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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1NAME OF THE
CANDIDATE AND ADDRESS
Ms. NIJISHA SHARLI
1ST YEAR MSc. NURSING STUDENT
NISARGA COLLEGE OF NURSING,
# 18KIADB,B. KATIHALLY,
INDUSTRIAL AREA, HASSAN,
KARNATAKA.
2NAME OF THE INSTITUTION
NISARGA COLLEGE OF NURSING
HASSAN, KARNATAKA.
3COURSE OF THE STUDY
AND SUBJECT
MASTER OF SCIENCE IN NURSING,
OBSTETRIC AND GYNECOLOGICAL NURSING
4DATE OF ADMISSION TO
COURSE01/07/2011
5 TITLE OF THE STUDY
THE EFFECTIVENESS OF PLANNED TEACHING PROGRAMME ON KNWOLEDGE REGARDING PREVENTION OF POSTPARTUM INFECTIONS AMONG POSTNATAL MOTHERS
5.1STATEMENT OF THE
PROBLEM
“A STUDY TO EVALUATE THE EFFECTIVENESS OF PLANNED TEACHING PROGRAMME (PTP) ON KNWOLEGE OF POSTNATAL MOTHERS REGARDING PREVENTION OF POSTPARTUM INFECTIONS IN SELECTED HOSPITALS AT HASSAN, KARNATAKA.”
1
6. BRIEF RESUME OF THE INTENDED STUDY:
6.1) INTRODUCTION
“The ultimate value of life depends upon awareness rather than upon mere survival”.
(Aristotle)
A mother is a woman who conceives, gives birth to, or raises and nurtures a
child. The mother is a woman who holds a position of authority or responsibility.
Maternal love and tenderness: brought out the mother in.1
Postnatal is the period beginning immediately after the birth of a child and
extending for about six weeks. Another term would be postpartum period, as it refers
to the mother.2
Labour and delivery are especially hazardous times of pregnancy. Apart from
the risks of severe bleeding and obstructed labour, life threatening infections can be
introduced into the mother and baby’s organs and bloodstream. ‘Maternal sepsis is a
general term which has been used to include various obstetric and genitor-urinary tract
infections introduced into the mother. The World Health Organization ranks maternal
sepsis as the sixth leading cause of disease burden for the women aged 15-44 years,
after depression, HIV/AIDS, tuberculosis, abortion and schizophrenia. As many as 5.2
million new cases of maternal sepsis are thought to occur annually and an estimated
62,000 maternal deaths will result from the condition. A postpartum or puerperal
infection is any clinical infection of the genital canal that occurs within 28 days after
miscarriage, induced abortion, or childbirth.3
Postpartum infections are probably the major cause of maternal morbidity and
mortality throughout the world. Local spread of colonized bacteria is the most
2
common etiology for postpartum infection following vaginal delivery. Endometritis is
the most common infection in the postpartum period. Other postpartum infections
include (1) postsurgical wound infections, (2) perineal cellulites, (3) mastitis, (4)
respiratory complications from anesthesia, (5) retained products of conception, (6)
urinary tract infections (UTIs), and (7) septic pelvic phlebitis. Wound infection is
more common with cesarean delivery2.
Postpartum infections comprise a wide range of entities that can occur after
vaginal and cesarean delivery or during breastfeeding. In addition to trauma sustained
during the birth process or cesarean procedure, physiologic changes during pregnancy
contribute to the development of postpartum infections. The typical pain that many
women feel in the immediate postpartum period also makes it difficult to discern
postpartum infection from postpartum pain.2
Postpartum patients are frequently discharged within a couple days following
delivery. The short period of observation may not afford enough time to exclude
evidence of infection prior to discharge from the hospital. In one study, 94% of
postpartum infection cases were diagnosed after discharge from the hospital.
Postpartum fever is defined as a temperature greater than 38.0°C on any 2 of the first
10 days following delivery exclusive of the first 24 hours. The presence of postpartum
fever is generally accepted among clinicians as a sign of infection that must be
determined and managed.2
The most effective and least expensive treatment of postpartum infections is
prevention. Preventive measures include, good parental nutrition, good maternal
perineal hygiene with through hand washing is emphasized, strict adherence by all
health care personnel to aseptic techniques during childbirth and the postpartum period
3
is very important.4 In a study by Yokoe et al in 2001, 5.5% of vaginal deliveries
and 7.4% of cesarean deliveries resulted in a postpartum infection. The overall
postpartum infection rate was 6.0%. Endometritis accounted for nearly half of the
infections in patients following cesarean delivery (3.4% of cesarean deliveries).
Mastitis and urinary tract infections together accounted for 5% of vaginal deliveries.2
6. 2) N E E D FOR THE STUDY:
"An ounce of prevention is worth a pound of cure.”
(Gregory Y. Titelman)
Postpartum and Intra-amniotic infections are important causes of maternal and
neonatal morbidity and mortality. Puerperal infections, frequently associated with
intra-amniotic infection (IAI), are the fourth leading cause of maternal death in the
United States, accounting for 13% of maternal deaths. IAI accounts for 10% to 40% of
cases of febrile morbidity in the peripartum period and is associated with 20% to 40%
of cases of early neonatal sepsis and pneumonia. Postpartum infections develop in 1%
to 7% of women, accounting for more than 200,000 infections annually in the United
States. Thus, intra-amniotic and postpartum infections remain significant public health
problems.5
Postpartum infections remain an important cause of maternal morbidity and
mortality. A significant number of women (1% to 7%) develop postpartum
infections. One of the most complete studies identified postpartum infections in 598
(5.9%) of 10,181 deliveries Thus, approximately 200,000 postpartum infections
occur among the 3.5 million women delivering annually in the United States.5
4
Puerperal fever or childbed fever is a bacterial infection contracted by women
during childbirth or miscarriage. It can develop into puerperal sepsis, which is a
serious form of septicemia. If untreated, it is often fatal.6
Short-course antibiotic prophylaxis reduces by two thirds to three quarters the
incidence of both postpartum Endometritis (PPE) and wound infection among women
undergoing either elective or non elective cesarean delivery. More than 50 trials of
antibiotic prophylaxis after cesarean section have been reported.5
The near-elimination of maternal mortality in Europe and North America
occurred largely during the first half of the 20th century, before the development of
much high-technology equipments and medicines, and it is clear that the similar gains
could be achieved in developing countries within mere decades. The two keys appear
to be access to a skilled attendant, professional trained and competent in midwifery at
every birth, and emergency obstetric services available for referral when serious, but
5
mostly treatable, complications occur. WHO estimates that just over half (53%) of all
deliveries in developing countries currently take place with the assistance of a skilled
attendant and emergency services are not accessible in many places.
A set of specific antenatal interventions can also contribute to fewer perinatal,
and possibly maternal, deaths and to reduced morbidity in both mothers and neonates.
Access to appropriate family planning tools can reduce the overall number of
unwanted Pregnancies, and consequently the number of maternal deaths: where the
maternal mortality Ratio is high, each pregnancy is risky. Better spacing of births also
benefits the fetus. When unwanted pregnancies do occur, access to safe abortion will
avoid deaths due to the complications that often occur with unsafe, unskilled
abortions. Irrespective of the legality of abortion, access to post abortion care can also
avoid maternal deaths.7
A study was conducted in the Khyber Agency Pakistan to estimate the
prevalence and to identify the factors associate with vaginal infections among married
women between the ages of 15-49 years. Sectional study was conducted in the month
of July 2005 on 1084 mothers by using random sampling strategy by trained nurses.
The multivariate analysis showed that the associated factors with vaginal infection
were the use of unhygienic material to soak up the lochia [aOR=3.45, 95% CI (1.36,
8.75)], bathing after 40 days [aOR=2.10,95% CI (1.55, 3.14)], and women who did not
receive antenatal care [OR=3.87, 95% CI (1.93, 7.75)]. Also women who did not have
medical facilities available [OR=2.45, 95% CI (1.23, 5.06)] reported of vaginal
infection. This study concluded that there is considerable need for health education
among women and the entire community for the maintenance of hygiene, safe delivery
6
through medical personnel and improvement inthe mobility of mothers and female
education8
A functional health system is a necessary part of efforts to achieve maternal
mortality reduction in developing countries. Puerperal sepsis is an infection contracted
during childbirth and one of the commonest causes of maternal mortality in
developing countries, despite the discovery of antibiotics over eighty years ago.
Infections can be contracted during childbirth either in the community or in health
facilities. Drug and technological developments need to be combined with effective
health system interventions to reduce infections, including puerperal sepsis. This
article reviews health system infection control measures pertinent to labour and
delivery units in developing country health facilities. . Organisational improvements,
training, surveillance and continuous quality improvement initiatives, used alone or in
combination have been shown to decrease infection rates in some clinical settings. A
health systems approach is necessary to reduce maternal mortality and the occurrence
of infections resulting from childbirth. Organisational and behavioural change
underpins the success of infection control interventions. A global, targeted initiative
could raise awareness of the need for improved infection control measures during
childbirth3
In 2002-2003, all deaths (n=156) of women aged 15-49 years in a block of
southern Rajasthan were investigated to determine the cause of death and care-seeking
behaviour. Family members of 156 (98%) of 160 deceased women were interviewed
following the comprehensive listing of all deaths among women of reproductive age.
Of the 156 deaths, 31 (20%) were pregnancy-related; 77% of these women died during
the postpartum period, and 74% of the deaths occurred in the home. Direct and
7
indirect obstetric causes were responsible for 58% and 29% of the deaths respectively;
12% were injury-related deaths. Medical care was sought for 65% of the women, and
29% were hospitalized. Family perception of not being able to afford treatment at
distant hospitals was a major barrier to seeking care, and 60% of those who sought
care had to borrow money for treatment. Lack of skilled attendance and immediate
postpartum care were major factors contributing to deaths. Improved access to
emergency obstetric care facilities in rural areas and steps to eliminate costs at public
hospitals would be crucial to prevent pregnancy-related deaths.9
6.3) STATEMENT OF THE PROBLEM
“A STUDY TO EVALUATE THE EFFECTIVENESS OF PLANNED
TEACHING PROGRAMME (PTP) ON KNWOLEDGE OF POSTNATAL
MOTHERS REGARDING PREVENTION OF POSTPARTUM INFECTIONS
IN SELECTED HOSPITALS AT HASSAN, KARNATAKA.”
6.4) OBJECTIVES OF THE STUDY ARE:
To assess the pre-test knowledge of postnatal mothers regarding prevention of
postpartum infections.
To prepare and administer PTP on prevention of postpartum infections.
To assess the post-test knowledge of postnatal mothers regarding prevention
of postpartum infections.
To compare the pre-test and post-test scores.
To find out the association between the selected demographic variables with
the posttest knowledge of postnatal mothers.
8
6.5) HYPOTHESIS
H1: The post-test knowledge scores of postnatal mothers will be significantly higher
than their pre-test knowledge scores after planned teaching programme.
H2: There will be significant association between the post-test knowledge scores of
postnatal mothers and the selected socio-demographic variables.
6.6) ASSUMPTION
This study assumed that: -
1. The postnatal mothers may have less than adequate knowledge regarding
prevention of postnatal infections.
2. The planned teaching programme will enhance the knowledge of postnatal
mothers regarding prevention of postpartum infections.
6.7) OPERATIONAL DEFINITION
1. Evaluation: - It refers to the estimation of outcome of the PPT on knowledge
regarding prevention of postpartum infections.
2. Effectiveness: - It refers to the extent to which the information in the PPT has
achieved the desired out come as measured by increase in post-test knowledge
scores of structured questionnaires.
3. Planned teaching program (PTP): It refers to well planned teaching design to
provide information to improve knowledge of postnatal mothers regarding
prevention of postpartum infections.
9
4. Knowledge: - It is defined as the correct response to knowledge questions as
measured by structured questionnaire and calculated as knowledge score
about prevention of postpartum infections.
5. Postpartum infections:-It refers to any clinical infection of the genital canal
that occurs within 28 days after miscarriage, induced abortion or childbirth.
6. Postnatal mothers: It refers to the period beginning immediately after the
birth of a child and extending for about 6 weeks.
6.8) CRITERIA FOR SELECTION OF SAMPLE
Inclusion Criteria
Postnatal mothers who are;
Admitted at time of data collection in selected hospitals
Willing to participate in the study.
Exclusion Criteria
Postnatal mothers who are;
Not willing to participate in the study.
Not present at the time of data collection.
6.9) LIMITATION OF THE STUDY
This study is limited to: -
1. Sample size of 80 postnatal mothers in selected hospitals at Hassan.
2. 4-6 weeks duration.
10
6.10) SIGNIFICANCE OF STUDY
The study signifies the importance of planned teaching programme regarding
prevention of postnatal infections and it will enhance the knowledge of postnatal
mothers and that will enable them to prevent the postnatal infections.
6.11) THEORETICAL FRAME WORK
This study is based on “Widden Back’s Model”.
6.12) REVIEW OF LITERATURE.
Review of literature has been divided into three
1. Review of literature related to general information regarding postpartum
infections
2. Review of literature related to incidence and prevalence of postpartum
infections
3. Review of literature related to prevention and treatment of postpartum
infections
1. Review of literature related to general information regarding postpartum
infections
Zainur RZ, Loh KY conducted a study on "Postpartum morbidity--what we
can do". which says that Postpartum is a crucial period for a mother. During this
period a mother is going through the physiological process of uterine involution and at
the same time adapting to her new role in the family. Many postpartum complications
and infection occur during this period. Among the important obstetric morbidities are
Endometritis, perineal cellulitis, mastitis, pulmonary embolism and puerperal sepsis.
Common surgical complications are wound breakdown, breast abscess and urinary
11
fecal incontinence. Medical conditions such as anemia, headache, backache,
constipation and sexual problems may also be present. Unrecognized postpartum
disorders can lead to physical discomfort, psychological distress and a poor quality10
Magee KP, Blanco JD, Graham JM et al conducted a study on “perineal
cellulitis and mastitis after cesarean: the effect of age” which says that the rate of
perineal cellulitis and mastitis after cesarean section in two age groups. The first group
consisted of patients who were 17 years old or younger (teenage group) and the second
group of patients were 35 years of age or older (advanced maternal age group).
Patients in each group were matched for length of labor, length of rupture of
membranes, and the use of prophylactic antibiotics. In the teenage group, 18 of 41
(43.9%) developed perineal cellulitis and mastitis compared with 6 of 41 (14.6%) in
the advanced maternal age group (P < 0.003). This study supports the concept that
young age is a risk factor for perineal cellulitis and mastitis after cesarean section.11
2. Review of literature related to the incidence and prevalence of postpartum
infections:-
Olsen MA, Butler AM, conducted a study on “Risk factors for
endometritis after low transverse cesarean delivery” with an objective to
determine independent risk factors for endometritis after low transverse cesarean
delivery.they performed a retrospective case-control study during in a large tertiary
care academic hospital. Endometritis was identified in 124 (7.7%) of 1,605 women
within 30 days after low transverse cesarean delivery. Independent risk factors for
endometritis included younger age and anemia or perioperative blood transfusion Risk
of endometritis was marginally associated with a proxy for low socioeconomic status,
lack of private health insurance with amniotomy and with longer duration of rupture of
12
membranes. Which concluded as Risk of endometritis associated with lack of private
health insurance,poor postnatal care and amniotomy. Knowledge of these risk factors
can guide selective use of prophylactic antibiotics during labor and heighten awareness
of the risk in subgroups at highest risk of infection.12
Bello C, Eskandar M, et al conducted a study on “Staphylococcus
lugdunensis endometritis” a case report with an objective to describe a case of
Staphylococcus lugdunensis endometritis associated with premature rupture of
membranes.A 39-year old woman presented with premature rupture of membrane
(PROM) and underwent an emergency caesarean section at 40 weeks of gestation. Her
endometritis was characterized by a foul odour and was so extensive that the baby was
adherent to the endometrium Recent studies have identified clinical features that are
major risk factors for puerperal infection. Patients of low socioeconomic status
undergoing cesarean section who have had prolonged labor and rupture of membranes
(ROM) incur a 40 to 85% risk of endometritis. Infection occurs generally in less than
10% of women undergoing vaginal delivery, even when complicated by prolonged
ROM, and often in considerably fewer cases.13
A study was conducted in the Gynaecology / Obstetric Unit-II, Liaquat University
Hospital,Hyderabad Pakistan from 1st January 2006 to 30th December 2006 to determine
the frequency, causative factors and outcome of delivery by trained or untrained
personnel. Out of total 2885 maternal admissions 135 patients had various postpartum
problems,61 patients had puerperal sepsis. Majority (67.2%) was less than 30 years of
age and52.5% of low parity. Among study population 67.2% belonged to low scio-
economic group and96% were illiterate. Majority (67%) of women did not receive any
13
level of care, only 9.8% hadlevel 3 care. Patients who had vaginal delivery were 93.4%
while 6.6% had caesarean section. Inmajority of patients (57.4%) high grade fever was
the major symptom followed by distension ofabdomen in 26.2%. Evacuation of uterus
and laparotomy were done in 39.3%, only evacuation ofuterus was carried out in 24.6%
and 3.3% had hysterectomy. One third (32.8%) had prolongedhospital stay and other
one third (32.8%) died inspite of all possible measures.The study conclude that in
majority of women sepsis as well as maternal deathwas preventable. It can be reduced
by proper counseling of women about importance of antepartum, intrapartum and
postpartum care and training of Dais and refreshing courses of trainedbirth attendants
(TBAs).14
Malavaud S, Bou-Segonds E et al conducted a study on “Determination of
nosocomial infection incidence in mothers and newborns during the early postpartum
period” with an objective to determine the incidence of postpartum infections in the
mother during the early postpartum period. Over a three-month period, the same
investigator collected 50 different clinical and microbiological, standardized data
related to infectious diseases in parturients and postnatal mothers.Data were collected
on 804 deliveries. The overall rate of postnatal infection was 2.9% (23/804). For
vaginal deliveries, the rate was 1.9% (12/615) and for deliveries by Cesarean section,
the rate was 5.8% (11/189). These results are in line with previously published rates of
postnatal infections, which varied between 0.2% to 2.3% for vaginal deliveries, 1.6%
to 18.9% for Cesarean section,. Regular surveys of the incidence or the prevalence of
postnatal infections are necessary to monitor the effectiveness of educational
programs, aimed to reduce infections.15
Shy KK, Eschenbach DA. Conducted a study on Fatal perineal cellulitis from
an episiotomy site. which says that Perineal cellulitis originating from an episiotomy 14
incision resulted in 20% of the maternal mortality in King County, Washington,
Necrotizing fasciitis is also a fatal, rapidly progressive, often initially unrecognized
condition. Mortality rates range from 30% to 76%. Prognosis depends on the delay of
diagnosis, antimicrobial treatment and surgical excision of all necrotic tissue. A case
of postpartum perineal cellulitis and necrotizing fasciitis arising from episiotomy is
presented. Prompt recognition and aggressive therapy resulted in a favorable outcome
despite significant morbidity.These fatalities occurred because the practitioners were
not aware that post partum infections such as perineal cellulitis and necrotizing
fasciitis can occur in the fatty superficial fascia of the perineum.which concluded as
intervention programme is needed for the health professionals.16
3. Review of literature related to prevention and treatment of postpartum
infections:-
Knowledge, attitudes, and practices of obstetricians and gynecologists
regarding the Centers for Disease Control and Prevention (CDC) recommendations for
prevention of healthcare-associated group A streptococcal (GAS) infections as well as
general management of pregnancy-related and postpartum infections are unknown..
Results show that overall, 53% of providers responded. Postpartum and postsurgical
infections occurred in 3% and 7% of patients, respectively. Only 14% of clinicians
routinely obtain diagnostic specimens for postpartum infections; providers collecting
specimens determined the microbial etiology in 28%. Microbiologic diagnoses were
confirmed in 20% of postsurgical cases. Approximately 13% and 15% of postpartum
and postsurgical infections for which diagnoses were confirmed were attributed to
GAS, respectively. Over 70% of clinicians were unaware of CDC recommendations.
Researchers conclude that Postpartum and postsurgical infections are common.
15
Providing empiric treatment without attaining diagnostic cultures represents a missed
opportunity for potential prevention of diseases such as severe GAS infections.17
Chaim W, Burstein E. Conducted a study on ‘Postpartum infection
treatments: a review” which says that Upper genital tract infections are the most
common complications of the puerperium. Such frequent complications are mastitis
and septic pelvic thrombophlebitis. Several risk factors including obstetrical,
gynaecological, demographic and surgical, are associated with an increased rate of
postpartum infections and their influence is higher after a caesarean than vaginal
delivery. Postpartum infections rate range from 15 to 35%. Their identification should
be prioritized to prevent this complication. The vaginal flora plays a central role in the
development of infections. Prophylactic antibiotic treatment at the time of caesarean
delivery has helped reduce the rate of postpartum infections.18
Cunningham FG, Hauth JC, conducted a study on “Infectious morbidity
following cesarean section. Comparison of two treatment regimens.“ which says that
During a 4-month period 265 women delivered by cesarean section were studied to
determine what effect membrane rupture has on the incidence and severity of
postoperative infection Only 29% of women with intact membranes subsequently
developed endometritis with pelvic cellulitis, in contrast to 85% of those whose
membranes were ruptured for less than 6 hours. Wound and pelvic abscesses were
encountered in less than 1% of women delivered with intact membranes, yet these
complications developed in over 30% of women with membranes ruptured for less
than 6 hours. The incidence of septicemia was four times greater in those women
whose membranes were ruptured for less than 6 hours. Postpartum infection continues
16
to be a leading cause of morbidity in the puerperium.. Patients in labor with ruptured
membranes for more than three hours who undergo delivery by cesarean section19
7. MATERIAL AND METHODS OF STUDY
7.1 SOURCE OF DATA
Data will be collected from the postnatal mothers admitted in the selected hospitals at
Hassan.
7.2 METHODS OF COLLECTION OF DATA
7.2.1 Research design:
The research design is pre experimental single group pretest posttest design.
GROUP PRETEST INTERVENTION POSTTEST
E O1 X O2
Key:-
E = Postnatal mothers
O1 = Assessment of pretest.
X = Planned teaching programme on prevention of postpartum infections.
O2 = Assessment of posttest
7.2.2 Research setting:
This study will be conducted in the selected hospitals at Hassan District.
7.2.3 Population:17
Target population: All the postnatal mothers who are admitted in
hospitals at Hassan.
Accessible population: The postnatal mothers who are admitted in
selected hospitals at Hassan.
7.2.4 Sample:
All the postnatal mothers who fulfill the inclusion criteria from the selected
hospitals at Hassan.
7.2.5 Sample size:
The sample consists of 80 postnatal mothers from the selected hospitals.
7.2.6 Sampling technique:
Non Probability convenient sampling technique will be used.
7.2.7 Collection of data:
The data will be collected from the postnatal mothers admitted in selected
hospitals at Hassan.
7.2.8 Selection of tool:
Part A- Socio demographic profile.
Part B- Collection of data is done by using semi structured questionnaire on
knowledge regarding prevention of postpartum infections.
7.3 RESEARCH APPROACH:
18
Evaluative approach.
8. VARIABLES
Independent variable: PTP on prevention of postpartum infections.
Dependent variable: Knowledge of the postnatal mothers regarding
prevention of postpartum infections.
Extraneous variables: Socio demographic variables such as age, sex, religion,
type of family, family income, Education, Occupation, Habitant, Dietary
pattern, Religion, Sex of the Baby, Body Mass Index.
9. PLAN FOR DATA ANALYSIS.
Descriptive statistics: The statistical analysis includes frequency,
percentage, mean, and standard deviation
Inferential statistics: Chi -square test will be used to calculate and
analyse the association between scores with selected socio-demographic
variables. The paired‘t’ test is used to find out the significant difference
between pretest and posttest scores.
10. PILOT STUDY:
The pilot study is planned with 10% of the total sample size which will
be conducted in selected nursing colleges at Hassan and that will be excluded in the
main study.
19
11. ETHICAL CONSIDERATION
Has the consent being taken from the hospitals?
Yes. Consent has been taken from the selected hospitals.
Has the study require intervention to be conducted on patients or any
other human beings?
Yes. Study conducted on postnatal mothers.
12. LIST OF REFERENCES:
1) Definition of mothers. Allwords.com. English Dictionary
Available on – http:/allwords.com/word-mother.html
20
2) Andy W.Wong, Pamela L Dyne. Postpartum infections. April 14, 2010.
Available on – http://emedicine.medscape.com/article/796892 overview.
3) Julia Hussein, Dileep, Sheetal Sharma and Lucia D’Ambrouso. A review of health
system infection control measures in developing countries: what can be tearned to
reduce maternal mortality. May 19, 201.
Available on – http://www.globalization&health.com/content/pdf/1744-8603-7-
14.pdf
4) Lowdermilk, Perry, Kathryn, Robin Webb Corbett. Maternity Nursing. Mosby
Elsevier publication, 7th edition 2006.
5) Michael G, Gravett. Intraamniotic and postpartum infections.2008.
Available on – http://www.glowm.com/index.html?p=glowm.com/section-
view&articleid=76.
6) Puerperal fever, the free encyclopedia. November 20, 2011.
Available on – http://enwikipedia.org/wiki/puerperalfever.
7) H. Gelband, J. Liljestrand, L. nemer, M. Islam, J. Zupan, P.Jha. Maternal and
neonatal , mortality, page-2. WG5 Paper number 5.
Available on – http://who india .org/linkfiles/commissions.
8) Nasreen Ghanil, Rafat Jan Rukanuddin, Tazeen S. Ali. Prevalence and factors
associated with Postpartum Vaginal infection in the Khyber Agency Federally
Administered Tribal Areas, Pakistan.2007.
Available on – http://www.pakmedinet.com/11100
9) Kitri Iyengar, Sharad D. Iyengar, Virendra Suhalka, and Kalpana Dashora.
Pregnancy-related Deaths in Rural Rajasthan, India: Exploring Causes, Context,
and Care-seeking Through Verbal Autopsy. . J Health Popul Nutr. 2009 April.
Available on-http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2761776/?
tool=pmcentrez
10) Zainur RZ , Loh KY. )"Postpartum morbidity--what we can do".TheMedical
Journal of Malaysia. 2006 Dec;61(5):651-6.
Available on- http://www.atgcchecker.com/pubmed/17623974
11) Magee KP , Blanco JD et al, perineal cellulitis and mastitis after cesarean: the
effect of age.American journal of perinatology, 1994 Jan;11(1):24-6. 21
Available on- http://www.library.nhs.uk/booksandjournals/results.aspx?t=Anemia
%2Fprevention+
%26+control&stfo=True&sc=bnj.ovi.amed,bnj.ovi.bnia,bnj.ebs.cinahl,bnj.ovi.eme
z,bnj.ebs.heh,bnj.ovi.hmic,bnj.pub.MED,bnj.ovi.psyh&p=12&sf=srt.publicationda
te&sfld=fld.title
12) Olsen MA , Butler AM, et al, Risk factors for endometritis after low transverse
cesarean delivery, Infection Control and Hospital Epidemiology-The official
journal. 2010 Jan;31(1):69-77.
13) Bello C , Eskandar M, El GR et al, Staphylococcus lugdunensis endometritis: a
case report. West African Journal of Medicine. 2007 Jul-Sep;26(3):243-5.
14) Razia Mustafa Abbassi, Naushaba Rizwan, Yasmeen Qazi and Firdous Mumta
Puerperal Sepsis: An Outcome of Suboptimal Obstetric Care.2009
http://www.lumhs.edu.pk/jlumhs/Vol08No01/pdfs/v8n1oa18.pdf
15) Magee KP , Blanco JD et al, perineal cellulitis and mastitis after cesarean: the
effect of age.American journal of perinatology, 1994 Jan;11(1):24-6.
16) Shy KK , Eschenbach DA. Fatal perineal cellulitis from an episiotomy site. Journal
of Obstetrics and Gynecology. 1999 Sep;54(3):292-8.
17) Chris A Van Beneden,1* Lauri A. Hicks,1, 2 Laura E. Riley,3 and Jay Schulkin4
Provider Knowledge, Attitudes, and Practices regarding Obstetric and Postsurgical
Gynecologic Infections Due to Group A Streptococcus and Other Infectious; 2007:
90189. Published online 2008 January 16. doi: 10.1155/2007/90189
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2248426
18) Chaim W , Burstein E. Postpartum infection treatments: a review, Expert Opinion
on Pharmacotherapy. 2003 Aug;4(8):1297-313.
19) Cunningham FG , Hauth JC, Infectious morbidity following cesarean section.
Comparison of two treatment regimens, The journal of Obstetrics and Gynecology.
2002 Dec;52(6):656-61.
22
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