Comparative study to assess the level of stress among primiparas whohave undergone caesarean section versus normal vaginal delivery with aview to develop an informational booklet on stress management

INTRODUCTION

A Woman is the light of the family. A woman shows many roles such as daughter, wife, mother and great responsibility to be carried out in the family. So, the physical and mental health of mothers is very important for the health of the family.

Postpartum is an event, is characterized by tremendous psychological changes that require major behavioral adjustment within 6 weeks of time. Postpartum period is marked by drastic hormonal fluctuations, irritability, sadness, intense joy, intense anger, and intense frustration and sobbing at something as mundane as television commercials are par for the course.¹

The postpartum blues is a transient condition that 75-80% of mothers could experience shortly after childbirth with a wide variety of symptoms which generally involve mood liability, tearfulness, and some mild anxiety and depressive symptoms. After the placenta is delivered, the placental "hormone factory" shuts down causing radical changes in hormone levels, and the woman can suffer symptoms due to withdrawal from the high pregnancy levels of oestrogen, progesterone and endorphins. Combined with this shift in hormone levels is the physical, mental and emotional exhaustion - as well as sleep deprivation typical of parenting a newborn. All of these factors contribute to the condition. However women with postpartum blues are important, because up to 20% go on to develop postpartum stress syndrome.² 

Stress is the part of day to-day living. It is a common human phenomenon and part of life with any circumstances which could affect the mental health. Stressful situations may occur to the woman in many states such as developmental, marriage, child birth and as a mother for her lovely little child etc. As a mother for newborn baby may experience stress meeting demands of baby, family, finance, pain after delivery, emotional experiences etc,. the stress experience is not necessarily harmful. Mild forms of stress can act as a motivator and energizer if taken as positive. However, if stress level is too high, medical and social problems can result.³

The birth of a child is generally viewed as a time for rejoicing, despite the physical pain and exhaustion experienced by many women during child birth. However, for some women the experience can be a traumatic event for a variety of reasons. These include the new demands a baby can bring, stress is about parenting abilities, the responsibility of looking after the baby, and a host of more complex psychological, sociological, and biological matters that arise during these time of change (Currid 2002). When these issues are not resolved positively, women may experience crisis leading to periods of mental illness, ranging from mild to severe.³

UNICEF’s report that India’s fight due to growing social inequalities and shortages in primary health care facilities and 80% of women suffer from the maternity blues which is merely a mild transitory form of moodiness where symptoms typically last from a few hours to several days and include tearfulness, irritability, hypochondriasis, sleeplessness, impairment of concentration, isolation and headache.⁴

In recent time the caesarean delivery is 50% of child birth and it also performed upon request for childbirths that could otherwise have been natural.3 In Kempegowda Institute of Medical Science and Research Centre there are 52.48% of caesarean section and 47.52% vaginal delivery in 2010.so, there is increase in traumatic injury during child birth which leads to post traumatic stress disorder in mothers after childbirth.⁴

REVIEW OF LITERATURE:

A study conducted on 264 women who had normal births were assessed within 72 hours to identify the prevalence and potential predictors of post-traumatic stress type symptoms following labour in UK. The study results that 3% showed questionnaire responses suggesting clinically significant levels on all three posttraumatic stress dimensions and a further 24% on at least one of these dimensions. Forward stepwise regression analysis yielded models for predicting outcome variables. Perceptions of low levels of support from partner and staff, patterns of blame and low perceived control in labour were found to be particularly related to experience of post-traumatic stress symptoms. Personal vulnerability factors such as previous mental health difficulties and trait anxiety were also related to such symptoms as well as being relevant predictors for anxiety and depression.⁵

A descriptive study conducted on 104 primipara mothers to investigate the problems related to breast feeding in Karnataka. The findings revealed that 54% of mothers had stress regarding lack of privacy, discomfort and pain due to episiotomy stitches while breast feeding and primary breast engorgement as major hindrance for breast feeding. Researcher concluded that physical ailments such as breast problems and episiotomy pain causes stress among postnatal mothers.⁶

A study was conducted on 60 postnatal mothers to find out the stress and coping strategies in Bangalore. The findings revealed that 53% had difficulties in breastfeeding,40% had sleep disturbances .100% of mothers reported that they used coping mechanism like praying,26% adopted coping mechanism as reading books,40% of mothers coped well by expressing emotions to others. Researcher concluded that stress is common among postnatal mothers and ventilating emotions to others is the best coping strategy to reduce stress.⁷

A study conducted on postpartum blues is common in economically and socially insecure mothers in Bangalore, Karnataka. A sample of 130 mothers within 2 weeks of delivery at a referral hospitals. Of 123 women screened, 72 were diagnosed to have postpartum blues, accounting for 58.5% prevalence rate , most of the mothers were literate (91%) and house wives (77%) about 9% of the mothers had a history of psychiatric illness, two mothers had marked suicidal tendency. Edinburgh depression scale score of 10 and above was seen in mothers with female offspring (69%, p<0.05), low family income (62%, p=0.05) and living in joint family (71%, P<0.001), poor marital relationship (91%, P<0.001) were also associated with support (P<0.001) were also associated with postpartum blues.⁸   

STATEMENT OF THE PROBLEM

“A comparative study to assess the level of stress among primiparas who have undergone caesarean section versus normal vaginal delivery at selected hospitals, Bangalore, with a view to develop an informational booklet on stress management.” 

OBJECTIVES OF THE STUDY

1. To assess the level of stress among primiparas, undergone caesarean section and normal Vaginal delivery.

2. To compare the level of stress between primiparas with caesarean section and with normal vaginal delivery.

3. To find the association between stress of primiparas with caesarean section and normal vaginal delivery with selected demographic variables.

HYPOTHESES:

H1: There is a significant difference in the level of stress of women who had Caesarean Section with that of women who had normal vaginal delivery.

H2: There is a significant association between the level of stress of women with caesarean Section and normal vaginal delivery with selected demographic variables.

METHODOLOGY:

1. RESEARCH APPROACH

The research approach tells the basic procedure for conducting the research study. In the present study, a descriptive survey research approach was considered to be the most appropriate and adopted to assess the level of stress among primiparas who have undergone caesarean section versus normal vaginal delivery, with a view to develop an informational booklet on stress management.

2. RESEARCH DESIGN

Research design incorporates the most important methodological decisions that a researcher makes in conducting a research study. The research design selected for the present study was comparative descriptive research design in which pre-test only was conducted.

3. SETTING OF THE STUDY

The study was conducted in postnatal ward and postoperative ward of Kempegowda Institute of Medical Sciences, Hospital and Research Centre, Bangalore. 

i. Population

Population in the study consists of primiparas undergone normal delivery or caesarean section in Kempegowda Institute of Medical Sciences, Hospital and Research Centre, Bangalore.

ii. Sample Size and Sampling Technique

The sample size for the present study is 60 primiparas undergone normal delivery or caesarean section (30 normal vaginal delivery and 30 caesarean delivery) in Kempegowda Institute of Medical Sciences, Hospital and Research Centre, Bangalore. Purposive sampling was considered as appropriate for the study.

RESULTS:

Overall percentage of stress score among primiparas undergone normal vaginal delivery and caesarean section 

Figure 1: depicts that the mean stress level of primiparas of normal vaginal delivery participants was 52.1, the mean percentage was (28.94%) with standard deviation of 24.75. The mean stress level of caesarean delivery was 66.30, the mean percentage was (36.83%) with standard deviation of 26.95.

Aspectwise comparison of mean stress score among primiparas undergone normal vaginal delivery and caesarean section.

Figure 2: depicts that the mean stress level of primiparas of normal delivery participants in the aspect wise analysis the mean stress level 22.80 was high on emotional factors with mean percentage 30.4% and standard deviation 13.15 and least stress level was 0.3 on sex of the baby with mean percentage 3.33% and standard deviation 1.31. The mean stress level of primiparas of caesarean delivery participants in the aspect wise analysis the mean stress level 27.6 was high on emotional factors with mean percentage 36.8% and standard deviation 13.41 and least mean stress level was 0.26 on sex of the baby with mean percentage 2.88% and standard deviation 0.82. 

Table 1: depicts that the majority 60% in normal delivery had low level of stress, 33.33% had normal level of stress and remaining 6.66% had moderate level of stress. In caesarean delivery majority 63.33% had low level of stress, 23.33% had normal level of stress and 13.33% had moderate level of stress.

Table 2: depicts that the mean stress level of caesarean delivery participants was 66.30 with standard deviation 26.95 was high when compared to mean stress level of normal delivery participants 52.1 with standard deviation 24.75. Hence the ‘t’value 2.12 was significant at 5% level.

Table 3: depicts that aspect wise normal vaginal delivery and caesarean delivery mean stress scores of respondents. The caesarean delivery mean stress score was found to be higher (66.30 and SD of 26.95) when compared with normal vaginal delivery mean stress score value (52.1 and SD of 24.75)

Note: 1. The responses of some of the demographic variables have been merged as the expected frequencies was less than or equal to 5.

2. Fisher’s exact probabilities are computed in a 2 x 2 contingency tables where ever the expected cell frequencies are less than or equal to 5.

3. Not significant (P>0.05); Significant (P≤ 0.05)

Table –5 depicts that with regard to primiparas undergone caesarean delivery there is no significant association between the stress level and demographic variables such as age, age at marriage, religion , type of family, area of residence , educational status , occupation, monthly income, dietary pattern, and sex of the baby.

Nursing Practice.

Stress is a common problem where each mother experience during pregnancy, child birth and postpartum period which remit on care of baby and self. Nurses plays very important role in assisting primiparas in breast feeding, caring new born, preparing for maternal role and other demands. And also relinquish coping strategies can be the better application in practice.

The findings of the study indicate that all health team should be made aware of the need of observing, supervising, teaching and improving the knowledge of primiparas undergone normal vaginal delivery or caesarean section on stress management.

Nursing Education.

Nursing education emphasizes that health care system should pay more attention on training the students so that the nurses themselves will become more knowledgeable and can be their own selves as well as to the others by imparting knowledge by using various methods of educational technology.

 Planned health education programme by health professionals should be made on ongoing process in the outpatient departments, maternity wards and in the community settings.

Nursing Administration.

Institutions providing maternity services should review their policies and practices regarding postnatal care. They should develop policies, guidelines, for mothers. Nursing administrator should necessarily involved in formulating policies for health education in hospitals as well as in the community settings.

Nursing Research.

The findings of the study serve as a basis for the professional and the student nurses to conduct further studies on stress management. The study will motivate the initial researchers to conduct the same study on large scale, and the study will be a reference for the research scholars.

Limitations:

1. The study is limited to primiparas who have undergone normal vaginal delivery and caesarean delivery.

2. Assessment of the level of stress is based on responses to items used in scale. 

Recommendations.

1. Similar study may be replicated on a large sample

2. A comparative study may be conducted between multiparas undergone normal vaginal delivery and caesarean delivery.

3. A comparative study may be conducted between primiparas and multiparas.

4. A study to assess the level of stress and coping strategies among primiparas.

5. A study to assess the level of stress and coping strategies among multiparas