RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE BANGALORE - KARNATAKA

ANNEXURE – I

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION1 NAME OF THE CANDIDATE

AND ADDRESSMISS. K .ARCHANA,I st YEAR M.Sc. NURSING, CAUVERY COLLEGE OF NURSING, SUBASH NAGAR, MYSORE – 570007.

2 NAME OF THE INSTITUTION CAUVERY COLLEGE OF NURSING,MYSORE – 570007.

3 COURSE OF STUDY AND SUBJECT

MASTER IN OBSTETRICS AND GYNAECOLOGICAL NURSING

4 DATE OF ADMISSION TO THE COURSE

30. 06.2008

5.1 TITLE OF THE STUDY COMPARE THE KNOWLEDGE OF FINAL YEAR B.Sc ( N ) STUDENTS WITH THE FINAL YEAR GNM STUDENTS REGARDING THE POST OPERATIVE CARE OF LSCS MOTHERS AT SELECTED COLLEGES & SCHOOLS IN MYSORE.

5.2 STATEMENT OF THE PROBLEM

A STUDY TO COMPARE THE KNOWLEDGE OF FINAL YEAR B.Sc ( N ) STUDENTS WITH FINAL YEAR GNM STUDENTS REGARDING THE POST OPERATIVE CARE OF LSCS MOTHERS AT SELECTED COLLEGES & SCHOOLS IN MYSORE.

6. BRIEF RESUME OF THE INTENDED WORK

6.1 - INTRODUCTION

“MOTHER’S HEALTH REPRESENTS CHILDREN’S BEST HOPE FOR SURVIVAL.”

- FRANK . D . WILLIAMS ( 1999 )-

Child birth is viewed as an important life event. It is a natural physiological phenomena and one of the life events which introduces new experience in a woman’s reproductive life.

The healthy women actually represent the health of the country. Safe motherhood can only be reached if complete care is given to mothers. It is the comprehensive or total health care that can be offered to woman.

The word of caesarean is derived from the Latin word “Caedere means to cut”. Until the 20th century caesarean section work primarily equated with an attempt to salvage the fetus of a dying women.

Caesarean birth or abdominal deliveries refers to delivery of the fetus through an abdominal incision (laparotomy) and incision through uterus (hysterectomy).(Nagrath.A.2003)

Caesarean section denotes the delivery of the viable fetus, placenta and membranes through an incision in the abdominal wall and the uterine wall.

The first operation performed on a patient is referred as a “Primary caesarean section” .when the operation is

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performed in subsequent pregnancies it is called as “repeat caesarean section”.

This technique is used when the size of your pelvis, your physical conditions or other complications make vaginal delivery impractical or risky.

Caesarean delivery has become much safer. Some research studies indicates less risk of damage to pelvic support and fetus than in vaginal delivery.(Quenar J.T.2004)

The postpartum period or puerperium is coined (from the latin word in pure “child “and parera, to bring forth ) refers to the 6 weeks period after child birth – (Adele pillitheri, 1994).

The postnatal period or puerperium is a period of adjustment after delivery when the anatomic and physiological changes of pregnancy are reversed and body returns to the normal state. The period starts as soon as the placenta has been expelled and extends up to the period of 6 weeks. The puerperium will be normal and uneventful ,when the women is cared meeting her needs like nutritious diet, personal hygiene, post natal exercises, breast feeding, wound care, family planning and immunization to the baby.

( HELEN VARNEY. D .1987 )

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6.2-NEED FOR THE STUDY

The post partum recovery period is usually longer and hospitalization is longer with caesarean births. Physiological concern and women after birth may include fatigue activity, intolerance and incision problems (Breslim T.E.2003)

The postnatal period demands appropriate guidance from nurse,

so that the postnatal mother is able to adjust effectively to improve the health status of the mother.

During the year 1997 – 99, In India 23% of elective LSCS 12% of emergency LSCS and 6% of urgent LSCS have been reported ( Sharma J.B 1998, Luessley M.D, Baecker, N.D,(2004) and Nelson, et at (2005). Women from higher socio economic status and higher education, wanted LSCS more often to avoid pain or strain during labour and about 40.9% of women prefered an elective LSCS in the next pregnancy also ( Mould T.A. charge S 1996 ad behague D.P. 2002).

Various authors (Heilmann Liet at (1999) Chaffer (2003), James L.D et at (2003) have stated that the complications followed by LSCS were puerperal sepsis (2.5% to 16.1%),post operative urinary tract infections (2.16%). 55.8% of women have “strongly agreed” & 40.9% have agreed to have preferring LSCS was that, it would reduce risk to the fetus, risk of perineal injury and urinary and anal incontinence.

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6.3 - STATEMENT OF THE PROBLEM:

“A STUDY TO COMPARE THE KNOWLEDGE OF FINAL YEAR B.SC(N) STUDENTS WITH THE FINAL YEAR GNM STUDENTS REGARDING THE POST OPERATIVE CARE OF LSCS MOTHERS AT SELECTED COLLEGES & SCHOOLS IN MYSORE.”

6.4 - OBJECTIVES OF THE STUDY:

To assess the knowledge of final year B.Sc(N) students regarding the post operative care of LSCS mothers.

To assess the knowledge of final year GNM students regarding the post operative care of LSCS mothers.

To compare the knowledge of final year B.Sc (N) students with final year GNM students regarding the post operative care of LSCS mothers.

To find out the association between the knowledge of final year B.Sc (N) students with selected demographic variables.

To find out the association between the knowledge of final year GNM students with selected demographic variables.

6.5 - HYPOTHESIS:

1) The knowledge score of final year B.Sc (N) students regarding post operative care of LSCS mothers will be significantly higher than the knowledge score of final year GNM nursing students.

2) There will be a significant association between the knowledge of final year B.Sc(N) students with their selected demographic variables.

a) Ageb) Sexc) Optional subject in PUC,( Science / Arts group )d) Course of study (B.Sc (N )or GNM )e) Level of student (Final year )f) Source of knowledge regarding post operative care ( Lecture,

self study, Reference )g) Personal Interest to learn on the particular topic.

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3) There will be a significant association between the knowledge of final year GNM students with their selected demographic variables.

a) Ageb) Sexc) Optional subject in PUC,( Science / Arts group )d) Course of study (B.Sc (N ) or GNM )e) Level of student (Final year )f) Source of knowledge regarding post operative care ( Lecture,

self study, Reference )g) Personal Interest to learn on the particular topic.

6.6 - OPERATIONAL DEFINITIONS:

o Knowledge: Refers to the correct responses of the final year B.Sc (N)

students and final year GNM students to knowledge items on the post operative care of LSCS women.

o Final year B.Sc(N) students: Refers to the students who are studying in the IV year B.Sc( N )

degree course.o Final year GNM students:

Refers to the students who are studying in the III year GNM diploma course.

o Post Operative Care: Refers to the mode of actions that are selected to meet the

post operative needs of LSCS mothers.o LSCS Mothers:

Refers to the women who delivered through lower segment caesarean section operation.

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6.7 - ASSUMPTION:

o B.Sc (N) students will have higher knowledge level than the GNM

students

o Knowledge regarding post operative care of LSCS women will have

strong influence on the care of mother during the post operative

period.

o The student nurse has an important role in the care of LSCS mothers

during the post operative period.

6.8 - DELIMITATIONS:

o The study is limited to final year degree and final year diploma

nursing students.

o The study will be conducted only in two colleges and two schools of

nursing.

o The study period is only 4 to 6 weeks.

6.9 - SIGNIFICANCE OF THE STUDY :

The purpose of the study is to compare the knowledge of final

year B.Sc(N) students with final Year GNM students regarding the post

operative care of LSCS mothers, that influence their ability in caring in the

clinical setting.

6.10 - REVIEW OF LITERATUREThe review of literature is a broad, comprehensive, in depth

systemic and critical review of scholarly publication, unpublished scholarly print materials, AV materials and personal communications.

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A literature review is a written summary of the existing knowledge on a research problem. The task of reviewing research literature involves the identification, selection, critical analysis and written description of existing information on a topic (Polit and Hugler 2003)

The review of literature in this study is organized under the following headings.

Incidence of caesarean birth. Significance of post operative care regarding.

o Immediate post operative careo Nutritiono Breast feedingo Personal Hygieneo Exerciseso Wound care

Incidence of caesarean birth:

According to centers for diseases control and prevention (1998) the caesarean births have been increased to 20.7% with all births.

According to WHO (2002) report the rate of caesarean section is 10.15% of all births in developed countries 20% in UK, 23% USA and 21% in Canada.

Dafitary N.S. et.al.(2004) conducted a study on incidence of caesarean birth and revealed that the incidence is increased to 36% in Brazil , 21.4% in U.K. ,24.4% in USA , 22.4% in Italy,11.9% in Swedon, 32-34% in Taiwan, 9.5 % in Netherland (9.5%).

Chakaravarthi S.(2002) stated that the incidence at caesarean birth in India has increased from 5% at the delivery cases to almost 20% at present. During the 1997 – 1999 in India the incidence was about 23% of

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elective LSCS 12% at emergency LSCS and 6% of urgent LSCS have been repeated (Chakaravathi S.2002)

National goal for health people (2.10) initiated to reduce the rate of LSCS be not more than 15% with the primary LSCS being the more than 12% a total births.

Significance of Post operative careImmediate post operative care 1. Assessment of physical and physiologic parameters:Monitor Vital Signs, neurologic status, sensory and the motor

function. Assess the fundal height and degree of firmness, appearance of the

abdominal dressing, amount and color of lochia, intravenous therapy and fluid intake, urine output and patency of catheter, oxygen and suction are kept available for use, if needed, even when clients have received epidural or spinal anesthesia.

2. Assessment of pain and determination of need for analgesics as ordered:

Intra muscular analgesics, such as meperidine, may be given when the women is fully reactive from the anesthesia.

3. Assessment of psychologic parameters:The immediate response of the woman and her partner to the

cesarean delivery, the woman’s desire to be with her infant, the woman’s beginning acquaintance with the infant.

Nursing strategies that may promote the client’s comfort in the recovery room include:- Providing warmed blankets.- Providing mouth care.- Giving a sponge bath.- Administering prescribed analgesics.- Assisting with positioning.

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- Side rails remain raised at all times. - Orienting the woman and her support person to the recovery unit. - Providing reassurance that the cesarean is over. - Fostering opportunities for contact between the mother and her support person and between the couple and the new born.

A study stated that 46% of mothers who undergone LSCS developed surgical wound infection due to Hospital acquired infection and also concluded that puerperal sepsis (10-35%) and septicemia (76%) were the most common morbidity following LSCS. {Henderson IC and LOVE E.J.(1995)}

A study was conducted on what to be expected in the first 6 weeks after LSCS and concluded that the complications after LSCS were thrombo phlebitis, breast infections and infection in the abdominal incision. { Jennier.L. and Baidit M.(2004)}

A study stated that the infection of the uterine suture line can cause erosion of angle leading to secondary hemorrhage. Infection at the skin can cause delayed healing or wound dehiscence. (Nagarth A.(2003)}

Post operative careNutrition

The intravenous infusion may remain for 24 to 48 hours, or until the client tolerates fluids well by mouth. A Nutrition diet that meet the RDA for the Lactating mother is to benefit the mother and infant extra calorie ( 500 K.Cal) to maintain adequate milk, supply and she recommended that supplement diet with 30 mg to 60 mg elemental iron daily for 2 to 3 months or longer is required (F.P.Anita and Abraham P.2003) Energy requirement during lactation is 500 KCal / Day and protein requirements during 0-6 months is 9.4 gm/day and protein requirement during 6-12 months is 6.6 gm/day, calcium requirement during lactation for

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milk secretion is 1000 mg / day; and vitamin C is 40mg/day.( According to Indian council of medical research report {2004}).

A study was conducted that women’s nutrition continuous to be important through out the post partum period. The mother need a diet rich in protein and iron to facilitate tissue healing and to restore normal Hb level . { Litteton Y.L.(2002)}.

A Study was conducted on post operative nutrition after LSCS and stated that the liquids are the first substances tolerated by the mothers, and as soon as the mother tolerates soft foods, solid foods may be given. {Godgi M. and Bhattacharya R (2002)}

Nursing intervention includes teaching about the nourishment is needed to facilitate healing. A regular diet high in protein, vitamin-C along with sufficient fluids and calories gradually is recommended to prevent constipation and promote well being. [Maitak (2001)])

Breast feeding:

Some caesarean clients fear they will not be able to breast feed because of the caesarean. Caesarean mothers often have their first breast feeding experience several hours later than mothers who deliver vaginally. There is no reason, however, why a caesarean delivery alone should affect a mother’s ability to breast feed successfully. The nurse needs to identify caesarean related fears about breast feeding and to provide reassurance and assistance for the client who wants to breast feed.

A study was conducted on caesarean section as persistent barrier to early initiation of breast feeding and the result shows that the women who had LSCS experienced a significant delay in breast feeding with women giving birth vaginally (P.C.O.001). {Mierracy H.J.2002}

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A study was conducted on nursing after a caesarean birth and stated that the mothers want to put the baby to breast with in the first hours but definitely no later that the first 4-6 hours. {Bongota K. 2005}

More comfortable position for LSCS is the foot ball hold positions sit same what up right to the bed and place the baby on a pillow, between your arm and your side, with our hand up ping the underside of the head (Bonyate K. 2005

Personal Hygiene:Post operative pain limits mobility. The caesarean client will need

encouragement and physical assistance, especially in changing positions, getting out of bed, and handling her new born. Caesarean clients do need help with personal hygiene measures, such as sponge bathing hard-to-reach body areas.

On the second day, the mother can be showered without fear of injury to the incisions. The incision is generally covered for the first day with a light dressing, until the wound is sealed. The dressing is removed after the 1st post operative day. {Gabbe G.S.( 2004 )} By the III post operative day, showering is usually possible, however nursing assistance may be needed.

A study was conducted to assess the women’s knowledge of the health behaviors in the puerperium among 1000 women and only 4% of the women answered that during puerperium they are allowed to take bath. ( Dawidaoicc A.et.al. 2004}

A study was conducted on health, after caesarean delivery in Danbury Hospital and also recommended that the mothers may shower after caesarean section and it is important to keep the incision area clean and dry. Wong L.D. (1998) stated that daily care includes showering after the dressing has been removed. {Lawrence O. 2005}

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A study stated that the mother showered is taught perineal hygiene including daily washing with warm water and mild soap. The perineum should be cleaned after each voiding and bowel movement. Practices such as changing the perineal pad frequently at least 4 times a day removing pads front to back and hand washing will help decrease the risk of infection and promote wound healing. { Littleton and Sally et.al. 2002} Exercise

The best postnatal tummy exercise is laughter. Add some serious work with the pelvic muscles and abdomen and a few movements to keep the circulation going in the legs. If you have had stitches these exercises will help healing, and cannot possibly harm the stitches.

A study stated that deep breathing exercises should be performed at least 5 to 10 deep breaths/hour. A woman does this simply by inhaling as deeply as possible. Holdings her breath for a second or two as then exhaling as deeply as possible. (Fitz. R (2003)).

Post anesthesia effects on respiratory function necessitate that the nurse listen for breath sounds and supervise deep breathing and coughing exercise as well as early ambulation.

A study stated that pelvic tilting exercises can be performed by lift the head and stretching the hands towards the knees while holding the pelvis tilted, this is known as curl up always be performed with the knee bent. {Over end J.J. (2003)}

A study stated that kegel exercise can be performed with a full bladder, the mother should be able to jump up and with legs apart and cough deeply, with out leaking urine. It is performed after 2 to 3 months of LSCS. {Hall. C2003}

Knee rolling exercises can be performed with lying on back with knees bent pulling the abdomen and roll both knees to one side as for as

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comfort. Keeping the shoulders flat, return to up right position, than repeat to the other side. This can be performed 6 to 10 times/ day, done after 2hrs (Littleton 2002)

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A study was conducted to assess the women’s knowledge of health behaviors in the puerperium and concluded that only 22% of women consider physical exercises during puerperium is profitable. {Dewiddowicz.A.et al. 2004}

A study was conducted on prolonged bed rest after operation lead to DVT and also recommended that early ambulation is the effective method of choice for the prevention of deep vein thrombosis. { Huntleigh, 2001}

Wound care:The abdominal incision site needs to be inspected and any redness,

swelling, oozing, or separation reported to the physician and charted.

The incision will be painful for a few days. So the mother should stand tall and cup hands over the wound “Dickinson E.J.et.al – 2001 & Lowder milk and Perry – 2002”,. { A.M.Vagrt et.al 2003 }

The women should be changing positions, walking and coughing / deep breathing, support incision with a pillow or fold blanket, when getting out of bed, roll, on the side and use arm muscles for assistance.{ Micronna.D and Dornam J. – 2003}

A study stated that when the mothers need to cough (or) sneeze hung a pillow snugly against the incision to splint it and reduce the pressure over the incision. { Lawretice C.D.2005}

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Role of nurses:

Miovech. S.M et.al (1994) stated that maternity nursing offer a great educative and rehabilitative challenge. A mother with a baby undergoes a unique experience which will require considerable adjustments. Health, the role of the nurse is to identity the areas where health promotion, illness prevention or treatment is needed. She had to advice, counsel and educate the mothers according to the need.

A study stated that the nurse needs to educate each mother individually and to plan health teaching accordingly, this kind of instruction or teaching is focused on various aspects, post natal care and neonatal care will save the mother in many anxious movements when she is at hospital.(Shashhak-1995)

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7 . Material and Methods of Study

7.1) Source of data:

The data will be collected from the final year B.Sc(N) students and final year GNM students from 2 nursing colleges and nursing schools at Mysore.

7.2 Research Design: Comparative Descriptive Design

It examines and describes differences in variables in two or more groups that occur naturally in the setting.

7.3 Method of data collection:For collection of data the following structured knowledge questionnaire methods will be adopted.

Part A – Demographic data of the final year B.SC(N) and GNM students.

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Group I(Variable (S)Measured )

Group I(Variable (S)Measured )

Describe

Comparison of groupsOn select variables

Describe

Interpretation of Meaning

Development of hypotheses

COMPARATIVE DESCRIPTIVE DESIGN

Part B – Structured knowledge questionnaire comprises of 40 multiple choice questions on post operative care for the LSCS mothers.

Content of the knowledge questionnaire will be organized under the following sub headings

Immediate post operative care Nutrition Early Ambulation, Exercise. Breast feeding Personal Hygiene Wound care.

Section B:Sampling Procedure:

To enumerate all the students of final year B.Sc(N) and final year GNM students of the 2 selected Nursing colleges and nursing schools at Mysore.

Sample:4 Samples - Final year B.Sc(N) and final year GNM students of

the 2 selected Nursing colleges and nursing schools at Mysore.

Sample Size: -100 final year B.Sc nursing students from two colleges of

nursing.-100 final year GNM students from two schools of nursing.

Sampling Technique:Convenient sampling technique is preferred for this study.

Research Setting:The settings selected are 2 Nursing colleges and 2 Nursing

schools at Mysore.Pilot study:

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Pilot study is planned with 10% of population.

Inclusive Criteria and Exclusive Criteria.o Inclusive criteria:

Final year B.Sc Nursing Students in Cauvery college of nursing and Raman College of Nursing.

Final year GNM Students in Cauvery school of nursing and Ellamma school of Nursing.

o Exclusive criteria I, II and III year B.Sc Nursing Students in Cauvery

college of Nursing and Raman College of Nursing I, and II year GNM Students in Cauvery school of

Nursing and Ellamma school of Nursing.

8 - Ethical Considerations: Does study require any investigation or intervention to be conducted on

care givers clients undergoing LSCS . NO

Has ethical clearance been obtained from college authorities in case study requires investigation?

YES Informed consent will be taken from the respondents and the concerned

authorities of the college. Has ethical clearance being obtained from your institution

YES. Informed consent will be taken from the respondents and the concerned

authorities of the college.

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9. - LIST OF REFERANCES

1. ADELEPILLITTERI,(1999),” maternal and child Health Nursing”,3rd Edition New

York, Lippincott publishing.

2. BENNET V.Rath Myles, et al, (1998) “Text book of middle”, 13th Edition Edinburgh

company, London.

3. BENMIE.S.WORTTINGTON ET.AL,(1994). “Nutrition in pregnancy and

Lactation”, 6th Edition R.R.Domellrej and sons company.

4. BOBAK,JENSEN(1995) “maternity Gynaecology care” 5th Edition mosby publishing

New York.

5. BRUNNER AND SUDDARTHI’S2000 “Text Book of medical surgical Nsg” 10th

Eidition,Lippincot company, Philadelphia.

6. D.S.DAWN(1990) “Text Book obstetrica and neonatology”, 11th Edition Arti Dawn

publication Calcutta.

7. DAVID M. LUSELEY 2004, “Obsterics and obstetric”21st Edition british Library

catalogue in publication New York,Journals.

8. DUTTA D.C,(1998) “Text Book of obstetrics and contraception” 6th Edition New

central book agency, New Delhi

9. GORRI MYERS TRULA, et al (1998), “Foundation of maternal new born

Nursing”,2nd Edition W.B.Sunders company, Philadelphia.

10. GUPTA S.P/(2000) “Statistical method” 5th Edition sultan Chand and sons publishers,

Delhi.

11. JAMES STEER (2003), “High Risk prengnancy”, 2nd Edition W.B.Saunders

company, Chennai.

12. KOTHARI C.R (2005) Research “Methodology and Techniques” 2nd Edition,New

Delhi.

13. LADERJ .ET.AL (1994) “ESSENTIAL OF MATERIALS New born Nursing”, 3rd

Edition, Calfornia, Addison –WESLEY.

14. MUDALIAR(2000), “Clinical obstetrics”, 9th Edition orient Longman Ltd, Chennai.

15. POLIT,DF. AND HUNGLE, BP(1999), “ Nursing Research principles and

methods”6th Edition, Philadelphia,Lippincott company.

16. SHAW’S(1995), “Text book of Gynecology”, New Delhi, Church chill living stence

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Journals:

17. AFFONSO,(1994) “Culture spirituality women’s Health”, Journal of obstetrics and

gynecology of Nursing 24(3)

18. AGARUL,et al (1980), “Pattern of care during pregnancy and Lactation”, India

journal of pulica Health (24)2.

19. AHMED.V.N (2002), “A study to ceaserean birth in teaching Hospital”, Pakistan

journal of obstetrics and Gynaecology” 102(3).

20. ALLEN.V.M et al (2003) “Maternal morbidity associated with cesarean delivery

with out labours compared with spontaneous onset of labour at term” journal of

obstetrics and Gynoecology” 102(3).

21. AVERY.V.B.et al (2003) “Maternal morbidity association with cesarean delivery

without lobours compared with spontaneous onset of labour at term ”Journal of

obstetrics and Gyoecology”, 102(3).

22. AVERY,BURKET (1992), “Postnatalcare” Journal of Nursing midwifery 39(2).

23. BADRUUDDIN. S.H.et al (1997) “Appropriated breast feeding practices. For

SUCCESFUL Lactatcoin”; Journal of obstetrics and Gynaecology 47(2).

24. BAJPAL SMITH VD (1998), “ welcome New baby”,Health Actioin 9(4).

25. BARBAT.E.et al (2004), “Surgical site infections after cesarean section” journal of

Gynaecology obestrics Biological reproduction 33(6-1).

26. BEARK.AND TIGGES.B, (1993), “Breast feeding” Nurse practice, 18(6).

27. BILANI. R. C (1992) Nutrition A practical approach “Post operative diet”, Jaypee

brothers, New Delhi.

28. BROWN STEPHAINE (1993) physical Health problems after child birth and

maternal depression at six seven moths post partums, British journal of obstetrics

and gynecology 107.

29. CHATIRJEE ALKENDU (2000) puerperium Journal of obstetirics and gynecology

of India 53(5).

30. CHATURVEDI, et al (2000) knowledge and attitude Regarding breast feeding.

India founded of Dediatrics 67(4).

31. DAS D. K. et al (1995), “Mother knowledge and attitude Regarding breast

feeding”, IndiaJOURNAL OR PEDIATRICS 62(2).

32. KUMATA. N.B (1994), “Why colostrums is important in maternity Homes” the

Journal of obstetric and Gynacology of Indiaa 42(44).

33. MARIAM SHAFEEG (2002) puerperal sepsis, “Indian journal of continuing

Nursing Education”,

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34. MEHTA.A et al (2001) Trend in cesarean section rates at a maternity hospital in

Mumbai, India, Journal of Health population Nurtrition 19(4).

35. MONICA,S.R.(2000), “Perophylactic USC of Antibiotics for nonlabouring

patients undergoing C.S. with intact membrane” American journal of obstetrics and

Gynaecology 184(4).

36. MORKVED S(2000), “Effect of post partum pelvic floor muscle training course on

urinary in continence”, urinary incontidence”,British journal of obstetrics and

Gynecology 107(8)

37. MURRAY H.J. (2002), “Caesarean section as a persistant barrier to early initiation

of breat feeding”.Indian journal of midurifery. 29(2).

38. NTZAN –KALUSHI, D.et al (2000), “Gift of breast. Practices” the journal of

obstetrics and Gynaecology 138(8).

39. QUEERAN, J. T. 2004, “Elective cesarean delivery” American journal of obstetrics

and Gynaecology 103(6).

40. RAMESH PRABHA (1992), “Post partum collapse”. The journal of obstetrics and

Gynaecology.

41. SAMOSELLE et al (1998), “Pelvic floor muscle to treat postnatal urinary

incontinence”, International urogynecological journal 9(5).

42. STELLA MULDER (1994) “ Care of mother and new born”, Health action 9(4).

43. SUDHA .R.RADDI (2004), “Study to evaluate perineal care among High

riskmothers in selected Hospital of Belgium”. The Nursing journal of India vol.

XCV(7).

44. VENTOLINI. G. et.al (2004), “Decreasing infections morbidity in cesarean delivery

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45. WOTHINGTON I.M. et.al, (1999), “Attitudes do oral feeding following cesarean

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9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE

11. NAME AND DESIGNATION OF (IN BLOCK LETTERS)

11.1 GUIDE

11.2 SIGNATURE

11.3 CO-GUIDE (IF ANY)

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT

11.6 SIGNATURE

12. 12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL

12.2 SIGNATURE

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