PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

Mrs. JAYANTHI. G
I YEAR M. Sc NURSING
OBSTETRICS AND GYNECOLOGY
YEAR 2007-2009

PADMASHREE COLLEGE OF NURSING

GURUKRUPA LAYOUT, NAGARBHAVI
BANGALORE-560072

1
 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1 NAME OF THE CANDIDATE & MRS. JAYANTHI. G

I YEAR M.SC NURSING
ADDRESS PADMASHREE COLLEGE OF
NURSING
GURUKRUPA LAYOUT
NAGARBHAVI
BANGALORE-560072

2 NAME OF THE INSTITUTION Padmashree College of Nursing

3 COURSE OF STUDY AND I year M.sc (Nursing)

SUBJECT Obstetrics and gynecology

4 DATE OF ADMISSION TO 04 / 06 / 2007

COURSE
A Study To Assess The Knowledge And
5 TITLE OF THE TOPIC Attitude On Prevention Of Puerperal
Infection Among Staff Nurses At
Selected Hospital Bangalore.

2
6. BRIEF RESUME OF THE INTENDED WORK

“The only thing more expensive then education is ignorance’’

K. PARK
6.1 INTRODUCTION

Women who is pregnant will require regular health care visit with an obstetrician
and midwife, throughout their pregnancy known as prenatal care. These prenatal visits are
important because they may help physician to prevent pregnancy complications or increase
their awareness of potential problem.

Puerperium refers to the 6 weeks period following child birth during which
time anatomical and physiological changes restore the women to pre-pregnant stat.
Most women go through puerperium without any complications and emerge as happy
mothers. Some women, however may face unexpected complications. Some are
emergency situations needing prompt attention and treatment; these occurs mostly
within 24 hours of child birth. Most of the other problems occur in the first week but
some may be delayed up to 2-3 weeks. 1

Major risk factor for wound infections are poor surgical technique, extended
duration of labor and ruptured membranes, obesity, pre existing infection such as
chorioamnionitis etc, and the principal causative organisms are staphylococcus
aureus, aerobic streptococci and aerobic and anaerobic bacilli.2

Most Puerperal period is often seen as a smooth, uneventful time that follows,
the anticipation of pregnancy and the excitement and work of labor and birth and
often it is important for a nurse to be aware of problems, that may develop post partly
due to soft tissue trauma .Which provide an ideal environment for pathogenic
organisms which may lead to puerperal infection and increase the maternal morbidity
and mortality.3

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 According to the WHO “ a maternal death is defined as the death of a women
while pregnant are within 42 days of termination of pregnancy irrespective of the
duration and site of the pregnancy from any cause related to an aggravated by the
pregnancy or its management but not from accidental or incidental causes.”4

Because most deliveries are rightfully under the control of staff nurses. It is
essential that the staff nurses, reach a consensus on the implementations of
appropriate management technique if maternal morbidity and mortality are to be
minimized

The maternal mortality rate in India for the period 1990-1999 was
407/1,00,000 live births, inspite of all the scientific discoveries in terms of treatment
and drugs .This indicates there are social causes like socio-economic health practices,
medical causes like sepsis, infection that are responsible for maternal mortality rate in
India.5

6.2 NEED FOR STUDY

“ Protect maternal health for foetal enhancement”

As we all know “prevention is always better then cure”. So the nurses play
vital role in preventing the puerperal infections. Since small negligence or simple
ignorance can within a small period, become abnormal and successful delivery can
swiftly turn in to disease.

Maternal mortality refers to mortality of women due to complication of

pregnancy child birth or within 42 hours delivery from puerpal causes. The maternal
mortality rate (MMR) is expressed as number of maternal death per thousand live
births.

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 Globally, there are 430 maternal deaths for every 1,00,000 live births. In
developed countries there are 27 maternal deaths for every 1,00,000 live births.

The highest maternal mortality figure is in eastern and western Africa, where
in some countries more than 1000 women die for every 1,00,000 live births. The
lowest recorded figure is in northern Europe, where they range from 0-11 maternal
death every 1,00,000 live births. The maternal mortality rate has also lowered in
African countries like Tunisia and Kenya (310 and 190/1,00,000 live birth
respectively).

The maternal mortality rate in India is 408 per 1,00,000 live births (SRS
1997). This means that around 125,000 women die each year due to pregnancy related
causes. And 13% of maternal mortality is due to infection. The maternal mortality rate
is higher in Orissa (738/100,000) and lower in Karalla (87/100,000).6

Genital tract infection continues to present a life threatening problem to women

and table below shows the maternal death over the last 17 years..
Years Total Death Rate / Million Post natal Rate / Million
1985-87 9 4 2 0.9
1988-90 17 7.2 4 1.7
1991-93 15 6.5 4 1.7
1994-96 16 7.3 11 5.0
1997-99 18 8.5 4 1.9
2000-02 13 6.5 5 2.5

The most virulent organism is betahaemolytic streptococcus but more

commonly Chlamydia, Escherichia coli and other gram negative bacteria will be the
infective agents. The Breast should be examined for science of breast infection,
breast abscess formation is very unusual until after the fourteenth post natal day. 7

Urinary tract infection is a common infection in puerperium following the

frequent use of catheterization during labor. Some women will also develop urinary
5
retention and require indwelling catheters. E- Escherichia coli is commonest
pathogens. 8

The maternal mortality is also affected by a wide range of socio-economic

factors such as status for women, low level of female education, economic
dependency, lack of access to services and gender bias. 9

Post partum infection is a clinical infection of the genital canal that occurs with
in 28 days after abortion or child birth . Infection may result from bacteria commonly
found with in the vagina or from the introduction of pathogens from outside the
vagina. The infectious process may remain localized in the reproductive or genital
area, urinary tract or breast or it may progress resulting in metritis, endometritis,
peritonitis, such infections are a major cause of maternal death.10
Investigator had seen case of puerperal infection due to negligence of health
workers and identifying infection at later stage and providing care and then doing the
management. Many deaths are occurring due to lack of proper management of the
post partum mother.

The nurse was often ignorant of the prevention of infection in client with time,
increasing responsibility was given to the nurse who was expected to exercise
judgment in management of puerperal infections. In the practice of modern medicine,
increasing latitude is given to nurses to have thorough knowledge of prevention of
puerperal infection.

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 For this the nurse must update her knowledge about the current trends
regarding prevention of puerperal infection .The investigator hence rightly felt the
need to asses the nurses knowledge and even greater need to enlighten them about the
puerperal infection, which will in turn improve the quality of care, better recovery of
patient .

Hence the study under taken to asses the knowledge and attitude of staff nurses
on prevention of puerperal infection and to prepare health education pamphlet on
prevention of puerperal infection.

6.3 STATEMENT OF THE PROBLEM

A Study To Assess The Knowledge And Attitude On Prevention Of Puerperal

Infection Among Staff Nurses At Selected Hospital Bangalore.

6.4 OBJECTIVES

1. To assess the knowledge among staff nurses, regarding prevention of puerperal

infection.
2. To assess the attitude among staff nurses, regarding prevention of puerperal
infection .
3. To correlate between the knowledge and attitude among staff nurses, regarding
prevention of puerperal infection.
4. To associate the knowledge and attitude with the demographic variables.

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6.5. OPERATIONAL DEFINITION

1. Knowledge
It refers to awareness of staff nurses regarding prevention of puerperal
infection elicited through structured interview schedule.

2.Attitude
It refers to the opinion expressed by staff nurses regarding puerperal infection,
measured by liker scale

3 Staff nurse
Registered nurses with a qualification of B.Sc. nursing, post basic B.Sc nursing
and Diploma in general nursing with midwifery.

4.Prevention
It refers to the measures such as following aseptic technique that are taken to
stop the spread of the puerperal infection.

5. Puerperal Infections
It refers to the complication of post natal mothers, during their postnatal period
which include the following infections such as
1. Breast infections – Mastitis, Breast engorgement and cracked nipple.
2. Urinary tract infections- An infection of one or more structures in the urinary
tract. Most of the infections are caused by gram negative bacteria.
3. Puerperal sepsis- The infection of the genital tract which occurs as a
complications of delivery.

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6.6 ASSUMPTIONS

1. The staff nurses may have some knowledge regarding prevention of puerperal
infection.
2. The selected demographic variable have an influence on staff nurses knowledge
regarding prevention of puerperal infection.
3. The adequate knowledge of staff nurses regarding prevention of puerperal
infection have influence on the management of puerperal infection.

6.7. NULL HYPOTHESIS

1. There is no significant correlation between knowledge and attitude among staff

nurses of selected hospital regarding prevention of puerperal infection.
2. There is no significant association of knowledge and attitude with selected
demographic variables.

6.8 REVIEW OF LITARATURE

Review of literature for the present study is organized under the following headings.
1. Studies related to causes of puerperal infection
2. Studies related to incidence of puerperal infection
3. Studies related to prevention of puerperal infection
4. Studies related to knowledge of nurses on prevention of puerperal infection

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6.8.1 STUDIES RELATED TO CAUSES OF PUERPERAL INFECTION

Susan H.T and Aaron B(2002) conducted a retrospective cohort study on

meconium-stained amniotic fluid and its association with puerperal infection at
Francisco California, among 43200 women who were delivered at term. The findings
revealed that among the 43200 women who were delivered at term, 18.9% of the
women had meconium staining (8.8% thin, 5.5% moderate, 4.6% thick) compared
with deliveries with clear amniotic fluid. Those with meconium-stained amniotic fluid
had higher rates of endomyometritis the severity of meconium staining was associated
with increased rates of infection.11

A descriptive study was conducted among 31 women who are diagnosed with
lactation mastitis in the Midwestern states on mastitis symptomatology, self care and
treatment recurrence and complications by telephone interview. The study revealed
that as the lactation mastitis has greater impact on activities of daily living, breast
feeding women need specific information about mastitis, causes, symptoms and self
care strategies to help to prevent and treat the condition.12

A retrospective study by means of multi variant discriminate analysis was

performed on 496 deliveries, 250 vaginal and 246 cesarean section is identified risk
factors for puerperal infection. The infection rate by type of delivery were vaginal
3.6%, elective caesarean section 6.0%, primary cesarean section 22.2% and
emergency cesarean section 38.4%. The four statistically significant risk factors for
puerperal infection were duration of labor, number of pre-operative vaginal
examination, time membranes were ruptured prior to delivery and post – operative
anemia.13

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6.8.2 STUDIES RELATED TO INCIDENTS OF PUERPERAL
INFECTION.

A survey was conducted on incidence of postpartum infections among HIV

infected and uninfected women at Europe. The survey revield that vaginal delivery
and caesarian section were compared in both HIV infected and uninfected women.
Women delivering vaginally totaled 250, whereas 158 women had elective caesarian
section. The overall rate of puerperal infections was 29% in HIV infected women and
19% in uninfected control women in caesarian cases complications rates were 43%
for uninfected women and 13% for women who delivered vaginally. The study
concluded that HIV infected women are at an increased risk of post partum
complications after either vaginal delivery or caesarian section than uninfected
women14

A retrospective descriptive survey was conducted on all women who suffered

maternal death in the unit at Gogo-Chatinkha maternity unit Queen Elizebath Central
Hospital, Blantyre, Malawi. The objectives behind the study was to identify the social,
demographic and reproductive profile of women suffering a maternal death, to find
out the immediate causes and operations factors related to maternal death. The
findings revealed that there were a total of 204 maternal deaths and 19859 live births,
giving a maternal mortality ratio of 1027.2 / 1,00,000 live births, their ages ranged
from 16-40 years, adolescents comprised of 20.6% while the majority 56.4% were
aged 15-24 years. Most of the group 43.4% was para1 and less, with a range of 0-12.
The top five causes of death were puerperal sepsis 29.4%, post-abortal complications
23.5%, other infections conditions 20.1%, obstetric hemorrhage 10.6% and eclampsia
6.4%. other identified operational factors included delay in accessing and receiving
emergency obstetric care, pure quality services and H.I.V infections.15

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6.8.3 STUDIES RELATED TO PREVENTION OF PUERPERAL
INFECTION

Hand disinfections as the central factor in prevention of puerperal mastitis.

This is supported by the incidence of puerperal mastitis was evaluated in the course of
12 months periods with and without additional hand disinfections at the bedside in
universal teaching hospital at German. The survey reports stated that out of 1095
mothers 32 mothers developed mastitis without additional disinfections at the bedside
the incidence of mastitis was 29% when additional bedside disinfections was
available, mastitis dropped to 8 cases per 12 months. The survey recommendation
emphasizes, that puerperal women should practice strict hygiene in her post partum
period.16

At one hospital where over 400 of the cases were delivered, the morbidity rate
on the treated group was 1.0 percent, as compared with 5.8% in the untreated group.
These rates are compared with 7-3,8-1 and 5% in the total ante-natal cases delivered
in this hospital in the three years prior to the commencement of this investigation.
When the morbid cases were classified, the difference in the morbidity rates between
the two groups was 4.0%. In the victim group and 5.5% in the controls. However, the
difference between these morbid cases in the two groups was clinically very great;
thus 12 cases were classified as a clinically severe in the vitamin group and 26 in the
control group. The result of this large investigation suggests that vitamin A therapy
given before child birth has increased the resistance of the genitourinary tract to
invasion by micro-organisms.17

Vitamin A therapy given before child birth has increased the resistance of the
genitor – urinary tract to invasion by microorganisms. This is supported by the study
was conducted among 550 women attending antenatal clinics in Sheffield were
investigated. Alternate women (275) were given a supply of a preparation rich in
vitamin A and D during the last month of pregnancy, the remaining women were not
12
given any supplement. No vitamin preparation was given any patient after entering
Hospital. No instruction were given as to diet any case. The women at full term were
brought in to hospital and delivered, the attending doctors having no idea of previous
therapy. After discharge from the hospital, all the notes of the patients were collected
and analyzed. The results were as follows : The morbidity rate in the puerperium
using the B.M.A. standred was 1 percent. In vitamin group and 4-7 in the control
group, a difference of 3-6 percent. Which twice the standred error (1-4) and therefore
statiscally significance.18

6.8.4 STUDIES RELATED TO KNOWLEDGE OF NURSES ON

PREVENTION OF PUERPERAL INFECTION

In 1998, 20.2% of the approximately 4 million births in the United States

occurred via caesarian delivery, routine antibiotic prophylaxis has significantly
reduced morbidity, yet each year between 41,000 and 2,06,000 women develop a
subsequent infection of the uterus or surgical incision. A through understanding of the
pathophysiology and complex interaction of risk factors for metritis and wound
infection is vital for perinatal nurses. Nurses have a critical role in the identification
and treatment of post caesarian infection.12

A stepped wedge, cross sectional study was conducted in 10 survival sites

across two rural districts of Tanzania, to determine the effectiveness of an intervention
that incorporated education about the six cleans with the use of a cleaned delivery kit
in preventing puerperal infection. A total of 3262 pregnant women between the ages
of 17 and 45 years were enrolled in the study. The midwife administered
questionnaires to each mother at 5 days post partum and inspected the mother for
signs of infection. Women who use the kit for delivery were 3.2 less slightly to
develop puerperal sepsis than women who did not use the kit.19

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7. MATERIALS AND METHODS

7.1. SOURCE OF DATA

Data will be collected from the staff nurses working in selected hospital
Bangalore Karnataka

7.2. METHOD OF COLLECTION OF DATA

I.Research design
Non experimental design and descriptive approach will be used.

II. Research variables

i. Study variable; Knowledge and attitude among staff nurses of selected hospital
regarding prevention of puerperal infection
ii. Extraneous variable ; Age, experience, education, socio economic background

III. Research setting

Selected maternity hospital Bangalore

IV. Population
The Population for the study will be all staff nurses working in selected maternity
hospital in Bangalore

V. Sample
staff nurses in selected maternity hospital who meet the inclusion criteria and sample
size is 100.

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VI. Criteria for sample selection
Inclusion criteria
1. Staff Nurses who are exposed to the obstetrics and gynecology ward for more
than 2 years
2. Staff Nurses who are available at the time of data collection.

Exclusion Criteria
1. Staff nurses who are working in the night duties
2. Staff nurses who are not willing to participate in the study
3. Practical nurses or aids and nursing students who are getting training in the
hospital

VII. Sampling technique

The non-probability, convenient sampling technique will be followed to allot the
samples.

VIII. Tool for data collection

The structured interview schedule consists of following section;

Section A- To assess demographic data
Section B - Structured interview schedule, to assess the level of knowledge.
Section C –Likert scale to assess the level of attitude.

XI. Method of data collection

After obtaining the permission from concerned authority and informed

concerned from the samples ,the investigator personally assess the level of
knowledge by conducting interview and assess the level of attitude by likert scale.
Duration of the study is 4 weeks.

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X. Plan for data analysis

The data collected will be analyzed by means of descriptive and inferential statistics

Descriptive statistics
Mean, percentage distribution and standard deviation will be used
Inferential statistics
Chi-square and person correlation will be used.

XI. Projected outcome

After the study the researcher will know the level of knowledge and attitude of
staff nurses of selected hospitals regarding prevention of puerperal infection.

7.3. Does the Study require any investigations or interventions to be conducted

on patients or other humans or animals?
No this study does not involved any active manipulation

7.4. Has ethical clearance been obtained from your institutions?

Yes, permission will be obtained from the concerned authorities in the selected
maternity hospital.

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LIST OF REFERENCES
1. Padubidri v and Ela Anand.Text Book of obstetrics.1st edition.New Delhi; BI publications;
2006: 385-403.

2. Gibbs R S,Blanco J D,St.Clair P J A case controle study of wound abscess after caesarean
delivery.Obstetric Gynecology; 1998: 62 : 498.
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3.Lisa M.Koonin M.N. M.P.H, Hani K. Atrash, M.D. M.P.H, Roger W, Rochat, M.D.
Jack C. Smith, M.S. Maternal mortality surveillance. United states, 1980-1985
MMWR 12/1/1988:37(S.S.5): 19-29.

4.WHO Puerperal infection WHO Geneva;2005 . Available from http://www.who

.org /

5. Text Book of preventive and social medicine. 17th edition. Premnager, Jabulpur;
banarsidas Bhanot Publications;2003 : 338-339.

6.Ruth.V, Bennett, Linda. K, Brown. Myles textbook for midwives.13th edition.

Philadelphia ;Churchill Livingstone Company;2001: 238-39.

7.Keith Edmonds D.Obstetrics and gynaecology.7th edition. London;Blackwell

publication; 2007:71-79.

8. Duff.P; Urinary tract infections, primary care update obstetric Gynecology,

1994;1-12.

9.Krishna Kumari Gulani. Community Health Nursing. 1st edition. Newdelhi:

Kumar publishing House; 2006:348-50.

10.Lowdermilk D.L,Perry T.M. Maternity and women’ shealth care.6th edition.New

York;Mosby Publications; 1997:316-318.

11.Susan H.T & Aaron B. Meconium stained amniotic fluid associated with puerperal
infection. Journal of Obstetrics and Gynecology 2003. February 3(8):746-49

12.Wamback K.A. Lactation mastitis. Journal of human lactation. ‘2003 Feb;

19(5):24-34.

13.Hawrylyshyn PA, Bernsten P, Papsin FR. Risk factor associated with infection
following caesarean section. Journal of Obsterics and Gynecology 2001, feb: 139
(3) : 1294 – 8.

14.High rates of post-partum complications in HIV-infected than un-infected women

irrespective of mode of delivery. Obstetric and Gynecological survey.

17
15.Lema VM, Changlole J, Kanyige C, Malunga EV. Maternal mortality at the queen
Elizabeth central teaching hospital, Blantyre, malavi. 2005 Jan; 82 (1):1-2.

16.Peters F, Flick-Fikies D, Ebel S. Habd disinfaction as the central factor in

prevention of puerperal mastitis. Article in German journal.

17.Edward Mellanby M.D. A study of Nutrition and disease the interaction clinical
experimental work. 2004Feb;78(20:65-9.

18. E.dward Mellanby M.D. A study of Nutrition and Disease the interaction clinical
experimental work. 2004 Feb : 78 (2) 65 – 9.

19.Obstertric gynecology, Neonatal Nurse, 2001 Nov-Dec; 30 (6):642-8

20.American College of Nurse midwives published by elsevier INC. Prevention of

puerperal infection available from http://www.pubmed.com accessed on 19.11.07.

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9. Signature of Candidate :

10. Remarks of the Guide :

11. Name and Designation of :

11.1 Guide :

11.2 Signature :

11.3 Co-Guide (if any) :

11.4 Signature :

11.5 Head of Department :

11.6 Signature :

12.1 Remarks of the Chairman & Principal:

12.2 Signature :

19