self Instructional Module on

prevention and management

of postnatal complications.

Knowledge of post natal

mothers.

Age, socioeconomic status,

education.

7.2.4. SETTING OF THE STUDY Study will be conducted in the post

10

natal ward in a selected hospital,

Bangalore.

7.2.5. SAMPLING TECHNIQUE The researcher will adopt

convenience sampling technique.

7.2.6. SAMPLING SIZE The sample size consists of 40 post

natal mothers.

7.2.7. TOOL FOR RESEARCH 1. A structured questionnaire to

assess the demographic variables

among the post natal mothers.

2. A structured questionnaire to

assess the level of knowledge on

prevention and management of

episiotomy complications.

7.2.8 DATA COLLECTION An informed consent will be obtained

from the concerned authority, an

informal consent will be obtained

from the subjects .The purpose of the

study will be explained and structured

questionnaire will be administered to

the subject to assess the knowledge

level as pretest. Subsequently, a Self

Instructional Module on prevention

and management of episiotomy

complications will be given to the

sample. Following this on 5th day the

investigator will reassess the

knowledge scores by post test using

the same structured questionnaire.

Study duration is 30 days.

7.2.9. METHOD OF DATA

ANALYSIS

AND PRESENTATION

By using descriptive and inferential

statistics .The plan of data analysis

will be as follows –

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1. Organise the data in a master

sheet or computer.

2. Frequencies and percentage for

analysis of background data.

3. Mean, median, SD, and ‘f’ values

determine the significance.

4. Chi-square test to determine the

association.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR

INTERVENTION TO BE CONDUCTED ON PATIENTS OR

OTHER HUMAN OR ANIMALS? IF SO, PLEASE DESCRIBED

BRIEFLY.

Yes, the study will be conducted among postnatal mothers

in a selected hospital.

7.4. HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM

THE HOSPITAL AUTHORITY OF THE PARTICULAR

INSTITUTION AND PATIENTS?

Yes, ethical clearance and informed consent will be obtained from

the institutional authorities and the mothers. Privacy, confidentiality and

anonymity will be guarded, scientific objectivity of the study will be

maintained with honesty and impartially .

8. LIST OF REFERENCES:

1. Dutta DC. Textbook of obstetrics. 4th Ed. New central agency(p)Ltd

Chintamoni Das Lane; Calcutta. (2001). Page -605.

2. Julian N Robinson, Charles J Lockwood, Vanessa A Barss.

Prevalence of episiotomy procedure. Last literature review version 16.

May 2008;16(2).

3. Bulletin of World Health Organisation.

4. Langer B, Minetti A. Immediate and long term complication of

episiotomy. Gynecol Obstet Biol Rrprod (Paris)Feb2006; 35(1

12

suppl) : 1S59 - 1S67.

5. OtoideV.O, Ogbonmwan S.M, Okonofuaf.E. Episiotomy.Department

of obstetrics and gynaecology. University of Benin.Nigeria.

6. Anna Corkill, Tina Lavender, Stephen A, Walkinshawand Zarko

Alfirevic. Reducing post natal pain from perineal tears by using

Lignocain gel. Liverpool, United Kingdam.

7. Noronha Judith Angelita. Effectiveness of teaching on episiotomy and

perineal care. Nursing Journal of India. May 2004.

8. Sule S T, Shittu SO.Puerperal complications of episiotomy.

Department of Obstetrics and gynaecology, Ahmadu Bello University

Teaching Hospital, zaria, Nigeria.

9. Regeth JC, Buerklen A, Hirsch H A.Late complication of episiotomy.

Universitats frauenklinik, Schleichstr. 4 , D- 7400 Tubingen

10.Dimitrov A , Tsenov D, GanevaG. Causes for healing complications in

episiotomy. Akush Ginekol(Sofiia).2000; 40(4):17-20.

11.Chigbu B, On were S,Aluka C, KamanuC, Adibe E. Factors

influencing the use of episiotomy during vaginal delivery. Department

of Obstetrics and Gynaecology, Abia.Nigeria.

12.Fabio Facchinette, Maria Luisa Casini,Loredana Costabile, Barbara

Malavasi , Vittorio Unfer. DiclofenacPyrrodine versus Ketoprofen.

Acta Obstetricia et Gynecologica Scandinavica. Oct.2005; 84(10);

Page 951-955.

13.Lolafoy,Elizabeth A. Genden. Postnatal pain.University of Missouri,

Columbia. MO 65211.

14.Ayandrali Dutta. Post delivery sex. 23th Sep.2008;IST

15.J.B Sharma,Nupur Gupta,Pakhee Aggarwal, Suneeta Mitta.Jun

17,2008; IST

16.Ms. N. Ramanjamma. The effectiveness of Self Instructional Module

on Causes, hazards and prevention of child labour among the mothers.

Dept. of Pediatric of Nursing. Goutham College of Nursing,

Bangalore. 2007; p-96.

17.Ms. Enu Boro. The effectiveness of Self Instructional Module on self

care strategies of antenatal mothers. Dept of obstetrics and

Gynecological Nursing, Goutham College of Nursing, Bangalore.

13

2007; P-77

18. Basavanthappa BT. Nursing Reaserch.1ST Ed. New Delhi; Jaypee

Brother; 2003.P.49-50.

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