DR SYAMALA REDDY COLLEGE OF NURSING, …



RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

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|1. Name of the candidate and address |Mrs. Rajiya. H, |

| |M.Sc Nursing 1st year, |

| |Dr.Syamala Reddy College of Nursing, |

| |No. 111/1, SGR Main Road, Munnekolala, Marathahalli - Post, |

| |Bangalore-560037. |

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|2. Name of the Institution |Dr. Syamala Reddy College of Nursing. |

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|3. Course of study and subject |M.Sc Nursing I year. |

| |Obstetric & gynecology |

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|4. Date of admission to course |June – 2009 |

| |A study on effectiveness of video assisted teaching regarding |

|5. Title of the topic |postnatal exercises among postnatal mother in a selected hospital at |

| |Bangalore. |

6. BRIEF RESUME OF INTENTED WORK:

6.1 INTRODUCTION:-

“God could not be every where and

There fore he made mother.”

(Jewish proverb)

“Every life is a profession of faith and

Exercise an inevitable and silent influence.”

(Henri Frederic amiel)

Child birth is a significant event in women. It is a privilege the mother to deliver a baby woman role is completing after child birth. Childbirth is the culmination of a human pregnancy or gestation period with birth of one or more newborn infants from a woman's uterus. The process of normal human childbirth is categorized in three stages of labour: The shortening and dilation of the cervix, descent and birth of the infant, and birth of the placenta. In some cases, childbirth is achieved through caesarean section, the removal of the neonate through a surgical incision in the abdomen, rather than through vaginal birth1.

Postnatal is the period beginning immediately after the birth of a child and extending for about six weeks. A more correct term would be postpartum period, as it refers to the mother and less frequently used is puerperium2. Having a baby means making many changes in life, losing sleep, learning how to take care of a tiny person, and dealing with the “new body” that pregnancy caused to have. Most women are eager to get to some abdominal exercises to firm up their now-stretched-out middles3.

The postnatal period is the time during which mother’s body adjusts physically and psychologically to the process of childbearing. The period following childbirth during which the body tissues, in particular the genital and the pelvic organs, return to the condition they were in pre-pregnancy, which lasts for approximately 6 weeks. Physiological changes during this time include: The cardiovascular system reverts to normal during the first 2 weeks, the vaginal wall is initially swollen, bluish and pouting but rapidly regains its tone although remaining fragile for 1-2 weeks, perineal edema may persist for some days, After delivery of the placenta, the uterus is at the size of 20-week pregnancy, but reduces in size on abdominal examination by 1 finger-breadth each day such that on the 12th day it cannot be palpated. By end of puerperium it is only slightly larger than pre-pregnancy, for the first 3 to 4 days; lochia comprises mainly blood and remnants of trophoblastic tissue. During days 3 to 12 the colour is reddish-brown but then changes to yellow. Occasionally, lochia may become red again for a few days due to thrombi at end of vessels breaking. Biologically, postnatal period is a time during which the mother's body including hormone levels and uterus size returns to pre-pregnancy conditions4.

In Postnatal care, Women should be offered information to enable them to promote their own and their baby health and well-being and to recognize and respond to problems. At the first postnatal contact, women should be advised of the signs and symptoms, and appropriate action for potentially life-threatening conditions. Rest and exercises, Local asepsis, Diet, Care of the bowel, Care of the bladder, Care of the breasts, Observations are important aspect in postnatal period. Health care personals should teach the mother regarding all those aspect mainly to manage the preventable complication5.

Post natal exercise is playing important role such as, encourage drainage of lochia , encourage ante-version of the uterus, Movement in and outside the bed and breathing exercises are advised during this period to minimize the risk of deep venous thrombosis (DVT), contraction and relaxation of the pelvic floor muscles, Diminish respiratory and vascular complications, Minimize future prolapse and stress incontinence, prevent back ache and genital prolapse, including losing that extra baby weight and getting fit and healthy, Concentrate on proper postures, body alignments and keep abdominal muscles contracted6.

Recommended postnatal exercise includes: Kegals, Deep breathing, , abdominal crunches, Pelvic floor exercise (lying down, sitting), Neck exercises, Hip exercises, Exercise for the lower abdominal muscles, Gentle tummy exercise, Brisk walking ,Sit-ups, Exercising with your baby, .leg and arm exercise7.

Exercise can make a huge difference to recovery after mother have her baby – even if they are feeling exhausted from baby care. It’ll boost mother self-esteem and confidence by getting back in shape, give a shot of much-needed energy and help fight the baby blues and postnatal depression by combating any stress and anxiety mother may be feeling8.

According to the American Council of Obstetricians and Gynecologists, mother can start postpartum exercise as soon as she feels that she is ready. Start slowly- give body time to heal. Work out for at least 30 minutes of exercise - include exercises targeted at toning the muscles most affected by pregnancy - at least three to five days a week. If the mother weren't active during pregnancy, start with a 15-minute program and gradually increase to 30 minutes. If mother tapered off fitness routine as pregnancy progressed, begin at the level the mother stopped exercising at when she was pregnant and increase the intensity or time as she feel ready9.

Many new mothers are understandably eager to work off the extra weight of pregnancy as soon as their baby is born. Eating sensibly and exercising regularly together give them the best chance of returning to a healthy weight more quickly and safely. A good goal is to lose no more than half a kilo a week10.

A Study shows that most of the women gain an average of about 30 pounds during pregnancy, although many of us end up gaining a lot more than that. On average, 18 to 20 pounds are usually lost within a month of having a baby, but it's those extra pounds that can be tough to get rid of. Body may be different after having a baby. But, with a little patience and consistent exercise, one can get back into shape. Exercise should make mother feel better after delivery. It is important to find a sport or exercise that suits the mother well11.

WHO 2008 reports, the outcome on the full range of issues relevant to the postpartum period for the mother and newborn which is a comprehensive view of maternal and newborn needs at a time which is decisive for the life and health of both the mother and her newborn. Taking woman’s own perception of their needs during this period, it is major maternal and neonatal health challenges12.

The postnatal exercise is important during postpartum period, neglecting the mother doing postnatal exercise is the one of the factor contributing to the mother to develop. A major reason for the high mortality rate is lack of care at birth and less awareness about the postnatal exercise. In India most the mothers are not aware of postnatal exercise. It is the responsibility of the nurse to educate mothers regarding the postnatal exercise, which is an extended activity for promotion of maternal and child well being13.

6.2 NEED FOR STUDY:-

Postnatal women who have given birth are extremely interested in regaining their non pregnant feature. Postnatal exercise can begin soon after birth, although the women should be encouraged and start with simple exercise and gradually progress to more strenuous once14.

There are many factors that will determine the mother’s postnatal recovery. Some of these are the exercise routine before and during pregnancy, general health during pregnancy, and of course the type of labour and delivery the mother has. Every woman will have her own unique experience of pregnancy, childbirth and postnatal recovery. Whatever is the situation, it is important not to expect too much of the body and not to feel pressurized into exercising too vigorously, too soon. The mothers have just had a baby and for those that have had a caesarean, don’t forget that she has just had major abdominal surgery. Exercise should be started as soon after delivery as possible in order to improve circulation, strengthen pelvic floor & abdominal muscles & prevent transient & long - term problems15.

In the first few weeks after the baby’s birth, the important things for the mother are a good diet, enough sleep, relaxation and some light gentle exercise. The mother can begin pelvic floor exercises whilst she is still in hospital during the few days after her baby’s birth. Even if she had an episiotomy or tear requiring sutures, the sooner she begin these exercises, the stronger her pelvic floor muscles will become. The midwife looking after the mother in hospital will teach and give advice on postnatal exercises.  These classes and information sessions are very beneficial in the days following the baby’s birth, and give her an opportunity to ask any questions she may have prior to leaving hospital16.

Many women experience some leaking of urine (stress incontinence) in the weeks following their baby’s birth. Sometimes the muscles running down the centre of mother abdomen can separate during pregnancy. The medical term for this is rectus diastasis or diastasis of rectus abdominus. If the gap down the midline is 3cm or more, the mother will need to see a physiotherapist for specific exercises to help bring these muscles back together17.

In the caesarean section, it is important that begin walking as soon as the mother is able to.  Whilst resting in bed, simple leg exercises such as moving feet in a circle will keep the circulation going and help remove excess fluid retained during pregnancy. Deep breathing is also important, so ensure she have adequate pain relief to do this. It is still important to do pelvic floor exercises even though you haven’t had a vaginal birth.During the first few weeks many new mothers observe the confinement period which is laced with many restrictions in food and movement. Some choose not to follow the concept of confinement rigorously and get back to their routine sooner than others18.

There are several reasons why it's a good idea to start some gentle exercise soon after the mother had a baby. It help boost the mood by increasing the levels of feel-good chemicals in the brain, help to regain the pre-baby figure and lose weight, protect from aches and pains and give more energy if the mother is feeling tired, improve physical strength and stamina which will make looking after a newborn baby easier, Speedier healing and recovery from the rigours of the birthing process, helps to reduce post-natal depression known as the “baby blues and Stress release19.

There is also some research which shows that taking part in regular exercise after the birth of your baby can help alleviate the symptoms of postnatal depression. Pain may cause shallow breathing, thus reducing the entry of air into the base of the lungs. There is an increased risk of blood clotting in the legs. For these reasons deep breathing and leg movements should be performed regularly and can be done while lying on the bed or when sitting on a bed or chair20.

The most important postpartum exercise that the mother should do is brisk walking, The Perfect Postnatal Workout contains a short workout that she can do in her first month and two more vigorous 15-minute workouts that she can do with her baby. These are sculpting workouts it will increase the mother’s metabolism and gives her a more toned physique, helping her to burn fat faster21.

A study conducted on the role of exercise in treating postpartum depression: There is growing recognition and acceptance of exercise as a useful treatment option for depression among general populations. The study concluded that exercise may be efficacious in reducing symptoms of depression, although the authors expressed concerns about the quality and small sample size of many studies and the inclusion of individuals without clinical levels of depression. It provides convincing statistical evidence to support the use of exercise for the treatment of clinically significant depression. It also gives guidelines for treating depression in mothers, advised about the benefits of exercise also concluded that exercise can promote mental health and feelings of well-being. It seems plausible that regular exercise may also have a positive effect in the management of depression, specifically in postpartum women22.

A study conducted on Effect of Postpartum Exercise on Mothers and their Offspring; Epidemiological studies suggest that childbearing may contribute to the development of obesity. In the past 12 years, several cross-sectional and randomized trials have addressed the effect of postpartum exercise on weight loss and/or energy balance in mostly lactating women. These studies suggest that moderate exercise without specific calorie restriction does not promote greater weight or fat loss. This may be because exercise may promote greater energy intake and/or reduced energy expenditure from non-exercise physical activity (thus preventing negative energy balance), but further research is needed. Regular exercise, however, is likely to have other important health benefits after childbirth23.

A study  conducted on systematic literature search in December 2006 using the CINAHL, Medline and Cochrane Library databases, hand-searching of selected textbooks, checking reference lists and contacting experts. There were no date restrictions. The review included randomized controlled trials, published in English, of unassisted pelvic floor exercises in postnatal women. Two reviewers independently extracted data and assessed study quality. Main outcomes were reduction in symptoms of incontinence, patient satisfaction and quality of life. Interventions ranged from written information to structured exercise classes, while usual care varied from a leaflet to group sessions with a midwife. Three out of four studies demonstrated short-term improvement in incontinence symptoms, which was statistically significant in two. However, at later follow-up there was no longer a statistically significant effect on continence. All trials found that women in the intervention group were more likely to 2007 do the exercises. They few trials, quality were variable, and comparisons were difficult because of variations in interventions and outcomes measured. Further high quality evaluations are needed, using standardized interventions and outcome measures, patient-relevant outcomes such as quality of life, and follow-up periods that enable evaluation of long-term effectiveness24.

A few published studies suggest that postpartum exercise improves high-density lipoprotein-cholesterol levels, and insulin sensitivity. Exercise may also enhance psychological well-being, but controlled clinical studies are needed. Although two published studies have addressed whether exercise training attenuates lactation-induced bone loss, better controlled studies are needed to determine whether postpartum weight-bearing exercise can improve bone mineral density in lactating and non lactating women alike25.

In lactating women, several studies have collectively determined that neither acute nor regular exercise has adverse effects on a mother's ability to successfully breast-feed. It needs to be determined whether a woman's participation in regular exercise after childbirth will improve her ability to mother or instill lifetime habits of regular physical activity in either herself or her offspring. Overall, published studies have established the importance of regular exercise during the postpartum period. It suggested that there should be more research is needed in this area26.

A longitudinal study conducted among postnatal mother for incontinence about 12 months period. It revealed that postpartum periods, 19.5% were experiencing varying degrees of urinary incontinence. While 42.2% of the women suffered from stress incontinence, 10.3% had urge incontinence, 47.5% complained of a mixed type of urinary incontinence, 7.3% reported leakage of urine during sexual intercourse and 14.4% reported the need to use protective pads. It was found that 12.3% of the women were performing pelvic floor muscle exercises. Pelvic floor muscle training is the most commonly recommended physical therapy treatment for women with stress leakage of urine. It is also used in the treatment of women with mixed incontinence, and less commonly for urge incontinence. Stress incontinence is a common and embarrassing problem. Childbirth is a major cause and problems can be persistent for some. All trials found that women in the intervention group were more likely to do the exercises27.

Postnatal exercise can help the mother to get pre-pregnancy shape. It’s not true that all new mothers lose weight from breastfeeding alone. In fact, some mothers actually put on weight while breastfeeding. Women who are most likely to lose body fat from breastfeeding alone are younger rather than older, and didn’t put on more than the recommended weight gain during pregnancy. The best advice is to rely on regular exercise and a sensible diet to lose weight, rather than expect that breastfeeding will trim the kilos28.

The department of health and family welfare had implemented several important programs and schemes to address the issue of highest infant and child mortality rate in the country. Approximately 50% of perinatal and neonatal deaths can be prevented by simple measures at the primary care. The neglect of nutrition, exercise, health and health education of mothers are the fundamental reason for adverse state of perinatal health in the country29.

Only scantly research data are available on the needs of woman in the postpartum period in India. A study has been done on the knowledge, practice and experience of woman on different postnatal exercise were experiencing great differences such as, decreasing postpartum complication, promoting maternal well being and help the mother to regain the pre-pregnant stage30.

Hence the postnatal mothers are not aware of postnatal exercise. They must be educated and impact the knowledge regarding various aspects of postnatal exercise to decrease the incidence of postpartum complication rate from preventable and manageable cause. Postnatal exercise can be suggested as one of the Non-pharmacological treatments to get into pre-pregnancy. Most research studies stating that the knowledge level of the mother regarding the postnatal exercise is low. So there is a need to teach about the postnatal exercise to the postnatal mother.

6.3. REVIEW OF LITERATURE:

Exercising in the postpartum period is a way to help the mother get back into shape and stay healthy for her baby and herself and to prevent postpartum complication. Many mothers want to know when they can start exercising after giving birth. The general advice from midwives is need before, getting into a fitness routine. Start postpartum exercise routine slowly, and gradually increase it to meet the needs of mother body and it help to “Burn the Baby Fat and Get the Body Back”31.

THE LITERATURE REVIEW HAS BEEN ARRANGED AND PRESENTED IN THE FOLLOWING HEADING:

1. Meaning of postnatal exercise.

2. Types of postnatal exercise.

3. Studies related to postnatal exercise.

4. Studies related to knowledge regarding postnatal exercise among postnatal mother.

5. Studies related to teaching and practice regarding postnatal exercise among postnatal mother.

1. MEANING OF POSTNATAL EXERCISE:

Exercise has considerable benefits for postnatal mother’s including losing that extra baby weight and getting fit and healthy important in helping mother’s cope with the life changes of being a mother32.

2. TYPES OF EXERCISES 33:

A. Pelvic floor exercises.

B. Kegals exercise.

C. Tummy muscle exercises.

D. Abdominal crunches.

E. Sit-up.

F. Neck exercises.

G. Brisk walking.

H. Deep Breathing.

I. Hip exercises.

J. Exercises with baby.

K. Arm & Leg exercise.

A) PELVIC FLOOR EXERCISES:

The Location of Pelvic Floor Muscles; in front, they attach to the pubic bone, and in back to the coccyx, or tailbone. On the sides, these muscles connect to the bottom bones of the pelvis, the ischium also called the “sit bones”.

Strong pelvic-floor muscles are an integral part of the mother’s body internal core stabilizers. Maintaining and enhancing their strength will increase her likelihood of having a comparatively quick, complication-free delivery and recovery from childbirth. This is a great exercise for toning and strengthening the stomach.

Female urinary incontinence (UI) is often considered a problem primarily occurring after childbirth. After childbirth, deep coughing for prolonged periods may cause uterine or bladder prolapses. Prolapsed organs function poorly and may require surgical repair. Whenever mother feel a bad coughing spell coming on, support her pelvic-floor muscles by sitting on a hard chair, on the floor, or on a large exercise ball.

B) KEGALS EXERCISE

Using Kegel contractions after childbirth will increase blood flow to the pelvic floor and help speed healing. Contrary to what the mother might expect, exercising these muscles reduces pressure on episiotomy stitches and helps relieve perineum tenderness. These exercises will also help alleviate the discomfort of vulva edema, hemorrhoids, and anal fissures.

It’s best to do Kegals while in a position that helps the mother accurately isolate her Pubococcygeals, from the inner thigh and buttocks muscles. Kegals can be done sitting up on a hard chair, sitting on the floor, lying on her side, or on lying on her back with her knees bent. For this exercise to be most effective, the mother need to close both the anal and vaginal sphincters, and lift the entire area up into her abdominal cavity just a little bit.

C) GENTLE TUMMY EXERCISE:

Pregnancy splits the abdominal muscles down the middle. It is important to make sure the muscles have healed before to do any vigorous abdominal exercises, such as abdominal crunches and makes tummy flat. Stretching of the Abdominal Muscles during pregnancy may reduce their efficiency in maintaining good posture and back support. It is therefore important to exercise these muscles regularly.

D) ABDOMINAL CRUNCH:

Lie on the back with knees bent and feet flat on the floor. Slowly lift the head off the floor, pull the abdomen towards the spine and exhaling as to do so.

It will contract the abdominals in towards the spine for two seconds and then release. Do this exercise soon it will begin to feel the abdominals getting stronger.

E) SIT UPS:

These exercises flat the abdominal muscles. It is also important to bear in mind that to shed the spare tire around the middle or indeed any excess fat on the body if need to do cardiovascular exercise and increase the amount of muscle on the body.

Muscles are active and need energy to survive, but fat is inactive and uses very few calories. Therefore in order to increase the metabolism and burn more calories, an increase in muscle mass is needed.

F) BREATHING:-

Some evidence revealed that breathing exercise will help in mother to reduce abdominal tension, alleviate pain, reduce the stress, depression and relax mind because postnatal depression is a serious mental health problem that may be reduced by exercise.

G) NECK EXERCISES:-

Help boost the mood by increasing the levels of feel-good chemicals in your brain, protect mother from aches and pains and give more energy if mothers are feeling tired, and improve the blood circulation.

H) BRISK WALKING:-

Recent evidence shows us that there is a very simple method to preventing the pounds from packing on after birth, Walk every day, Walking 30 minutes a day also reduced the risk of keeping pounds and adding new ones for new mothers.

I) HIP EXERCISES:-

Hip exercises are useful exercises which gently move and stretch your back, and also exercise your tummy muscles. They can also help to alleviate back pain and regains pre-pregnancy posture.

J) EXERCISING WITH YOUR BABY:-

Mother has to involve the baby during exercise it will help the mother to enjoying exercise together. Doing exercise with the baby not only helping the mother, it also improves maternal and child bonding, baby will feel secure, and also mother mind will get relax.

K) ARM & LEG EXERCISE:-

The mother can do this exercise while sitting on the floor watching her baby or lying on the bed. Leg exercise is very effective to reduce the risk of blood clots during post-operative period.

3. STUDIES RELATED TO POSTNATAL EXERCISE:-

A study conducted on to test whether supervised pelvic floor exercises antenatally will reduce the incidence of postpartum stress incontinence in at-risk primigravida with bladder neck mobility, ultrasonically proven. Single blind randomized controlled trial. Among 268 primigravidae attending an antenatal clinic at approximately 20 weeks of gestation with bladder neck mobility in UK NHS Trust Hospital. The study findings revealed that, fewer women in the supervised pelvic floor exercise group reported postpartum stress incontinence, 19.2% compared with 32.7% in the control group. There was no change in bladder neck mobility and no difference in pelvic floor strength between groups after exercise; although all those developing postpartum stress incontinence had significantly poorer perineometry scores than those who were continent. The findings suggest that antenatal supervised pelvic floor exercises are effective in reducing the risk of postpartum stress incontinence in primigravidae with bladder neck mobility34.

A longitudinal follows up of women in their practice of perinatal pelvic floor exercises and stress urinary incontinence using a postnatal postal questionnaire, among 257 women in the North-East of Scotland. The study finding shows that, no significant difference was found in reported rates of stress incontinence between women who had different modes of delivery. The practice of pelvic floor exercises daily or more often during pregnancy was associated with less reported postnatal incontinence compared with less frequent practice. Self-reported rates of practice of pelvic floor exercises increased from pregnancy to the immediate postnatal period and subsequently declined. A third of women reported the symptoms of stress incontinence after delivery. Daily or more frequent practice of the exercises during pregnancy may be required in order to prevent postnatal incontinence (although further research is required to confirm this finding) 35.

A study conducted on Urinary Incontinence in the Postpartum 12-Month Postpartum Period among 523 women, who had obstetrical deliveries. The aim of this study is to describe the prevalence and severity of urinary incontinence to relate the several potential risk factors including body mass index, smoking, oral contraceptives, breast-feeding, and pelvic floor muscle exercise. The women were interviewed in their rooms on postpartum day 2 or 3 and by telephone 6 weeks, 3 months, 6 months, and 12 months postpartum. Chart abstraction was conducted to obtain obstetrical data from the index delivery. The study findings revealed that, At 6 weeks postpartum, 11.36% of women reported some degree of urinary incontinence. Postpartum incontinence is associated with several risk factors, some of which are potentially modifiable and others that can help target at-risk women for early intervention36.

A study conducted on Pelvic floor muscle training for urinary incontinence in women, Among 15 postnatal women with symptoms of stress, urge or mixed incontinence that included pelvic floor muscle training. The study findings revealed Pelvic floor muscle training appeared to be an effective treatment for postnatal women with stress or mixed incontinence. Pelvic floor muscle training was better than no treatment or placebo treatments. In addition there was a lack of consistency in the choice and reporting of outcome measures that made data difficult to combine. Methodological problems limit the confidence that can be placed in the findings of the review. Further, large, high quality trials are necessary37.

A study conducted on the role of exercise in treating postpartum depression, this article reviews the evidence regarding the potential role of exercise, particularly pram walking, as an adjunctive treatment for postpartum depression. Database searches revealed two small randomized controlled trials conducted in Australia which support exercise as a useful treatment for women with postpartum depression. In addition, uncontrolled studies and observational evidence suggest that postpartum women, some of whom were depressed, report benefit from participation in exercise program. There are plausible mechanisms by which exercise could have such an effect. Limited evidence supports a relationship between participation in exercise and reduction in postpartum depression. Given the reluctance by some women to use antidepressant medication postpartum and the limited availability of psychological therapies, exercise as a therapeutic possibility deserves further exploration. Further research using well-designed randomized controlled trial methodologies are warranted38.

A study conducted on Pelvic Floor Muscle Training during Pregnancy and After Delivery, Ten articles were identified addressing the effect of pelvic floor muscle training postpartum; seven of these presented RCTs, two presented matched controlled studies and a controlled study. Three were follow-up studies. The interventions included pelvic floor muscle training; however, various training protocols were used. All studies, except for two, reported statistically and clinically significant effects of the interventions, with a significant reduction in symptoms or frequency of urinary incontinence after the intervention period. No adverse effects of the interventions were reported. This review suggests that women should be encouraged to perform pelvic floor muscle training during pregnancy and postpartum to prevent and/or treat urinary incontinence39.

A study conducted on Feasibility of an exercise intervention for women with postnatal depression, participants were recruited from various sources and randomized to an exercise intervention or usual care with follow-up at 12 weeks.38 eligible participants were randomized. The study finding shows that, Exercise participation over the 12-week period was not significantly increased, possibly because it is difficult to motivate women with postnatal depression to exercise, or the intervention was not sufficiently intensive. Eligible patients were recruited into this study but response rates were low. Optimum methods of recruitment in this difficult-to-reach population are required prior to a substantive trial. Further research is imperative given poorly-evidenced recommendations by the National Institute for Health and Clinical Excellence to consider this treatment40.

A study conducted on Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth. The study revealed that Genital tract trauma is common following vaginal childbirth, and perineal pain is a frequent symptom reported by new mothers. The following techniques and care measures are associated with lower rates of obstetric lacerations and related pain following spontaneous vaginal birth: antenatal perineal massage for nulliparous women, upright or lateral positions for birth, avoidance of valsalva pushing, delayed pushing with epidural analgesia, avoidance of episiotomy, controlled delivery of the baby’s head, use of Dexon or Vicryl suture material, the “Fleming method” for suturing lacerations, and oral or rectal ibuprofen for perineal pain relief after delivery. Further research is warranted to determine the role of prenatal pelvic floor (Kegel) exercises, general exercise, and body mass index in reducing obstetric trauma, and also the role of pelvic floor and general exercise in pelvic floor recovery after childbirth41.

4. STUDIES RELATED TO KNOWLEDGE REGARDING POSTNATAL EXERCISE AMONG POSTNATAL MOTHER:-

This study investigated the frequency, nature and experience of urinary incontinence in post-natal women. Surveys were completed by 224 women, 50% of whom indicated that they had experienced accidental urine loss. The majority of women who had experienced any symptoms were moderately to greatly bother by them. A variety of strategies were used to manage the problem; however, 42% of the women who experienced accidental urine loss had taken no action to ease the problem. Women received information about urinary incontinence and pelvic floor exercises from a variety of health care professionals, but this was not consistently provided. The implications of these findings are discussed42.

A study conducted on Women's knowledge, practices, and intentions regarding correct pelvic floor exercises, among 720 postpartum women, this study investigates women's PFX regimens both before and during pregnancy and postpartum. Findings demonstrated that most women were aware of the required frequency for PFXs (at least every second day): just over half had done them this often during pregnancy and 91% intended to do so postpartum. However, few had done them at this level before pregnancy and less than half knew that PFXs should be carried out indefinitely throughout the lifetime. Moreover, only two thirds were confident that they were doing PFXs correctly. The findings suggest that, despite good knowledge of the required frequency of PFXs, few women practice them regularly over their lifetime, many apparently perceiving PFXs as relevant only to the childbirth years43.

A cross-sectional study conducted on knowledge and practice of pelvic floor exercises during postnatal and associated symptoms of stress urinary incontinence in North-East Scotland among postnatal women over the age of 16 years. Of 350 women who agreed to participate, 289 (82.6%) were interviewed between July 1999 and March 2000.the study findings revealed that the number of women who indicated a desire for more information and the low number who reported practice of the exercises suggest that improvements could be made. The gaps in information provision and practice suggest areas for future health promotion about the exercises, particularly by midwives. Reported levels of incontinence during postnatal period confirm previous findings and highlight the prevalence of incontinence in postnatal period44.

A study conducted on Treatment of Female Urinary Incontinence; in evidence-based knowledge on short- and long-term effects, adverse effects, adherence, dropout and motivational problems of pelvic floor muscle (PFM) training for stress urinary incontinence (SUI). The study revealed that, Several RCTs have demonstrated that PFM training is more effective than no treatment for SUI. Successful results were maintained in two thirds of the patients originally classified as successful, to organize better health services for SUI patients and for planning of future high quality clinical trials45.

5. STUDIES RELATED TO TEACHING AND PRACTICE REGARDING POSTNATAL EXERCISE AMONG POSTNATAL MOTHER:-

A study conducted on Physical therapy for female pelvic floor disorders Non-surgical, non-pharmacological treatment for female pelvic floor dysfunction is represented by rehabilitation in urogynecology. Since Kegel, in 1948, who proposed the concept of functional restoration of the perineal muscles, no specific term has actually been established. Owing to the number of specialists involved in the management of female pelvic floor disorders and the different types of health care providers concerned ,it is difficult to make the proper choice between 'physical therapy for pelvic floor', 'pelvic floor rehabilitation', 'pelvic muscle re-education', and 'pelvic floor training'. Because muscle re-education is under the control of physical therapists, we have chosen the term of physical therapy for female pelvic floor disorders. Muscle re-education has an important role in the primary treatment of lower urinary tract dysfunction. A multidisciplinary collaboration may be of particular interest, and a thorough evaluation is useful for a proper selection of patients46.

A study conducted on structured brisk walking program for six weeks was practiced by postnatal mothers, among 46 postnatal women regarding brisk walking and its benefits; the study revealed that several physical and psychological benefits and group reported decreased emotional distress. So it contributes statistically significant evidence that exercise potentially reduces psychological stress47.

A study conducted on Exercise in the Postpartum Period, the study revealed that it is important to examine the theoretic concerns and potential benefits of exercise during this period, especially with respect to weight retention following lactation performance. It is recommended to increase the definition of the postpartum period to 1 year, because many physiologic changes due to pregnancy remain up to 1 year after delivery. Evidence-based guidelines are presented for postpartum exercise and lactation. Future research should address the impact of exercise and lactation on bone mineral density, nutrition status and weight loss, cardiovascular health, and how to optimize health promotion during the postpartum period48.

A study conducted on postnatal pelvic floor muscle training for preventing and treating urinary incontinence, the study findings shows that, only three systematic reviews, six trials, and four follow-up studies have been published in the past two decades. In the prevention/treatment of postnatal urinary incontinence immediately after delivery and in persistent incontinence, supervised intensive programs prove more effective than standard postnatal care. Although a certain exercise dosage must be respected for a postnatal pelvic floor muscle training program to be effective, a few randomized controlled trials present such dosage. Randomized controlled trials should study the effect of supervised, intensive training protocols with adherence aids. As standard care does not seem to reduce the prevalence of postnatal urinary incontinence, obstetrics services must address delivery of postnatal pelvic floor muscle training49.

A conducted study on a systematic review of Pelvic floor muscle training and adjunctive therapies for the treatment of stress urinary incontinence in women. 24 studies, including 17 RCTs and seven non-RCTs, met the inclusion criteria. This review found consistent evidence from a number of high quality RCTs that PFMT alone and in combination with adjunctive therapies is effective treatment for women with SUI with rates of 'cure' and 'cure/improvement' up to 73% and 97% respectively. The contribution of adjunctive therapies is unclear and there is limited evidence about treatment outcomes in primary care settings. There is strong evidence for the efficacy of physical therapy for the treatment for SUI in women but further high quality studies are needed to evaluate the optimal treatment programs and training protocols in subgroups of women and their effectiveness in clinical practice50.

A study conducted on a structured pushing exercise programme among postnatal mother to see the effectiveness of reducing postnatal depression .It found that the exercise was significantly more effective to reducing depressive symptoms in postnatal period. There is insufficient evidence to justify using this multifaceted intervention in routine clinical practice. However, exercise is generally believed to be of benefit in depressive disorders, and so it may be beneficial to women with postnatal depression51.

A study conducted on Teaching and practicing of pelvic floor muscle exercises in primiparous women during pregnancy and the postpartum period, this was a secondary data analysis from a prospective multicenter cohort study, the Childbirth and Pelvic Symptoms study, by the Pelvic Floor Disorders Network. Primiparous women (n = 759) the study findings revealed that 64% percent of the women had been taught PFME, most with verbal (76%) and/or written instructions (55%) and a few (10%) during pelvic examination. Women with anal sphincter tears were not more likely to receive instruction or reminders after delivery. More white women (75%) were taught PFME than were Asian women (48%), African American women (36%), or Hispanic women (39%). More women with college education (74%) were taught, compared with women without a college education (37%). Of those women who were taught, 68% performed PFME after delivery, and 63% were still performing the exercises 6 months after delivery. Results reveal tremendous potential for the improvement of PFME education and targeting at-risk women in the peripartum period52.

6.4 STATEMENT OF THE PROBLEM:-

A study on effectiveness of video assisted teaching regarding postnatal exercises among postnatal mother in a selected hospital at Bangalore.

6.5 OBJECTIVES:-

1) To assess the knowledge of postnatal mother regarding postnatal exercise.

2) To evaluate the effectiveness of video assisted teaching among postnatal mother.

3) To determine the relationship between knowledge and socio-demographic variables.

6.6 HYPOTHESIS:-

H1:- There is significant relationship between video assisted teaching and level of knowledge among postnatal mother.

H2:- There is significant relationship between level of knowledge & socio demographic variables among postnatal mother.

6.7 OPERATIONAL DEFINITIONS:-

POSTNATAL MOTHER: - Mother who has been admitted in postnatal ward after delivery.

EXERCISES: - Activities which is done to improve physical fitness of the postnatal mother.

KNOWLEDGE: - Information possessed by postnatal mother about postnatal exercise.

VIDEO-ASSISSTED TEACHING: - It is a planned structured teaching program conducted among postnatal mother on postnatal exercise using video.

EFFECTIVENESS: - Improvement on the level of knowledge of postnatal mother after video assisted teaching on postnatal exercise measured by using self administer questionnaire.

6.8 ASSUMPTION:-

A1: Exercise prevents postnatal complication like incontinence of urine, postnatal psychosis, anxiety, thromboembolism, etc

A2: Physical fitness helps mother to provide effective care to the child.

A3: video assisted teaching influence the knowledge level of mother on postnatal exercise.

A4: Socio demographic variables influence the level of knowledge among postnatal mother.

6.9 MATERIALS METHODS: -

SOURCE OF DATA: - Mothers admitted in postnatal ward for postnatal care about 1 to 5 days in HAL hospital located at HAL, Bangalore.

7. METHOD OF DATA COLLECTION PROCEDURE:-

RESEACH APPROACH: Quasi-experimental.

RESEACH METHOD: Quasi-experimental method, one group Pre & Post test only.

E=O1xO2

RESEARCH DESIGN: It is a Quasi-experimental design to teach sample of 30 postnatal mothers regarding postnatal exercise in HAL Hospital.

SAMPLING TECHIQUE: 30 postnatal mothers will be selected using non-probability convenience sampling technique. Data will be collected by using self-administered questionnaire, after obtaining verbal consent from the postnatal mothers.

SAMPLE SIZE: 30 postnatal mothers who are admitted in the postnatal ward for about 1 to 5 days will be selected for the study.

SETTING OF THE STUDY: The quasi-experimental study will be conducted in postnatal ward of HAL Hospital. The samples for this study are postnatal mothers who undergone vaginal delivery and cesarean section. The postnatal ward of HAL Hospital has total of 50 beds out of which equal 25 beds is used for mothers who undergone normal delivery and cesarean section in separate wards.

7.1 SAMPLING CRITERIA:-

Inclusion criteria:

1) Postnatal mothers those who are willing to participate in the study.

2) Postnatal mothers delivered through spontaneous vaginal delivery and cesarean section

3) Postnatal mothers who can able to understand Tamil and English language.

Exclusion criteria:

1) Postnatal mother with puerperal complications.

2) Postnatal mothers with known history of medical illness.

7.2 DATA COLECTION TOOL: -

A self administer questionnaire will be prepared to assess the knowledge of postnatal mother regarding postnatal exercise includes: Pelvic floor exercise, Kegals exercise, Tummy muscle exercises, Abdominal crunches, Sit-ups, Neck exercises, Brisk walking, deep Breathing, Hip exercises, Exercise with baby , Arm and Leg exercise .

The questionnaire consists of 2 sections.

Section I - socio demographic variable such as name, age, sex, education, occupation etc…

Section II - closed ended questionnaire on knowledge of postnatal mother regarding postnatal exercises. The entire question has 4 options where as one will be the correct answer and other 3 will be the wrong answers.

Validity of tool will be ascertained in consultation with guide and other experts from various fields like nursing and obstetrics and gynecologist.

7.3 DATA COLLETION PROCEDURE:-

This is a quasi experimental study will be conducted in HAL Hospital. Minimum sample of 30 postnatal mothers between 1 to 5 days of postnatal day will be included in the study. A self-administer questionnaire is prepared to collect the relevant information for pre & post video assisted teaching regarding postnatal exercise. The duration of the data collection will be 4 weeks. Per day, the data will be collected from 4 to 5 postnatal mothers.

7.4 DATA ANALYSIS METHOD:-

The collected data will be analyzed using descriptive statistics such as frequency distribution, percentage, mean and standard deviation for socio demographic variables and inferential statistics such as chi square to see the association between the socio demographic variables and level of knowledge among postnatal mother regarding postnatal exercise & t-test to see the association between pre & post test knowledge.

7.5 ETHICAL CLEARNCE BEEN OBTAINED?

• Yes

• Ethical clearance is obtained from HAL Hospital and written consent from participants.

• Confidentiality of the subjects will be maintained.

8. LIST OF REFERENCE:-

1) Lewder milk, Perry, Bobak. Maternity and woman’s health care. Sixth edition. New York; Mosby Publication; 2006.450-52 pp

2) Bent V. Ruthilinda.K.Brown; Myles Text Book for Midwives; 13th edition; (1999); Churchill Livingstone Publishers.

3) Spencer, Paula. Parenting Guide to Pregnancy and Childbirth Ballantine Published 1998.

4) Laura. R. Kathryn. Comprehensive Maternity Nursing .Second edition. London: J.B Lippincott Company: 1994. 65-7 pp.

5) Gurunath.A.K. Comprehensive View of Maternal and Newborn Needs, Indian Journal of Medical Science. 2007, May, 10. Volume 5(54): (3);

6) Dutta D.C. Text Book of Obstetrics. Sixth edition. Calcutta: New Central Book Agency ;( 2004).152-53pp

7) Lynna Y. Littleton Joan.C . Maternity woman’s and newborns health care. Sixth edition. Engabretson Publication;.898-900 pp

8) Scattergood, Emma. Mother and Baby Exercise, Sterling Publishing Co, Inc, 1995,

9) American College of Obstetricians and Gynecologists [ACOG]. Exercise during pregnancy and the postpartum period. ACOG Committee Opinion No. 2002; 267 January 2002. Washington, DC: Author.

10) Shruti Saxena. Shape Up with Baby; In Parenting Magazine 12/2000

11) Sara Shelley. The Perfect Postnatal Workout, 2008 Far Star Productions, Inc, Washington.

12) Gurunath.A.K. Comprehensive View of Maternal and Newborn Needs. Indian Journal of Medical Science. 2007, May, 10. Volume 5(54): (3); .

13) Julie Tupler, Lose Your Mummy Tummy by Deceptively simple abdominal and breathing exercises designed to firm and flatten abs after pregnancy and birth; (2008).

14) Ashton leigh and wigan information for patients about postnatal exercises, obstetrics & gynaecology directorate,jan-2008

15) Melinda Nicci. Postnatal exercise - issues to consider, 23/03/2007

16) R Artal and M O'Toole.during pregnancy and the postpartum period, Obstetricians and Gynecologists for exercise on December 7, 2009 - Published by group.

17) Tracey Mallett. Post Natal Exercise: Why Exercise is Important after Baby, England. Sep -2007.

18) Lesley Ann Page, Patricia Percival. The New Midwifery Science and Sensitivity in Practice. Second Edition, New York: Churchill Livingstone; (2000) pp.34-36

19) R Artal and M O'Toole.during pregnancy and the postpartum period, Obstetricians and Gynecologists for exercise on December 7, 2009 - Published by group.

20) Shashank.v.parlekar. Textbook for Midwives. Second edition, Mumbai. Vora Medical Publications (1998).

21) Lewder milk, Perry, Bobak. Maternity and woman’s health care. Sixth edition. New York; Mosby Publication; 2006.12-5 pp

22) Daley AJ, MacArthur C, Winter H. The Role of Exercise in Treating Postpartum Depression: A Review of the Literature. J Midwifery Women's Health 2007; 52:56–62. [PubMed ]

23) Dawnine Enette Larson-Meyer. Effect of Postpartum Exercise on Mothers and their Offspring: A Review of the Literature, Obesity Research (2002) 10, 841–853

24) Ann Wagg & Frances Bunn. Unassisted pelvic floor exercises for postnatal women: a systematic review; UK, journal of Advanced Nursing Volume 58 Issue 5, Pages 407 – 417 Published Online: 21 May 2007.

25) Ashton leigh and wigan information for patients about postnatal exercises, obstetrics & gynecology directorate,jan-2008

26) G. P. Herbison, Thomas M, Acute nor regular exercise has adverse effects on a mother's ability to successfully breast-feed, New South Wales. Journal of Obstetric Gynecology. 2000; 40(3):331–337.

27) Armstrong and Edwards Lawlor and Hopker. A longitudinal study conducted among postnatal mother for incontinence about 12 months period; Obstet Gynecol. 2004; 104:504-510.

28) Beverley Brooke. Article by Postnatal exercise - issues to consider, Royal Women's Hospital, Parkville, .

29) Jaiwanti p.dhaulta. A Community Health Nursing Manual, Ninth reprint .New Delhi: 2002, TNAI. 32-3 pp.

30) Walia.Care of the Newborn; Journal of Obstetrics and Gynecology.2 September 1997, (26) pp 535-537.

31) Julie Tupler, Lose Your Mummy Tummy by Deceptively simple abdominal and breathing exercises designed to firm and flatten abs after pregnancy and birth; (2008)

32) Great article by Claire Vande Polder Pace.Your Postpartum Weight Loss: 6 Strategies for Losing That Baby Weight 

33) Lewder milk, Perry, Bobak. Maternity and woman’s health care, Sixth edition. New York; Mosby Publication; 2006.12-5 pp

34) Reilly ET, Freeman RM, a randomized controlled trial of antenatal pelvic floor exercises in Derriford Hospital, Plymouth, UK; BJOG. 2002 Jan; 109(1):68-76

35) Whitford HM, Alder B, Jones M. A longitudinal follow up of women in their practice of Perinatal pelvic floor exercises and stress urinary incontinence in North-East Scotland; PubMed.

36) Burgio, Kathryn L.Urinary Incontinence in the 12-Month Postpartum Period; Obstetrics & Gynecology: December 2003 - Volume 102 - Issue 6 - p 1291-1298

37) Hay-Smith EJ, B.K, Berghmans LC. A study conducted on Pelvic floor muscle training for urinary incontinence in women; Cochrane Database System Rev, 18 Jul 2007.

38) Daley AJ, Macarthur C. The role of exercise in treating postpartum depression; Journal Midwifery Women’s Health Pub-Med. 2007 Jan-Feb; 52(1):56-62.

39) Morkved, Siv. Pelvic Floor Muscle Training During Pregnancy and After Delivery; Current Women's Health Reviews, Volume 3, Number 1, February 2007, pp. 55-62(8).

40) Amanda J Daley, PhD, C Psychol. Feasibility of an exercise intervention for women with postnatal depression; British Journal of General Practice, 2008, March 1; 58(548): 178–183.

41) L. Albers, N. Borders. Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth; Journal of Midwifery & Women's Health, Volume 52, Issue 3, Pages 246-253, 2009

42) Bev O'Connell, Linda Baker. The nature and severity of urinary incontinence in post-natal women; Contemporary Nurse | Volume: 24 | Issue: 1 | Pps: 65-78, oct-2002.

43) Pauline Chiarelli, Barbara Murphy, Jill Cockburn. Women's knowledge, practices, and intentions regarding correct pelvic floor exercises in Australia, 2003, Neurourology and Urodynamics Volume 22 Issue 3, Pages 246 – 249.

44) Heather M. Whitford PhD, BN, MM, RM. A cross-sectional study of knowledge and practice of pelvic floor exercises during pregnancy and associated symptoms of stress urinary incontinence in North-East Scotland Midwifery, Volume 23, Issue 2, June 2007, Pages 204-217

45) Teresa Cook, Grad Dip. Treatment of Female Urinary Incontinence; EAU Update Series, Volume 1, Issue 3, Page 145, 2009

46) Bourcier, Alain P. Physical therapy for female pelvic floor disorders; Current Opinion in Obstetrics and Gynecology, August 1994 - Volume 6 - Issue 4 pp-146-150.

47) Mock and colleagues. Structured brisk walking program for six weeks by postnatal mothers J Gen Pract, 1997Mar; 58(548):178-83.

48) Mottola, Michelle F. PhD Exercise in the Postpartum Period: Practical Applications; American College of Sports Medicine, 2002

References and further reading may be available for this article. To view references and further reading you must purchase this article.

49) Dumoulin, Chantale. Postnatal pelvic floor muscle training for preventing and treating urinary incontinence; Current Opinion in Obstetrics and Gynecology, October 2006 - Volume 18 - Issue 5 - p 538-543.

50) Patricia B Neumann. Pelvic floor muscle training and adjunctive therapies for the treatment of stress urinary incontinence in women; BMC Women's Health, 28th June 2006

51) Michael Craig, Louise Howard. A structured pushing exercise programme among postnatal mother to see the effectiveness of reducing postnatal depression-2008

52) Fine, K. Burgio. Teaching and practicing of pelvic floor muscle exercises in primiparous women during pregnancy and the postpartum period; American Journal of Obstetrics and Gynecology, Volume 197, Issue 1, Pages 107.e1-107.e5

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