Download 6 - Rajiv Gandhi University of Health Sciences

Rajiv Gandhi University of Health Sciences, Karnataka
Bangalore.
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
1.
Name of the candidate and
address
MOHAMMAD. HUSNA BHANU,
KRUPANIDHI COLLEGE OF
NURSING,
CHIKKABELLANDUR,
CARMALARAM POST,VARTHUR
HOBLI, BANGALORE – 560035.
2.
Name of the institution
Krupanidhi College Of Nursing
3.
Course of study and subject M.Sc Nursing
Obstetrics and Gynaecological Nursing
4.
Date of admission to course 01-06-2008
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5. TITLE OF THE TOPIC:
A STUDY TO ASSESS THE EFFECTIVENESS OF WARM COMPRESS
ON
LUMBAR
AND SACRAL REGION DURING FIRST STAGE OF
LABOUR AMONG PRIMI MOTHERS IN LABOUR ROOM OF SELECTED
MATERNITY HOSPITAL, AT BANGALORE.
6. BRIEF RESUME OF THE INTENDED WORK
6.1 NEED FOR THE STUDY:
Pain is a highly unpleasant and very personal sensation that can not be shared with
others. No two people experience pain in exactly the same way.1 Among pains, the
pain of child birth is a time honored and inevitable part of the human existence.
Labour pain is a fluctuating cycle pain, appearing in waves, radiating and then
subsiding inturn.2 The causes of labour pain are uterine contractions and dilatation
of cervix which causes unbearable pain in mothers.3 The obstetricians and
midwives are the health care providers who need to provide current maternity
services to manage a women who is in labour.
A descriptive study was conducted on 100 low risk parturients who delivered
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vaginally in labour room. Three instruments, the numeric pain intensity scale, a
pain assessment questionnaire and demographic questionnaire were used to assess
labour experience and labour pain intensity levels. The results have shown that
majority of parturients who did not receive pain relief measures reported pain
intensity levels in I stage as >8 in Numeric Pain Intensity Scale (ranging from
0-10) and as 8.83 in second stage.4
Normally labour pain in primi mothers is unbearable, usually they cry out for help
when the intensity increases. To relieve this pain there are many pharmacological
and Non-pharmacological measures. But these pharmacological measures may
cause some adverse effects. So, many women in labour would like to keep drug
use to minimum level. A study was conducted to examine the relationship between
epidural anesthesia and long term back ache after child birth among 11,701 women
who delivered at maternity hospital, Birmingham. The results have shown that a
significant association was found between back ache and epidural anaesthesia; nine
hundred and three women out of four thousand seven hundred and sixty six
women who had epidural anaesthesia reported backache compared with 731 of
6935 women who had not received epidural anaesthesia. This study concludes that
the relation between backache and epidural anaesthesia is causal and back ache
results from a combination of effective analgesia and stressed posture during
labour.5
3
A randomized study was conducted among 50 women to evaluate the efficacy of
spinal Clonidine combined with Ropivacaine and Sufentanil to reduce labour pain
and its effects on maternal & fetal outcomes. The assessed factors were onset and
duration of analgesia, pain, blood pressure, heart rate, incidence of nausea,
pruiritis, umbilical artery pH, fetal heart rate abnormalities and Apgar score. The
results revealed that intrathecal Clonidine with Ropivocaine and Sufentanil
prolongs spinal analgesia, but it causes maternal hypertension.6
A prospective study was conducted over 700 women who gave birth at six
maternity units in South England. The results showed that most women preferred
to keep drug use to a minimum, though they expected labour to be quite or more
painful. Women who preferred to avoid drugs were more satisfied with overall
birth experiences than women who had drugs.7
Treating pain is important because coping of parturients with pain influences the
birth experience as being perceived good or bad. Vaginal birth without analgesia or
anaesthesia contributes to optimal health outcome for mother and babies.8 There
are some non pharmacological measures to reduce labour pain such as TENS
application, aromatherapy, acupressure, heat applications, hypnosis and breathing
& relaxation techniques etc.Among these measures women prefer to have heat
applications as it is considered as effective measure in relieving pain.2
4
A study was conducted to determine perineal outcomes and maternal comforts
related to application of perineal warm pack in second stage of labour. The results
have shown that women in warm pack group had significantly fewer III, IV degree
tears and had lower perineal pain scores while giving birth and on first and second
postnatal day when compared with control group. This study concludes that warm
packs are simple, inexpensive practice and should be incorporated into second
stage of labour.9 The heat brings more blood supply to the area where it is applied
and reduces inflammation there by pain will be reduced.
A prospective study was carried out to assess the effect of warm tub bath during
labour among 88 women. The results have shown that experimental group who
bathed in warm tub bath for 30 minutes - 1 hour had cervical dilatation up to
2.5 cms/hr where as in control group it was 1.25 cms /hr. the study has concluded
that warm tub bath during labour facilitates good cervical dilatation and reduces
pain and discomfort.11
The investigator as a midwife has come across many women suffering from
agonizing pain and discomfort during labour. On investigating women suffering in
labour pain, the investigator found majority of women would like to receive
Non – pharmacological pain relief strategies and avoid pharmacological measures
probably due to their side effects. This prompted the researcher to carry out the
study and if found effective, heat application can be recommended to adopt in the
clinical practice to reduce labour pain.
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6.2 REVIEW OF LITERATURE:
Pain is a universal unpleasant, sensory and emotional experience which is highly
subjective in nature. Labour pain is a progressive and unbearable pain during child
birth. In this study review of literature is categorized into three categories and they
are
1) Labour pain perception
2) Heat application to relieve pain.
3) Heat application in labour
1) Labour pain perception:
A descriptive study was conducted to describe the quality and intensity of
adolescent’s pain during the progression of labour. The Gaston-Johansson Pain-OMeter was administered to 33 adolescents during the three labor phases (2-4 cm,
5-7 cm, and 8-10 cm) following a contraction. The most frequently selected
sensory words were cramping in Phase I and pressing in Phases II and III.
Miserable and killing were the most commonly chosen affective words during the
three labour phases. The results showed that total pain intensity scores were highest
during Phase III of labour and delivery. A t-test of independent samples found that
quality and intensity pain scores for primiparous and multiparous adolescent
participants were not significantly different during the progression of labour.10
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A descriptive study was conducted to assess labour pain experience and intensity
among 100 low risk Jordanian parturients who delivered vaginally in labour room
of a major hospital in the city of Amman. Three instruments, the numeric pain
scale, a pain assessment questionnaire and demographic questionnaire were used to
assess labour experiences and labour pain intensity levels. The results have shown
that majority of parturients ( 81% ) who did not receive pain relief measures
reported painful labour experiences and pain intensity levels as >8 in I stage and
8.83 in II stage of labour on numerical pain intensity scale (ranging from zero –
ten) . The study concluded that role of supporters and educators among maternity
nurses and midwifes need to improve considerably.4
A study was conducted on perception of labour pain among mothers and their
attending midwives in The Queen Elizabeth Hospital, South Australia. The study
used Short Form Mc Gill Pain Questionnaire to assess labour pain for every 15 min
during I stage of labour. The results have shown that both midwives and mothers
pain scores were similar at mild and moderate pain levels, but have shown
significant difference at severe pain levels at 0.05 level of significance. The study
concluded that experience and perception of pain are subjective and thus remains
difficult for an observer to estimate.12
2) Heat application to relieve pain :
A randomized placebo and active controlled study was conducted to assess the
effectiveness of continuous low level topical heat application in the treatment of
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dysmenorrhoea. The study used an abdominal patch (heated and unheated) for
approximately 12 consecutive hours per day and oral medications (Ibuprofen
400mg) three times daily, approximately 6hrs apart for 2 consecutive days. Pain
relief and pain intensity were recorded at 17 time points. The results have shown
that eighty four patients were enrolled and eighty one completed the study
protocol. Over two days of treatment, the heated patch plus placebo tablet group
( mean 3.27, P< 0.001), the unheated patch plus Ibuprofen group (mean 3.07,
P< 0.001 ) , and a combination of heated patch plus Ibuprofen group ( mean 3.55
P< 0.001) had significantly greater pain relief than the unheated patch and placebo
group. The study concluded that continuous low level heat therapy was as effective
as ibuprofen for the treatment of dysmenorrhoea.13
Nine randomized and non randomized controlled trials were conducted among
1117 participants to examine the effect of superficial heat therapy to reduce
low back pain. In two trials 258 participants were provided heat wrap therapy
and control group was on oral placebo treatment. The results have shown that
experimental group have significantly reduced pain after 5 days at 0.05 level of
significance. In one trial of 90 participants, it was found that a heated blanket
significantly decreased back pain at 0.05 level of significance and in one more trial
of 100 participants the additional effect of exercise to heat wrap was examined and
with this back pain was reduced after 7 days. The study has concluded that heat
therapy has good effect to reduce back pain.14
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A study was
conducted to
assess
the effect
of heat on amplitude of
myoelectronic activity in back muscle by using frequency standardized surface
Electro Myogram recording on healthy volunteers . The results have shown that
there was a significant reduction of amplitude after applying mudpacks ( 500 c) in
wilcoxon matched pair signed ranks test at 0.05 level of significance where as the
control group showed no alteration in amplitude even after a period of 20 minutes
rest.15
3 ) Heat application in labour :
A randomized controlled trial was conducted on women's experience and
midwives opinion on use of perineal warm packs in second stage of labour. warm
packs. Out of Seven hundred and seventeen primi women, 360 women were
applied warm packs on perineum and 375 women received standard care. The
findings stated that warm packs were highly acceptable to both women and
midwives as a mean of relieving pain during the last second stage of labour.
Almost the same number of women (79.7%) and midwives (80.4%) felt that warm
packs will reduce pain during the birth. Both women and midwives were positive
about using warm packs in the future. Majority of the women (85.7%) said that
they would like to use perineal warm packs again for their next birth and about
86.6% of women would like to recommended for their friends. Like wise 91% of
midwives were positive about using them in the future as a part of routine
maternity care in second stage of labour. The study concluded that warm packs on
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perineum in second stage of labour was highly acceptable and effective in helping
to relieve perineal pain and increases comfort.9
A prospective study was undertaken where 88 women had warm tub bath for
30 minutes - 2 hours during first stage of labour after a strict normal pregnancy. A
control consisted of seventy two women during pregnancy and labour, but did not
want to take a warm tub bath during labour. Apart from the bath, the two groups
followed the usual obstetric procedures of the department. The results have shown
that cervical dilatation in Bath group was 2.5 cms compared with 1.25 cms in
control group. Mean pain score in bath group was higher before the bath and they
experienced pain relief during and after bath which was not observed in control
group.11
A quasi experimental study (pre test post test control group) was conducted on
effectiveness of warm compress on labour pain. The sample consisted 60, second
and third gravid women in labour who met inclusion criteria were randomly
assigned to group 1, group 2 and group 3. All the three groups had usual care and
support from health care professionals. Data was collected by using visual
analogue scale and structured observational check list. The study revealed the
experimental group had reduction in pain and experienced comfort than the control
group at 0.05 level of significance. The study concluded that warm compress is one
of the simple, effective, non invasive and cost effective method having no side
effects on mother and infant.16
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6.3 STATEMENT OF THE PROBLEM:
A study to assess the effectiveness of warm compress on lumbar and sacral region
during first stage of labour among primi mothers in labour room of selected
Maternity hospital, at Bangalore.
6.4 OBJECTIVES OF THE STUDY:
 To assess the level of pain and behavioral responses in primi mothers during
the first stage of labour.
 To assess the effectiveness of warm compress on labour pain.
 To determine the association between pain and behavioral response scores and
selected demographic variables.
6.5 HYPOTHESIS:
H1 - Post test pain score and behavioral responses will be lesser than pretest pain
score and behavioral responses at 0.05 level of significance.
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6.6 OPERATIONAL DEFINITIONS:
Effectiveness:
Effectiveness refers to the extent to which the warm compress has its
impact on reducing the labour pain experienced by primi mothers as measured by
Numerical pain scale and observational check list.
Warm compress:
Warm compress is the application of moist heat over lumbar and sacral region by
means of Turkish towel wrung out of hot water (temp – 1000-1010 F). Warm
compress will be applied for a period of 15 minutes at half an hour interval for four
hours in I stage of labour.
First stage of labour:
First stage of labour refers to the time interval from 3cms cervical dilatation
till full dilatation cervix.
Pain:
It refers to intense never felt subjective discomfort experienced by primi
mothers in first stage of labour reported on Numerical pain scale.
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6.7 ASSUMPTIONS:
1) Primi mothers in first stage of labour will have severe pain during uterine
contractions.
2) Warm compress as a non pharmacological measure will reduce the intensity of
labour pain.
6.8 DELIMITATIONS:
This study is limited to primi mothers who are in first stage of labour and admitted
in a labour room of selected hospital.
6.9 PROJECTED OUTCOME:
The findings of this study will reveal that after application of warm compress there
may be a noticeable reduction in the level of labour pain experienced by primi
mothers in labour room.
7. MATERIALS AND METHODS:
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7.1 SOURCE OF DATA
7.1.1 Research design
Quasi experimental design will be used to conduct the study.
Pretest
Treatment
O1
Post test
X
O2
7.1.2 Setting:
This study will be conducted in labour room setting of Yediur Maternity Hospital.
Yediur Maternity Hospital is located in Jaya Nagar, Bangalore. The hospital
consisted a labour room, a post natal ward, an operation theatre and OPD. The
monthly statistics of labour cases are about 140, among which the primi cases will
be 40-50 per month.
7.1.3 Population
The study population consist of primi mothers in first stage of labour admitted in
labour room.
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7.2 METHOD OF DATA COLLECTION:
7.2.1 Sampling procedure:
Purposive sampling method will be used in the study to select the primi mothers
who meets the inclusion criteria.
7.2.2 Sample size:
Forty Primi mothers who are in first stage of labour.
7.2.3 Inclusion criteria: Primi mothers who are
1) in first stage of labour
2) with term pregnancy.
3) with singleton pregnancy.
4) willing to participate in the study.
7.2.4 Exclusion Criteria: Primi mothers
1) who are on analgesics and sedatives.
2) whose cervical dilatation > 6cms on admission.
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7.2.5 Instruments used for the study :
1) Part 1 - Baseline proforma
2) Part 2 - Numerical Pain Scale
Numerical pain scale is a straight line which has points, ranging from 0 to
10. Point 0 indicates no pain and point 10 indicates worst possible pain. The
subjects in the study will be given the scale and will be asked to mark to the point
at which they feel pain17.
3) Part 3 - Observational Check List
a) Observation during contractions
b) Observation in between uterine contractions
c) Manifestations of participation
7.2.6 Data collection method:
After securing written permission from the respective authority and based on
criteria informed consent will be taken, pre test will be conducted among primi
mothers who meets the inclusion criteria using numerical pain scale to assess pain
scores and behavioral responses using Observational check list. Warm compress
will be administered for 15 minutes at half an hour interval for four hours in first
stage of labour. Post test pain scores and behavioral responses will be assessed
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using numerical pain scale and Observational check list.
7.2.7 Data analysis plan:
Descriptive and inferential statistics will be used to analyse data according
to objectives.
7.3
DOES THE STUDY REQUIRES ANY INVESTIGATION OR
INVESTIGATION TO BE CONDUCTED ON PATIENT OR OTHER
HUMAN OR ANIMALS?
No
7.4 HAS ETHICAL CLEARANCE OBTAINED FROM YOUR
INSTITUTION ?
No invasive intervention will be used. Prior permission from the respective
authority and individual consent will be taken.
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8. LIST OF REFERENCE:
1) Barbara Kozier, Glenora Erb, Andrey Jean Bermann, Karen Burke.
Funsdamentals of Nursing. 7th ed. New Delhi: Dorking Kindersly Pvt.Ltd; 2007.
p.1081.
2) Lowne NK. The pain and discomfort during labour and birth. JOGNN 1996
Jan; 25(1): 82-92.
3) Ruth Bennet, Linda Brown. Myles text book for Midwives. 12th ed. Churchill
Livingston: 1993. p. 186-97.
4) Lubna Abushaikha, Arwa Oweis. Labour Pain experience and Intensity - A
Jourdin perspective. Journal of Transcultural Nursing 2007 Jan; 18(1): 35-40.
5) C.Mac Artur, M Lowis, EG Knox, JS Grawford. Epidural Anaesthesia and
Long term Bachache after Child birth. British Medical Journal 1990 Jul;
301(6742): 9-12.
6) David H, Rosen M. Perinatal morbidity after analgesia. British Medical Journal
1996 Oct; 31(8): 1054–59.
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7) H. Homer, Brodrick. Expectations and experiences of pain in labour. Journal of
Obstetrics and Gynaecology 2001 Jun; 29(7): 53-57.
8) Francis Nichols, Elaine Zwellin. Maternal Newborn Nursing theory and
Practice. 1 st ed. Philadelphia: W.B Saunder; 1997. p. 832-39.
9) Hannah G.Dahlon, Carolie SE.Homer, Margaret cooke, Alexis M. Upton.
Australian women's and midwives experience of using perineal warm packs in II
stage of labour. Journal of Birth and Management 2007 Apr; 34(3): 132-35.
10) Diane Brage Hudson. Christie Campbell Grossman. Adolescents pain during
the progression of labour. Journal of Nursing Clinical research 1998 Jul; 7(1) :
82-93
11) Carsten Lenstrup, Anne Schantz, Arne Berget, Elisabeth Feder, Helle sper Yer.
Warm tub bath during delivery. Journal of Acta Obstetricia et Gynaecologia
Scandinavia 1987 Mar; 66(8): 707-12.
12) Angela Bakar, Sally A. Ferguson, Gregory. Perception of labour pain by
mothers and midwives. Issues and Innovations in Nursing 2001; 35(2).
13) Mark D.Akin, Kurt Weingand, David a. Hengehold, Mary Beth, Robert
T.Hinkle. Continuous low level topical heat in treatment of Dysmenorrhoea.
Journal of Ostetrics and Gynaecology 2001 Apr; 97(8): 343-49.
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14) French SD, Cameron M, Walker BF, Esterman AJ. Superficial heat and cold
for back pain. Cochrane Database for Systematic reviews 2006 Jan; 26 (1):
1002-13.
15) Magyarosy, Krause, Resch K.L, Guggemose. Surface EMG response to heat
and cold application on back muscle. European journal of Physical Medicine and
Rehabilitation !996 Jun; 6(33): 39-42.
16) Shirley Joseph. Effectiveness of warm compress on sacral area to women in
labour pain during first stage in a selected hospital at Bangalore. (Unpublished
master of Science Nursing dessertation submitted to Rajiv Gandhi University of
Health Sciences, Bangalore.)
17) Hartrick CT, Kovan JP, Shapiro S. The numeric rating scale for clinical pain
measurement:2003; 3 (4): available from: URLhttp://www.pain assessment
scales.org
doi:10.1111/j.1530-7085.2003.03034.x.PMID17166126.
December 2005.
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Accessed
Signature of candidate
Remarks of the guide
Name & Designation
(In block letters)
11.1 Guide
MRS.MARIA PREETHI MIRANDA
ASSOCIATE PROFESSOR
11.2 Signature
11.3 Co-Guide
MISS.HEPSI BEULAH
LECTURER
11.4 Signature
11.5 Head of Department
MRS. MARIA PREETHI MIRANDA
ASSSOCIATE PROFESSOR
11.6 Signature
12.1 Remarks of the principal
12.2 Signature
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