Effectiveness Of Bundle of Care on Reduction of After Pain Among Primi Mothers Undergone Normal Vaginal Delivery

Abstract

Introduction: Pregnancy is very special journey for a woman. It is a journey of dramatic physical, psychological and social change of becoming a mother of redefining family relationships and taking on the long-term responsibility for caring a new born baby. Birth is a beautiful experience of parents to welcome a baby into the world. Most women experience some degree of pain after childbirth. Pain can interfere with a woman’s ability to care herself and her baby after delivery. After pain means more often in multi paras or in women whose uterus was overly distended. Primi mothers’ uterine tone is good, the fundus generally remains firm and the woman usually perceives only mild uterine cramping. Periodic relaxation and vigorous contraction are more common in subsequent pregnancies and may cause uncomfortable cramping called after pains that persist throughout the early puerperium.

Objectives of the Study:

a) To assess the level of after pain among Primi mothers.
b) To assess the effectiveness of Bundle of care regarding reduction of after pain among Primi mothers.
c) Compare the pre-test and post-test regarding reduction of after pain among primi mothers.
d) Association between the pre intervention and post intervention reduction of after pain among Primi mothers with their selected demographic variables and obstetrical variables.

Research Methodology: The investigator obtained formal permission from research department and Institutional Ethical Committee of Sri Manakula Vinayagar Medical College and Hospital. The population of the study was primi mothers, admitted in the postnatal ward with spontaneous vaginal delivery at SMVMCH. The research design was used in the study is Experimental research design - True Experimental design. Sampling technique was used in the study Simple Random Sampling Technique. The sampling size was 60, settings of the study was - SMVMCH, Puducherry.

Major findings of the study: In pretest, amount of vaginal bleeding 22(36.7%) had moderate 22(36.7%), had mild level of vaginal bleeding 16(26.7%). In post-test, amount of vaginal bleeding 6(10%) had moderate 14(23.3%), had mild level of vaginal bleeding 40(66.7%). REEDA scale assessment for overall pre-test 6 Mean score, 2.25 Standard deviation, and mean percentage were 50%. REEDA scale assessment for overall Post-test 3.07 Mean score, 2.31 Standard deviation, 26% was mean percentage, 2.93 were in difference in mean percentage t - Value is (8.02), P - Value is (p= 0.001) are statistically highly Significant. Level of pain scale in pre-test 5.85 Mean score, 1.36 Standard deviation, and mean percentage were 59%. Level of pain Scale in Post-test 1.98 Mean score,1.35 Standard deviation, 20% was mean percentage, 3.87 were in difference in mean percentage t - Value is (20.26), P - Value is (p= 0.001) are statistically highly Significant. The association between reduction of after Pain in pre-test with selected demographic variables are shown highly significant in educational status, religion, residency, dietary pattern, occupation family income and postnatal day. In obstetrical variables shows amount of vaginal bleeding, weight of the baby and number of breasts feeding per day shows statistically significant with chi - Square value at p<0.05 level. The other demographic variables had not shown statistically significant.

Conclusion: The analysis of the study revealed that, the paired’t’ test value of 20.26, were very highly significant at the level of p<0.001. It indicates the effectiveness of Bundle of care such as fundal massage, alternative leg lifting exercise, Sitz Bath, Kegel’s exercise and Episiotomy care on reduction of after pains among Primi mothers.

Keywords:Effectiveness, Bundle of Care, Reduction of After Pain, Primi mothers and Normal Vaginal Delivery

Introduction

Pregnancy is a unique and significant experience for women, marked by significant physical, psychological, and social changes. It involves becoming a mother, redefining family relationships, and taking on the long-term responsibility of caring for a newborn baby. Welcoming a newborn into the world is a precious moment for parents. Throughout her journey, a mother plays a unique and important role in experiencing the crucial events that occur during different stages, broadly classified as the antenatal period, intranatal period, and postnatal period. After pain is a term used to describe the occasional spasmodic pain felt in the lower abdomen after childbirth. This pain is caused by postpartum contractions of the uterus as it shrinks back to its pre-pregnancy size and position. Hypertonic contractions of the uterus can occur when blood clots or bits of the afterbirth remain, and the uterus tries to expel them. During pregnancy, the uterus loses muscle tone due to its contraction- relaxation cycle, which can lead to after-pain.

After the delivery of the placenta, there is an open wound left in the uterus which bleeds. The placenta acts like a scab, and once it is removed, the wound is exposed. To push out the blood and clots, the uterus needs to contract, just like it did during the delivery of the baby and placenta. These contractions can cause mild after- pains, like menstrual cramps. Usually subsides within 48 hours after childbirth. Breastfeeding mothers may experience more afterpains, as the baby’s sucking triggers the release of oxytocin from the posterior pituitary, which causes the uterus to contract. Mild analgesics may be prescribed to help alleviate the after-pains.

Need for the Study

Episiotomy is a surgical procedure to enlarge the vaginal orifice, often performed during the second stage of labor or just before delivery. Stitches in the perineum should dissolve within three weeks. New mothers should continue careful perineal care until their first post-birth check-up. Post-birth, women often worry about caring for their perineal area, which can cause reduced strength, a torn or cut perineum, hemorrhoids, and lochia. Proper care can help manage these issues and encourage healing. Initial perineal care after childbirth focuses on treating pain and swelling. Applying cooling packs and pain relievers, heat is applied for healing. Sitz baths, using toilet bowl-fitted tubs, are helpful for soothing soreness. Sit on water for 10-20 minutes 1-3 times daily. Proper perineal care is essential for healing.

After childbirth, it’s crucial for women to properly care for their perineum. Regularly changing sanitary pads, flushing with water, and drying the area are essential steps. Hand washing is also crucial. Mothers may pass small clots and lochia, but heavy bleeding, fever, redness, swelling, foul-smelling discharge, or abdominal pain require immediate attention. In India 2018, 103 mothers with acute dacryocystitis were randomly assigned to receive care bundles (55 cases, research group) or conventional care (48 cases, control group). The RG and CG groups were comprised of 18-65-yearolds and 32-63-year-olds respectively.

The researcher identified from the mothers who undergone spontaneous vaginal delivery with episiotomy, are in needs of Nursing care to reduce after pain by using bundle of care in primi mothers.

Statement of the Problem

“Effectiveness of Bundle of care on reduction of after pain among primi mothers undergone Normal vaginal delivery at SMVMCH, Puducherry”.

Objectives

a) To assess the level of after pain among primi mothers at smvmch, Puducherry.
b) To assess the effectiveness of Bundle of care on reduction of after pain among primi mothers. smvmch, Puducherry.
c) Compare the pretest and posttest regarding reduction of after pain among primi mothers. smvmch, Puducherry.
d) Association between the pre intervention and post intervention level of reduction of after pain

among primi mothers with their selected demographic variables and obstetrical variables.

Operational Definitions

Effectiveness

In this study, it refers to difference between the pre- and posttest intervention in reduction of after pain.

Bundle of Care

In this study, it refers to the Nursing interventions such as Fundal massage, initiating breast feeding, Sitz bath, Kegel’s exercise, Episiotomy care and alternative leg lifting exercise for the Primi mothers.

Fundal Massage

In this study, it refers to manual massage given on the fundus with one hand supporting the fundus and other hand just above the symphysis pubis in a rotatory movement for 30 seconds was given 2 times in a day and for 1 day after normal vaginal delivery.

Sitz Bath

In this study, it refers to immersing the perineum in a basin of warm water at a temperature of 105-degree Fahrenheit for 10 minutes every morning and evening for 3 days.

Kegel’s Exercise

In this study, it refers to lifting and holding and relaxing pelvic floor muscle. Hold tight and count 3 to 5 seconds. Relax the muscles and count 3 to 5 seconds. Repeat 10 times,3 times a day (morning, afternoon, and night).

Episiotomy Care

In this study, it refers to an episiotomy is a cut (incision) through the area your anus and it is measured by REEDA scale with its scores. Episiotomy care given for 1week after normal vaginal delivery.

Alternative Leg Lifting Exercise

In this study, it refers to the lifting the legs alternatively the left and right (each lift for 30 seconds) repeated for 10 times (5 times each leg) Place the mother in supine position.

After Pain

In this study, it refers to relive the spasmodic lower abdominal cramps experienced by the mothers after delivery for 3 days.

Primi Mothers

In this study, it refers to a primigravida is a female who is pregnant for the first time or has been pregnant once.

Normal Vaginal Delivery

In this study, it refers to a vaginal delivery is when a mother gives birth through their vagina.

Hypothesis

a) There is a significant difference between level of after pain in pre and post interventions among primi mothers.
b) here is a significant in comparison between pre and post intervention regarding reduction of after pain among primi mothers.
c) There is a significant Association between pre and post intervention regarding reduction of after pain among primi mothers with their selected demographic variables and obstetrical variables.

Delimitations

a) The sample size were 60 mothers.
b) The period of study were 6 weeks.
c) The study delimitation to primi mothers.

Conceptual Framework

Wieden Bach’s helping art of clinical nursing theory (1970)

Research Methodology

Research approach: Quantitative Research approach

Research design: True experimental research design

Variables under the Study

Independent variable: In this study the independent variable were Bundle of care which includes Fundal massage, initiating of breast feeding, Sitz bath, Kegel’s exercise, Episiotomy care and alternative leg lifting exercise.

Dependent variable: In this study refers to reduction of after pain.

Population: The population of the study includes postnatal mothers in SMVMCH, Puducherry.

Sample: The sample consist of Primi mothers with Normal delivery were admitted in the post-natal ward at SMVMCH, Puducherry.

Sample Size: The sample consists of 60 Primi mothers who were admitted in the postnatal ward at SMVMCH, Puducherry.

Sample Technique: Sampling refers to the process of selecting a portion of the population to representative entire population. Sampling technique were Simple Random sampling technique.

Criteria for Sample Selection: He sample was selected based on the following inclusion and exclusion criteria.

Inclusion Criteria:

I. Primi mothers who have undergone normal vaginal delivery with episiotomy.
II. Primi mothers who is not having any postnatal complications.
III. Primi mothers those who are willing to participate in the study.
IV. Primi mothers who delivered within 48 hours of normal vaginal deliveries.

Exclusion Criteria:

I. Primi mothers who are undergone caesarean section and instrumental delivery are not included in the study.
II. Primi mothers who had delivered twins.
III. Primi mothers those who not willing to participated in the study

Setting of the Study: The study was conducted in the SMVMCH, Puducherry. The hospital consists of emergency room, labor ward, separate antenatal and postnatal ward. There is also a separate neonatal unit to provide resuscitate the newborn and there was 24 hours free ambulance service, monthly 100 to 120 normal vaginal deliveries conducted in the SMVMCH. The other facilities include outpatient department, pharmacy, laboratory, and ultrasonography for diagnostic evaluation.

Study Duration: The duration of the study will be six weeks after the Institution Ethical Committee (IEC) clearance.

Data Collection Procedure

The data were collected after obtaining formal permission from the SMVMCH, to conduct the study. The data was collected for one month from 15.09.2023 to 25.10.2023. The investigator collected the list of deliveries from the labour room, The Primi mothers who fulfilled the inclusion criteria were selected as a sample. Written consent was obtained from the samples before starting the data collection procedure. The investigator introduced herself to the Primi mothers. The Primi mothers were explained about the procedure and the assessment tool. The Primi mothers were encouraged to empty the bladder, to assess the pretest reduction of after pain, Numerical pain scale was used to assess the pain level and applied REEDA scale for assessing the pre-test intervention and post-test intervention. After assessing the mother pain level Investigator used selected Nursing Interventions such as Initiating breast feeding, Sitz bath, Kegel’s exercise, Episiotomy care, and fundal massage for 30 seconds and alternative leg lifting exercise for minute, each leg lifting for 30 seconds respectively. This procedure was repeated for 5times within 10 minutes in the morning and evening of the same day. At the end of the procedure the post intervention, reduction of after pain were assessed by using the same 0-10 Numeric Rating Scale.

Tool Description

The tool was designed into three sections.

Section - I (a)

Consists of demographic Variables including age, education, religion, residency, Dietary Pattern, Mothers occupation, Family income, other activities like (yoga/Exercise) and postnatal day.

Section - I (b)

Consists of obstetrical variables of postnatal mothers like amount of vaginal bleeding, weight of the baby, duration of labor, number of breastfeeding per day.

Section - I

Scoring interpretation for pain assessment by Numerical Rating scale: (Tables 1-9, Figures 1&2).

Table 1:The level of pain was interrupted as following.

Table 2:The level of wound healing was assess by REEDA scale

Table 3:Frequency and percentage wise to assess the level of pain on reduction of after pain among primi mothers undergone Normal vaginal delivery at SMVMCH.

Section: II-Table 4:Effectiveness of Bundle of care on reduction of after pain among primi mothers undergone Normal vaginal delivery at SMVMCH.

Section -III Comparison between pre- test and post -test level of intervention regarding reduction of after pain among primi mothers undergone Normal vaginal delivery at SMVMCH

Table 5:shows that comparison between bundles of care in pre-test score in Mean were 6, 2.25 Standard deviation, 50% were mean percentage and post-test score in Mean were 3.07, 2.31 were Standard deviation, 26% were mean percentage and Difference in mean percentage were 24.

Table 6:Area wise Mean, SD to assess the effectiveness of Bundle of care on reduction of after pain among primi mothers undergone Normal vaginal delivery at SMVMCH.

Table 7:Area wise Mean, SD to assess the effectiveness of Bundle of care on reduction of after pain among primi mothers undergone Normal vaginal delivery at SMVMCH.

Table 8:depicts that educational staus, religion, resident, diteary pattrern,occupation, income and postnatal day shows that statistically highly significant in pre-test with selected demographic variables and obstetric variables.

Note*: *p<0.05 significant, ** p<0.01 & ***p<0.001 highly significant.

Table 9:Depicts that obstetric variable like amount of bleeding, weight of the baby had shown statistically high significant obstetric variables. The other obstetrical variable like duration of labour had shown that statistically Nil significant in reduction of after pain primi mothers.

Figure 1:Bar diagram represents to assess the level of pain on reduction of after pain among primi mothers undergone Normal vaginal delivery at SMVMCH.

Figure 2:Effectiveness of Bundle of care on reduction of after pain among primi mothers undergone Normal vaginal delivery at SMVMCH.

Nursing Implications

The present study emphasized on Nursing intervention such as fundal massage, alternative leg lifting exercises, Initiating breast feeding, Sitz bath, Kegel’s exercise and Episiotomy care on reduction of after pains among Primi mothers.

Nursing Practice

The midwives could have a vital role in enabling safe and effective measures on reduction of pain intensity by using of Bundle of care. The midwives should learn about accurate assessment of after pain with the use of appropriate pain scales. The midwives should understand the importance of Bundle of care and should know the non -pharmacological therapy in the field of obstetrics.

Nursing Education

The student nurses should be encouraging the importance of Bundle of care in primi mothers. The nurse educator should provide adequate clinical experience to the students, where Bundle of care can be effectively used by midwifery on reduction of after pain and encourage the students to demonstrate the nursing procedure in clinical setting. The nursing library could have available literature regarding after pain management for student’s reference. The nurse educator should encourage student nurses to bring out innovative and creative ideas pertaining to effective and safe management of after pain, thus the education can encourage the students for the effective utilization of research-based practice.

Nursing Administration

The role of a nurse administrator have collaboration with medical departments to administer the nursing interventions in reduction of after pains in postnatal period. The nurse administrator should arrange for a nurses’ awareness programs regarding the effectiveness of nursing interventions on reduction of after pains in the concern on reduce after pain. She can also initiate measures for introductions of nursing intervention in postnatal ward settings.

Nursing Research

Nurse researches can promote more research in after pain. As evident from the review of literature, more research needs to be warranted on this discipline. Disseminate the findings through conferences, seminars, publications in professional, national and international Journals.

Recommendations

a) A similar study can be conducted by increasing the sample size.
b) A comparative study on Bundle of care to see the effectiveness in reduction of after pain.
c) A correlation study between breast feeding and level of after pains among postnatal mother can be done.
d) A study can be done by providing back massage instead of fundal massage, Sitz bath, Kegel’s exercise, Episiotomy care, Alternative leg lifting exercise on reduce after pains.

Limitations

a) Primi mothers are limited for this study
b) Only 60 sample are included in this study

Conflict of Interest Statement

None.

Acknowledgement

None.

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