OF BREAST ENGORGEMENT AND BREAST FEEDING AMONG POSTNATAL MOTHERS

A STUDY TO EVALUATE THE EFFECTIVENESS OF REVERSE PRESSURE SOFTENING TECHNIQUE ON THE LEVEL

OF BREAST ENGORGEMENT AND BREAST FEEDING AMONG POSTNATAL MOTHERS

IN SELECTED HOSPITALS AT RANCHI.

COIMBATORE

A DISSERTATION SUBMITTED TO THE TAMILNADU DR. M.G.R MEDICAL UNIVERSITY, CHENNAI, IN PARTIAL FULFILLMENT

OF REQUIREMENT FOR THE DEGREE OF

OCTOBER 2019

A STUDY TO EVALUATE THE EFFECTIVENESS OF REVERSE PRESSURE SOFTENING TECHNIQUE ON THE LEVEL

OF BREAST ENGORGEMENT AND BREAST FEEDING AMONG POSTNATAL MOTHERS

IN SELECTED HOSPITALS AT RANCHI.

BY

TRS. ANANTHAVARSHENI

A DISSERTATION SUBMITTED TO THE TAMILNADU DR. M.G.R MEDICAL UNIVERSITY, CHENNAI, IN PARTIAL FULFILLMENT

OF REQUIREMENT FOR THE DEGREE OF

OCTOBER 2019

Nursing Degree Course under my guidance and supervision during the academic year October 2019.

NAME AND SIGNATURE OF THE GUIDE: _______________________________________

NAME AND SIGNATURE OF THE HOD : ________________________________________

NAME AND SIGNATURE OF THE DEAN/ PRINCIPAL : _____________________________

CERTIFIED THAT THIS IS THE BONAFIDE WORK OF

ANNAI MEENAKSHI COLLEGE OF NURSING, COIMBATORE, TAMILNADU.

SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING TO

THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY, CHENNAI.

COLLEGE SEAL:

PROF. Mrs. M. MUMTAZ, M.Sc.,(N)., MBA(HM).,M. Phil., PRINCIPAL,

ANNAI MEENAKSHI COLLEGE OF NURSING, COIMBATORE, TAMILNADU.

A STUDY TO EVALUATE THE EFFECTIVENESS OF REVERSE PRESSURE SOFTENING TECHNIQUE ON THE LEVEL OF BREAST ENGORGEMENT AND BREAST FEEDING AMONG POSTNATAL MOTHERS IN SELECTED

HOSPITALS AT RANCHI.

APPROVED BY THE DISSERTATION COMMITTEE ON...

RESEARCH GUIDE ……...………...…….

DR. S. SELVAKUMARI, M.A., M.Phil., Ph. d., PROFESSOR IN RESEARCH METHODS,

ANNAI MEENAKSHI COLLEGE OF NURSING, COIMBATORE.CLINICAL

GUIDE ……….

PROF.MRS. MUMTAZ, M.Sc.,(N)., MBA(HM)., M. Phil, PRINCIPAL,

ANNAI MEENAKSHI COLLEGE OF NURSING, COIMBATORE.

MEDICAL EXPERT ………

DR. A. RAJINI, M.B.B.S.,DGO., CONSULTANT GYNAECOLOGIST,

SHREE MEENAKSHI HOSPITAL,COIMBATORE.

A DISSERTATION SUBMITTED TO THE TAMILNADU DR.M.G.R.MEDICAL UNIVERSITY, CHENNAI, IN PARTIAL FULFILLMENT OF REQUIREMENT FOR

THE DEGREE OF MASTER OF SCIENCE IN NURSING OCTOBER - 2019

VIVA VOICE:

1. INTERNAL EXAMINER...

2. EXTERNAL EXAMINER...

DEDICATION

I dedicate this book to my parents for raising me to believe that anything was possible

And

To my husband for his patience, his advice and his faith on me .

ACKNOWLEDGEMENT

A journey is easier when we travel together. This dissertation is the result of unbound immeasurable contribution and support from many people. It is pleasure that, I have the opportunity to express my gratitude to all of them.

I praise and thank the Lord Almighty for his blessings, guidance and support throughout this research and enabling me to complete me research successfully.

I express my sincere thanks to Mr. A. KARUPPAIAH, D. Pharm, Correspondent of Annai Meenakshi College of Nursing, for having given me an opportunity to do this thesis successfully and provided the required facilities for successful completion of this study.

I am extremely grateful to Prof. M. MUMTAZ, M.Sc.,(N)., MBA(HM).,M. Phil., PRINCIPAL and Clinical Guide, Annai Meenakshi College of Nursing for her endless efforts, valuable guidance, constructive suggestions, and helped me to tide over the hardships encountered during the research.

I express my hearty gratitude to my Research Guide DR. S. SELVAKUMARI, M.A., M.Phil., Ph.d., for her intense encouragement, valuable suggestion and guidance.

I acknowledge my sincere gratitude and heartfelt thanks to my Medical guide DR. A.

RAJINI, M.B.B.S.,DGO., whose excellent guidance and expert suggestions that made the study purposeful.

I deeply express my sincere thanks to Dr. SUSHMA PRIYA, Consultant Gynaecologist, Hill View Hospital and Research Centre, Ranchi for granting permission for the study and her impressive suggestions and timely help extended for this research.

I extend my deepest gratitude to Dr. AKHOURI TRIPTI PRAKASH, M.B.B.S., DGO., Seventh Day Adventist Hospital, Ranchi for granting me permission to conduct the research study in the villages coming under her authority.

I am very grateful to Mrs. KOGILA.K, M.Sc (N), Reader, Obstetrics and Gynaecology Department, for her motivation and guidance throughout the study.

I extend my sincere thanks to our Class Co-ordinator Mrs. UDHAYA JAYANTHI, M.Sc(N)., M.Sc(Psychology)., Assistant Professor for her illuminating comments, intuitiveness, patience, and untiring interest shown throughout the study.

I express my sincere thanks to Statistician Dr. ANNASAMY, Ph.D., for his directions suggestion and guidance that helped me in the proper statistical method of application.

I would like to acknowledge my immense help and timely support by Mrs.SULOCHANA, M.Com., M.L.I.Sc, Librarian for her help in collection of literature needed for the study.

I specially thank all the Experts who validated the research tool for their valuable suggestion and constructive comments.

My Special thanks to M/S. Sify i way, Sundarapuram, for computing the manuscript clearly and effectively within short span of time.

I honestly thank my parents, family members, all my dear friends and well- wishers for their prayers, and blessings which helped to complete the study successfully.

My sincere thanks and gratitude to all M.Sc(N) Faculty, and non-teaching staffs of Annai Meenakshi College of Nursing and those who directly (or) indirectly helped to complete this dissertation.

ABSTRACT

INTRODUCTION

Breastfeeding remains the simplest, healthiest and least expensive feeding method that fulfils the baby’s needs. Approximately two days after giving birth the women’s breasts fill with milk, which is a normal process. This makes the breast heavy and swollen but under normal circumstances this should not be painful and hard. Breast engorgement develops in 72% to 85%

in postnatal mothers. It is a painful, unpleasant condition affecting large number of mothers during the early postpartum. During this time when mothers are coping with demands of the baby it may be particularly distressing. Breast engorgement quenches the development of successful breast feeding, leading to early breastfeeding cessation and is associated with more serious illness including breast infection.

STATEMENT OF THE PROBLEM

A study to evaluate the effectiveness of Reverse Pressure Softening Technique on level of Breast engorgement and breast feeding among Postnatal mothers in selected hospitals at Ranchi.

OBJECTIVES OF THE STUDY

1. To assess the level of breast engorgement among the postnatal mothers in experimental and control group.

2. To assess the level of breast feeding among the postnatal mothers in experimental group and control group.

3. To evaluate the effectiveness of reverse pressure softening technique on level of breast engorgement among postnatal mothers in experimental and control group.

4. To evaluate the effectiveness of reverse pressure softening technique on level of breast feeding among postnatal mothers in experimental and control group.

5. To examine the association between level of breast engorgement among postnatal mothers with their selected demographic variables in experimental group and control group.

HYPOTHESES

 H1 : There will be a significant difference between mean pre and post test level of breast engorgement of post natal mothers in experimental and control group.

 H2: There will be a significant difference between mean pre and post test level of breast feeding among postnatal mothers in experimental and control group .

 H3: There will be a significant difference in the post test level of breast engorgement among postnatal mothers in experimental and control group.

 H₄: There will be a significant difference in the post test level of breast feeding among postnatal mothers in experimental and control group.

 H₅: There will be a significant association between level of breast engorgement among postnatal mothers with their selected demographic variables in experimental group and control group.

METHODOLOGY

The conceptual frame work used in this study was Ernestine Wiedenbach‘s helping art of Clinical Nursing. A Quantitative Evaluative approach using Quasi-Experimental -Pre-test – Post-test control group design was used. The study was conducted at two selected hospitals, Ranchi. Non- Probability Sampling technique was used to select 50 postnatal mothers, as 25 for experimental group and 25 for control group. The intervention, Reverse Pressure Softening Technique was given to experimental group. The intervention was given thrice a day for three days, 2nd to 4th postnatal day, for a duration of 30 seconds per intervention. The control group did not receive any intervention. The pre-test and post-test was done by using the standardized Six-Point breast Engorgement Scale and LATCHES Breast Assessment Tool was used to assess the level of breast engorgement and breastfeeding among postnatal mothers.

RESULT

The collected data were analyzed by using both descriptive and inferential statistical methods. Unpaired ‘t’ test was used to was to evaluate the effectiveness of reverse pressure softening technique on level of breast engorgement and breast feeding among postnatal mothers in experimental group and control group. The obtained post-test ‘t’ value 26.93 on level of breast engorgement and 3.22 on level of breastfeeding was significant at p< 0.05 level.

CONCLUSION

The findings of the study revealed that there was a significant difference in the post test level of breast engorgement and breast feeding among postnatal mothers in experimental and control group. The study concluded that Reverse Pressure Softening (RPS) technique is effective

in reducing the level of breast engorgement and improving breast feeding among postnatal mothers.

Key words: Evaluate, Effectiveness, Reverse Pressure Softening Technique, Postnatal mothers, Breast Engorgement, Breastfeeding.

TABLE OF CONTENTS

NO.

CONTENTS PAGE NO

I

II

INTRODUCTION

 Back ground of the study

 Need for the Study

 Statement of the Problem

 Objectives of the Study

 Operational Definitions

 Hypotheses

 Assumptions

 Delimitations

 Projected Outcomes REVIEW OF LITERATURE

 Studies related to prevalence of breast engorgement among postnatal mothers.

 Studies related to management of breast

engorgement and breast feeding among postnatal mothers.

 Studies related to effectiveness of reverse pressure softening technique on breast engorgement.

CONCEPTUAL FRAME WORK

1 1 6 10 10 11 12 12 13 13 14 15

19

24

29

CHAPTER NO.

CONTENTS PAGE NO

III METHODOLOGY

 Research Approach

 Research Design

 Variables

 Setting of the Study

 Population of the Study

 Sample

 Sample Size

 Sampling Technique

 Criteria for Sample Selection

 Inclusion Criteria

 Exclusion Criteria

 Development of the Tool

 Scoring Procedure

 Validity and Reliability

 Pilot Study

 Data Collection Procedure

 Plan for Data Analysis

 Protection of Human Right

35 35 35 37 37 38 38 38 38 39 39 39 39 40 41 42 43 44 45

CHAPTER NO.

CONTENTS PAGE NO.

IV

V

VI

DATA ANALYSIS AND INTERPRETATION

DISCUSSIONS

SUMMARY, CONCLUSION AND RECOMMENDATIONS

 Summary of the study

 Major Study Findings

 Conclusion

 Implications of the Study

 Nursing Practice

 Nursing Education

 Nursing Administration

 Nursing Research

 Limitations

 Recommendations

REFERENCES APPENDICES

47

78

85

85 86 87 88 88 88 88 89 89 89

LIST OF TABLES TABLE

No.

TITLE

PAGE No.

1.

2.1

2.2

2.3

3.1

3.2

3.3

Frequency and Percentage Distribution of Postnatal Mothers in relation to their Demographic Variables

Frequency and Percentage Distribution Level of Breast Engorgement among postnatal mothers in experimental group and control group.

Mean, Standard deviation, Mean Difference and ‘t’ value of pre-test and post-level of breast engorgement of experimental group and control group.

Pre-test and Post-test overall Mean Score of Breast Engorgement and Standard deviation of experimental and control group day wise and level of significance

Frequency and Percentage Distribution of Level of Breastfeeding among postnatal mothers in experimental group and control group.

Mean, Standard deviation, Mean Difference and ‘t’ value of pre-test and post-level of breastfeeding of experimental group and control group.

Pre-test and Post-test overall Mean Score of Breastfeeding and Standard deviation of experimental and control group day wise and level of significance

49

53

56

58

60

63

66

4.1

4.2

5.1

5.2

Mean, Standard deviation, Mean Difference and ‘t’ value of post-test level of breast engorgement among postnatal mothers of experimental group and control group.

Mean, Standard deviation, Mean Difference and ‘t’ value of post-test level of breastfeeding among postnatal mothers of experimental group and control group.

Frequency, Percentage and χ² distribution on level of breast engorgement among postnatal mothers in experimental group with their demographic variables.

Frequency, Percentage and χ² distribution on level of breast engorgement among postnatal mothers in control group with their demographic variables.

68

69

70

74

LIST OF FIGURES

NO. TITLE PAGE

NO.

1

Conceptual Frame Work Based Modified Ernestine Wiedenbach’s

Helping Art of Clinical Nursing theory (1964) ³⁴ 2 The Schematic Representation of Research Methodology 46

3

Frequency and Percentage Distribution of Level of Breast

Engorgement among postnatal mothers in experimental group and

control group. ⁵⁵

4 Mean value of pre-test and post-level of breast engorgement of

experimental group and control group ₅₇

5 Frequency and Percentage Distribution of Level of Breastfeeding

among postnatal mothers in experimental group and control group. ₆₂

6 Mean value of pre-test and post-level of breastfeeding of

experimental group and control group ₆₅

LIST OF APPENDICES

APPENDIX TITLE

A B C D E F G H

I J K L

Letter Seeking and Granting Permission to Conduct Study.

Letter Requesting the Opinion of Experts on Content Validity of the Tool.

List of Experts Consulted for Content Validity.

Structured Interview Questionnaire (English) Structured Interview Questionnaire (Hindi) Scoring Key

Evaluation Criteria Rating Scale for Validation of Tool.

Evaluation Criteria checklist for validation of Reverse Pressure Softening Technique on breast engorgement and breastfeeding among Postnatal mothers.

Certificate for validation

Consent Form of Subjects for Participation in the Study Reverse Pressure Softening Technique – Procedure Certificate of plagiarism

1

CHAPTER I

INTRODUCTION

“Breastfeeding is an instinctual and natural act but it is also an art that is learned day by day. The reality is that almost all women can breastfeed, have enough milk for their babies and learn how to overcome problems both large and small. It is almost always simply a matter of practical knowledge and not a question of good luck.”

- La Leche League.

BACKGROUND OF THE STUDY

Breast milk is always fresh, perfectly clean, just has the right temperature and is a healthy choice at the minimum cost. Breast milk is the best food for babies as breastfed babies are healthier than formula fed babies(Chopra 2006).

The benefits of breast feeding extend well beyond basic nutrition. In addition to vitamins and nutrients, the breast milk is packed with disease-fighting substances that protect the baby from illness (American Academics of Pediatrics).

Breastfeeding has also been associated with cognitive development, preventing obesity and Insulin dependent Diabetes Mellitus (Leung 2005). It therefore lowers the rate of illness and hospital admission among newborns. Numerous studies from around the world have shown that stomach viruses, lower respiratory illnesses, ear infections, and meningitis occur less often in breastfed babies and are less severe when they get it. Children who are breastfed have 20 per cent lower risk of dying between the ages of 28 days and 1 year than children who weren't breastfed (National Institute of Environmental Health Sciences).

2

Breastfeeding results in decreased medical problems. WHO recommends that, in all parts of the world, babies should be breastfed for the first six months ―to

achieve optimal growth, development and healthy (WHO 2003) , giving the strong evidence of the benefits of breastfeeding for women and babies. In recognition of the importance of breastfeeding, the Baby-Friendly Hospital Initiative was launched by UNICEF/WHO in 1991 (Schubiger 1997). Other Cochrane reviews examine 15 interventions to promote breastfeeding and to support breastfeeding mothers (Britton 2007; Dyson2008).

.

According to NFHS surveys, only about a fourth of women (27%) initiate breast feeding within one hour after delivery. More than half of the women (57%) give pre-lacteals to their new born. All National surveys (surveys done by National Nutrition Monitoring Bureau 1, National Family Health Surveys 2 and District Level Household Surveys 3) have shown that in India, steps taken for the protection and promotion of breast-feeding from the 1970’s have been effective.

The art of breast feeding is something the mother learns by doing and gets easier with practice. The foremost thing is to establish proper breast feeding techniques. Correct breast feeding technique is identified to be important to ensure successful breast feeding as incorrect technique might contribute to breast engorgement. It is also important for the baby to latch on the breast correct so that it can suck effectively. Positioning the baby on the breast is very important to help establish breast feeding and prevent sore nipple. Whatever hold is used, mother should make sure that the baby's body is close to the mother, chest to chest, chin to breast and nose away from the breast (Australian Breastfeeding Association).

3

Approximately two days after giving birth the women’s breasts fill with milk, which is a normal process. This makes the breast heavy and swollen but under normal circumstances this should not be painful and hard. Breast engorgement develops in 72% to 85% in primipara postnatal mothers. It is a painful, unpleasant condition affecting large number of mothers during the early postpartum. During this time when mothers are coping with demands of the baby it may be particularly distressing.

Breast engorgement quenches the development of successful breast feeding, leading to early breastfeeding cessation and is associated with more serious illness including breast infection.

Breast engorgement is associated with hard painful throbbing aching and tender breasts and the related distress may make the women initiating breastfeeding not to be continued beyond the first few days after the childbirth. The National Family Health Survey (NFHS) has pointed out that painful breast is the second most common reason for giving up breast feeding in the first two weeks after birth in India.

Whether breastfeeding problems begin in the hospital or months later, they can be the source of great stress and threaten long-term breastfeeding. Most problems that cause women to discontinue breastfeeding before they had wanted arise within the first few weeks, but a breastfeeding complaint can present at any point in the course of lactation. The surprising and disappointing truth is that lactation problems do occur, even among women with the best of intentions and the highest motivation to succeed at breastfeeding. Sometimes problems involve the mother's breasts and nipples or relate to her overall health. At other times, breastfeeding problems involve the baby or impact the baby's well-being. Some problems are due to circumstances

4

beyond our control, while others are the direct result of lack of knowledge or lack of confidence, improper technique, or bad advice.

Breast engorgement is found equally evident in both normal delivery and caesarean section mothers. In caesarean section mothers, the incidence of breast engorgement is much greater than in the normal delivery as after caesarean section it can be tempting not to feed the baby overnight. Breast feeding after caesarean section is also testified to be difficult by many because of inappropriate positions adopted for establishing breast feeding.

All over the world the incidence rate of breast engorgement is 1:8000 and in India it is 1:6500. In India, 33% of women experiences breast problems in first 2 weeks of postpartum and 28% experienced in the weeks thereafter. These problems have been pointed out as reasons for failure of lactation and stopping breastfeeding (Somdatta Patra, et al, 2009).

Breast engorgement usually happens within a week of the birth, but can occur later too. Primary engorgement occurs in the first few days after the baby is born but the secondary engorgement occurs later when the mother is not feeding as frequently as she used to (or the baby removes less milk from the breast) (Acarturk 2005). Once engorgement occurs, puffiness around the nipple may make it even more difficult for the baby to latch-on and feed successfully and this may make the engorgement worse.

Breast engorgement if not given importance from early stage can bring many problems not only for the mother but also for the baby. It makes latch on difficult thus

5

making the baby reluctant towards breast feeding.. Breast engorgement develops if the baby isn‘t nursing often enough or vigorously enough or if mother is separated from her baby or do not remove the milk frequently and effectively.

Some of the traditional methods which are identified are wearing supportive bra, applying cold cabbage leaves, hot and cold applications, herbal compress, Gua Sha scraping therapy, acupuncture, and also other practices such as use of glycerine gel dressings, breast shells with lanolin. Reverse pressure Softening (RPS) technique is a way to soften the areola. It was developed by Jean Cottermen . Reverse pressure softening is helpful during the first weeks to help attachment problems or breast engorgement. It help attaching the baby and express milk easier.

6 NEED FOR THE STUDY

“A newborn baby has only three demands. They are warmth in the arms of its mother, food from her breasts and security in the knowledge of her presence.

Breastfeeding satisfies all three.”

-Grantly Dick Read . “Breast Milk is Nature’s Protection for the Baby”. One million infant lives can be saved by just breast feeding in the first hour following the birth of the child. If mothers and families comprehend the benefits of breast feeding for six months, it can save the life of 250,000 babies annually.

The incidence rate of breast engorgement throughout the world is 1:8000 and in India it is 1:6500. Signs and symptoms occur most commonly between days three and five (International Journal of Current Medical and Pharmaceutical Research, 2017). The chief editor of “The Nursing Journal of India” in her key address on the occasion of the Breastfeeding Week-2008 says lactating mothers face multifaceted limitations and difficulties in breastfeeding. They need support from various aspects– family, society, work place and government. The most often stated cause for cessation of breastfeeding in the first two weeks of postpartum is pain, which may be the result of breast engorgement.

K Iyengar ( 2012) conducted a community-based study on early postpartum maternal morbidity among rural women in Rajasthan. An intervention on postpartum care for women within the first week after delivery was initiated in a rural area of Rajasthan, India.

7

A total of 4,975 women, representing 87.1% of all expected deliveries in a population of 58,000, were examined in their first postpartum week during January 2007–December 2010. The most common morbidity was postpartum anaemia—7.4%

of women suffered from severe anaemia and 46% from moderate anaemia. Other common morbidities were fever (4%), breast conditions (4.9%), and perineal conditions (4.5%). Data on the initiation of feeding, feeding duration, rate of milk maturation and supplementation were obtained from 54 women. These variables were found to be significantly correlated with breast engorgement. The study concluded that it is essential that health programmes make investments to provide postpartum care to all women starting from the first week so that these conditions can be detected and managed in time.

A descriptive study was conducted to identify the concerns of breastfeeding mothers during the first 20 weeks postpartum. The study concluded that proportion of mothers expressing concerns decreased over time, but some concerns such as breast engorgement & nipple tenderness persisted over the 20 weeks. Engorgement is a well known but poorly researched aspect.

Breast engorgement usually develops when the breast switch off from colostrums to mature milk. When the milk oozes out for the first time swelling of breast tissue occurs due to flooding of lymph fluid and blood. As milk production increases over-distension of the alveoli causes the milk secreting cells to become flattened and occlude the capillary blood circulation surrounding the alveolar cells.

Congestion contributes to edema and obstructs lymphatic drainage of the breasts, stagnating the system that rid the breasts of toxins and bacteria leading to mastitis.

8

In very severe cases the pressure on the nerves due to edema extending to axilla can cause tingling of hands and numbness. In addition a protein called Feedback Inhibitor of Lactation accumulates in the mammary gland during milk stasis. It acts as a major trigger of apoptosis that causes the involution of the milk- secreting glands collapse of the alveolar structures and the cessation of milk production.

Up to one-third of the mother who experience the complications such as infection mastitis, abscess which had resulted from inappropriate management of engorgement, may change to alternate methods of infant nutrition within the first six weeks of postpartum. Existing Global and Indian data show that breastfeeding promotes infant survival and growth protects the infant against infections and at the same time the mother also get natural protection from next pregnancy.

Few mothers experience severe engorgement around the time their 'milk comes in'. In these situations, it is important to ensure that the baby is attaching well and feeding effectively, and that the length and frequency of feeds are being determined by the baby's needs.

Whitley N , conducted a retrospective survey of 4 breastfeeding mothers.

From the data the following recommendations were suggested for further study- preparation for breastfeeding with longer duration of nursing and breast massage , manual expression of colostrums during breast feeding will prevent sore nipple and postnatal breast engorgement.

9

Breast feeding techniques is very important for successful breast feeding. As incorrect technique may contribute to breast engorgement. Numerous strategies have been adopted over the ages in treatment of breast engorgement. Hot and cold application reduces pain and engorgement as it causes relaxation of blood vessels.

The researcher had seen many mothers who are suffering with breast engorgement, mastitis and breast abscess during post natal period. Because of breast engorgement the baby will not receive adequate milk, the breast may not empty completely and the nipples may become sore and cracked thus indirectly affects the newborn. The nurse should be aware of non-pharmacological measures for the effective management of engorged breast and the complications so that to some extend can reduce the suffering of mothers.

In this view the researcher felt that it is necessary to carry out an individualized postnatal care which is not harmful and it can be easily carried out by the caregiver or by the mother herself. This motivated the researcher to use a massage technique “Reverse Pressure Softening (RPS)” for relieving breast engorgement.

Interstitial fluid volume increases 30% above normal before edema becomes visible.(Guyton) To contain edema, areola tissues must expand, limiting their ability to extend the nipple well into the baby’s mouth. Early proactive use of RPS causes no harm and may facilitate increased milk transfer, reduce risk of nipple trauma, and help resolve engorgement. Reverse pressure softening(RPS) is a simple intervention that has proven very helpful in the first 14 days postpartum. RPS uses gentle positive pressure to soften a 12 inch area of the areola surrounding the base of the nipple,

10

temporarily moving some swelling slightly backward and upward into the breast.RPS is best performed immediately before each attempt to latch, for as many feedings as needed.

As Reverse pressure softening technique can give tremendous relief from breast engorgement which also improves breastfeeding and help baby get more milk, the researcher felt the need and selected this technique as intervention for the study.

STATEMENT OF THE PROBLEM

A study to evaluate the effectiveness of Reverse Pressure Softening Technique on level of Breast engorgement and breast feeding among Postnatal mothers in selected hospitals at Ranchi.

OBJECTIVES OF THE STUDY

1. To assess the level of breast engorgement among the postnatal mothers in experimental and control group.

2. To assess the level of breast feeding among the postnatal mothers in experimental group and control group.

3. To evaluate the effectiveness of reverse pressure softening technique on level of breast engorgement among postnatal mothers in experimental and control group.

4. To evaluate the effectiveness of reverse pressure softening technique on level of breast feeding among postnatal mothers in experimental and control group.

11

5. To examine the association between level of breast engorgement among postnatal mothers with their selected demographic variables in experimental group and control group.

OPERATIONAL DEFINITIONS Effectiveness

It means the ability to be successful and produce the indented results.

It refers to the reduction in tenderness, hardness and pain experienced by postnatal mothers on their breasts and improving the mothers comfort and breast feeding.

Breast engorgement

It means the breasts are painfully overfull of milk.

Here it refers to the painful overfilling of the breasts with milk which results with inappropriate emptying of milk and is evidenced by hard tender breasts. It is measured using a 6 point breast engorgement scale.

Postnatal mothers

It refers to the mothers after giving birth.

In this study it refers to the mothers who have undergone Caesarean section, for a period of 2 – 4 post-operative days.

Reverse Pressure Softening Technique (RPS)

It is a technique to soften areola when breasts become difficult to latch because of breast fullness.

12

In this study it is a done by applying gentle pressure using finger pads towards the chest wall, to about 1-2 inches of areola(area surrounding the base of the nipple) lateral, upper and lower aspects, for 10 seconds each. It is done to soften the areola and to improve latching and to reduce breast engorgement.

Hypotheses

H₁ : There will be a significant difference between mean pre and post test level of breast engorgement of post natal mothers in experimental and control group.

H₂: There will be a significant difference between mean pre and post test level of breast feeding among postnatal mothers in experimental and control group .

H3: There will be a significant difference in the post test level of breast engorgement among postnatal mothers in experimental and control group.

H4: There will be a significant difference in the post test level of breast feeding among postnatal mothers in experimental and control group.

H5: There will be a significant association between level of breast engorgement among postnatal mothers with their selected demographic variables in experimental group and control group.

ASSUMPTIONS

 Breast engorgement is one of the common problems among the postnatal mothers who delivered through Caesarean section.

 Breast engorgement results in pain and decreases the feed intake of the newborn.

 Numerous techniques are available to relieve breast engorgement pain and to improve breast feeding.

13

 Reverse Pressure Softening Technique is a simple intervention that helps the mother by reducing breast engorgement and promote breastfeeding.

DELIMITATIONS

 The study is delimited to 50 samples.

 The duration of the study is delimited to 4 weeks.

 The study is delimited to the postnatal mothers who had undergone caesarean section.

 The study is limited to the postnatal mothers in selected hospitals in Ranchi, Jharkhand.

PROJECTED OUTCOME

 The study findings will help to find best method to relieve breast engorgement and improve breastfeeding.

 The results of the study will provide evidence for effectiveness of the reverse pressure softening technique.

 The study will enable the nurse to teach the technique to the mother to minimize breast engorgement as it doesn‘t result in any side effects and can be easily understood and followed by the mother before each feed.

 The study will motivate nurses and nurse assistants to incorporated Reverse pressure softening technique to the routine hospital postnatal care.

14

CHAPTER – II

REVIEW OF LITERATURE

Literature review is a comprehensive summary of previous research on a topic.

The literature review surveys scholarly articles, books, and other sources relevant to a particular area of research.( LibGuides,2018).

A literature review is a description and analysis of the literature relevant to a particular field or topic. The main purpose of literature review is to convey the readers about the work already done and the knowledge and ideas that have been already established on a particular topic of research.

This chapter deals with information collected in relation to the current study through published and unpublished materials which provided the base to carry out this study.

The literatures which are found relevant and useful for the present study have been organized under the following headings.

 Studies related to prevalence of breast engorgement among postnatal mothers.

 Studies related to management of breast engorgement and breast feeding among postnatal mothers.

 Studies related to effectiveness of reverse pressure softening technique on breast engorgement.

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STUDIES RELATED TO PREVALENCE OF BREAST ENGORGEMENT AMONG POSTNATAL MOTHERS.

A Study of breastfeeding practices and problems among postnatal mothers by Pooja J. Mise.et., (2017) in Katnataka.112 lactating mothers were included in the study. Majority of subjects 86 (76.7%) were in the age group 21- 30 years. About 43 (38.4%) lactating mother initiated breast feeding practices within 1 hour after the delivery. 63.4% of the infants received exclusive breast feeding. Lactation failure 40% and unsatisfactory growth of baby 50% were the main reasons for early weaning.

Most common cause of delay in initiation in breast were caesarian section and delivery complication (53.12% and 21.88% respectively) Only 27 (24.1%) babies were given pre-lacteal feed.

Dowson,E.K(2014) conducted a cross sectional study to find out the prevalence of breast engorgement and breast feeding among postnatal mothers and reported that breast engorgement is caused by an imbalance between milk supply and infant demand. It often occurs in women who decide not to breastfeed. Breast engorgement can occur due to four main factors such as a suddenly increased milk production that is common during the first days after the baby is delivered or when the baby suddenly stops breastfeeding either because it is starting to eat solid foods or it is ill and has a poor appetite.

Sharron S. Humenick (2012) conducted a study on breast engorgement, patterns and selected outcomes under School of Nursing at the University of Wyoming, Laramie, Wyoming. For 14 days following birth, 114 breastfeeding mothers rated their level of breast engorgement twice daily, using a six-point breast

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engorgement scale. Individual engorgement ratings were plotted by intensity over time to provide a visual display of each subject's breast engorgement experience. The common problems reported by all the mothers were pain (53%), discomfort (62%) and difficulty in feeding (42%).

M D Philip (2010) has done a longitudinal cohort study on the breastfeeding practices and related problems among 327 rural women in Jammu and Kashmir. Data was obtained using an observational checklist and the data revealed that about one- quarter of mothers had lactation problems. The study showed that 28.4% had initial suckling problems, 8.6% had sore nipple, 8.6% had engorgement, 9.8% had mastitis and abscess, 4.9% had less milk and 3.7% had no milk.

Moon J, Humenick SS (2008) Conducted a descriptive study on “Breast Engorgement Patterns and Selected Outcomes”, for 14 days following birth, 114 breastfeeding mothers rated their level of breast engorgement twice daily, using a six point engorgement scale. Engorgement ratings are plotted by intensity over time to 21 provide a visual display of each subject's breast engorgement experience. They concluded that four distinct patterns of breast engorgement emerged; mothers experienced either a bell-shaped pattern, a multi-modal pattern, a pattern of intense engorgement, or a pattern of minimal engorgement.

Evans et al., (2008) conducted “retrospective study to find the reason for breast engorgement” researcher selected 100 samples by the convenience sampling technique in Ireland. Study concluded that poor attachment leading to milk stasis and engorgement might be more likely to occur on the side that was more difficult to feed.

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It shows the frequency of breast engorgement in left or right breast has no significant difference was observed. 37 % - 52 % of case involves engorgement in the right breast and 38 % - 52 % of case involvesengorgement in the left breast and 3 % - 12 % of cases involve bilateral engorgement.

Mallikarkuna (2008) conducted “a descriptive study on breast feeding problems in the first six months of life in rural Karnataka” Total sample of 420mothers selected by interview method. Study showed that onset of breast feeding problem occurred in 31.7 % of women during first month of life, 76.9 % in the first week, 7.7 % in second week, 15.4 % in third week, insufficient milk was reported by53.6 % while 23.1 % had problems like sore nipple, mastitis and engorgement.

Ksenia Bystrova et al (2007) conducted a randomized trial study in St Petersburg to evaluate the occurrence of breast engorgement during the first 3 days of postpartum. 176 mother-infant pairs were randomised into four groups. Data were recorded in the delivery ward at 25–120 minutes postpartum and later in the maternity ward. The study results showed that there was no difference in milk production between multiparous and primiparous mothers although multiparas had higher numbers of feedings than primiparas mothers. In addition during the first three days of postpartum, multiparous mothers had higher perception of physiological breast engorgement and lower intensity of feeling "low/blue" than primiparous mothers.

Quintella Aurea Rosa Fernandes (2006) conducted an exploratory descriptive study using quantitative approach in a private hospital, which treats patients of different covenants, located in a municipality in the state of Sao Paulo. The

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purpose of this study was to investigate the difficulties of the breastfeeding mothers.

The study population consisted of 64 women who gave birth to their babies in the institution, in the year, October 2003, regardless of the type of delivery. 64 women were interviewed on the 8th and 9th postpartum period. 92% reported that they had no difficulty in breastfeeding, 61 % had fissure between the 3rd and 4th day and 23%

remained with the problem. Among the mothers interviewed, 19% reported breast engorgement between the 4th and 5th days after delivery.

May kay smith (2003) conducted “a study on breast feeding and breast engorgement” has stated that breast engorgement is associated with materna l discomfort, difficulty with latch on which lead to plugged ducts and mastitis. He also reported that engorgement is most common during first week of breast feeding and occur as a result of delayed, infrequent or interrupted removal of breast milk from the breast. While breast fullness is normal from the second to fourth day after birth, this normal condition is caused by congestion and swelling of breast tissue as blood andother fluids begin to accumulate along with increased milk volume in the alveoli as milk production begins.

Robson, Beverley Anne (2000) conducted a study to assess breast engorgement in breast feeding mothers under Case Western Reserve University, Nursing. Breastfeeding patterns and practices in mothers who developed engorged breasts relative to mothers who did not develop engorged breasts were described. A total of 152 mothers who had Caesarean births participated in the study. Out of these, 88 mothers developed breast engorgement. Pain and discomfort was the most reported

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complaint (100%) by all the postnatal mothers. They too complain of difficulty in feeding their baby and putting the baby to the breast.

Pamela.D.Hill.et.al.(1994) conducted a Study on the occurrence of breast engorgement. This study describes breast engorgement during days 1-14 postpartum of 114 first and second time vaginal- and cesarean-delivery breastfeeding mothers.

Most mothers reported experiencing their most intense engorgement after hospital discharge. Previous breastfeeding experience of the mother is a more critical variable than parity in predicting engorgement. Second time breastfeeding mothers experienced engorgement sooner and more severely than did first time breastfeeding mothers, regardless of delivery method.

STUDIES RELATED TO MANAGEMENT OF BREAST ENGORGEMENT AND BREASTFEEDING AMONG POSTNATAL MOTHERS.

Anandhi R, et.al.(Puducherry, 2017), conducted a Quantitative study using post test control group only design , to compare the lukewarm water compress among postnatal mothers. A total of 226 samples were selected and the experimental group was given lukewarm water compress thrice a day on 3^rd and 4^th post natal day. The study concluded the lukewarm water compress was effective as there was a significant difference between the post test scores of nipple pain (p=0.001**) and breast engorgement (p=0.001**) among the post natal mothers after intervention.

Padmasree S.R. Linda Varghese et.al (Kerala, 2017) conducted a study to evaluate the prevention, recognition and management of breast engorgement. Quasi experimental, Quantitative study using pre- test post- test control group design was

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used. Prenatal teaching was provided to the experimental group. There was a significant increase in the knowledge score in experimental group. Comparing the incidence, 13.3% mothers reported in experimental group whereas 63.3% in the control group showed a remarkable decrease in the incidence of breast engorgement.

Tawheda Mohamed Khalefa El-Saidy , Reda Mohamed-Nabil Aboushady (2016).A Quasi-experimental (equivalent pre-posttest group) research design was adopted. Setting: This study was conducted at postnatal ward and outpatient clinic at El-Manial Maternity hospital, Cairo Governate, Egypt. A total of 90 postnatal mothers assigned 45 in each group. Four tools were used to collect data. More than twenty percent of each group suffered from firm and tender breasts (22.2% & 28.9%). Also, there was a statistically significant difference between the pre and post symptoms of breast engorgement, levels of breast engorgement, pain score, and engorgement score for both groups (p < .05*). The study concluded both the interventions warm compresses versus cold cabbage leaves were effective in relieving pain and reducing breast engorgement.

A quasi experimental study was conducted on, “A Comparison of Cabbage Leaves versus Hot and Cold Compresses in the Treatment of Breast Engorgement in the Post-Natal Ward of the All India Institute of Medical Sciences (AIIMS), New Delhi”. The study was conducted on 60 subjects. They concluded that cold cabbage leaves and hot and cold compress are equally effective in decreasing breast engorgement.

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Lindeka Mangesi et.al(2016) conducted a study related to treatments for breast engorgement during lactation The study concluded hot /cold packs were found to be more effective than acupressure. Gua Sha scraping therapy was found to be more effective than hot packs and massage in reducing symptoms of breast engorgement, though both forms of treatment decreased breast temperature, engorgement, pain and discomfort at five and 30 minutes after treatment.

P. Krishnaveni(2014) conducted a quasi-experimental study to assess the effectiveness of breast massage on reduction of breast engorgement among mothers undergone caesarean section in Tamil Nadu. The study findings concluded that breast massage is effective. Out of 30 caesarean mothers, 26(86.6%) are normal and 4(13.3%) are had mild engorgement, none of them had moderate or severe engorgement in the post test among experimental group.

Stutte,P.C.,G.Y.Morman (2014) conducted an interventional studies on effectiveness of breast massage for breast engorgement. They concluded while nursing Gentle breast compressions and massage during the nursing session can reduce engorgement. After nursing for a few minutes to soften the breast, it may be possible to obtain a better latch by removing baby from the breast and re-latching.

Green D, Moye L, Schreiner RL, Lemons JA.(2012) Conducted a Experimental study on effect of cabbage leaf extract on breast engorgement. By using a double-blind experiment with pre test / posttest design, 21participants received a cream containing cabbage leaf extract, while 18 received placebo cream. The two groups showing no difference on all outcome measures. Thus feeding had a greater

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effect than the application of cream on relieving discomfort and decreasing tissue hardness. It is therefore recommended that lactation consultant encourages mother to breast feeding if possible to relieve the discomfort of breast engorgement.

Kernerman (2010) conducted a study in Australia on the comparison of the breast engorgement relieving effects of two massage manipulations. The objective is to determine the better massage manipulation for relieving parturients‘ breast distention by comparing 2 methods. Before offering the massage, the breast engorgement of 200 women were assessed. Then the effects of two massage manipulation were assessed according to the pre conducted massage. The study 35 adopted a Quasi Experimental design and it concluded that the post massage distention & breast feeding of the parturient in the observation group were better than those of the control group. Thus two breast massage manipulation can reduce the parturient breast distention.

Evans K, Evans R, Simmer K (2009) Conducted an experimental study on the effect of breast massage on the subjective discomfort of mother. The subjects were 35 mothers & midwife measured breast engorgement using visual analogue scale rating from o-10. The breast skin surface temperature measurement was assessed by infrared thermometer after 1 mt ,3mt, and 5mt, after breast massage . They concluded that breast massage is good for blood circulation and is considered to be an effective way to ease the discomfort of breast engorgement.

Katharyn Roberts (2008) conducted “a comparative study to identify the effectiveness of cabbage leaf extract with placebo in treating breast engorgement

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among 39 lactating women in Tumkur”. In this study 21 participants received cream containing cabbage leaf extract and 18 received placebo cream. The study concluded that two groups received equal relief in breast engorgement. Mothers perceived both creams to be equally effective.

Ingelman-Sundberg (2003) conducted “a study to determine the effect of subcutaneous oxytocin versus placebo in treatment of breast engorgement among 45women in portuguese. The participants of the study were randomly selected and they received oxytocin for experimental group and placebo treatment for control. The main outcome of the study was duration of treatment; overall seven out of 45 women still had the symptoms of breast engorgement three days after starting the treatment.

The study concluded that majority of the women in the treatment group had decreased signs and symptoms when compared with the control group.

Relief measures for breast feeding mothers includes carry out breast massage, manual expression and nipple rolling. Nurse the baby every 2- 3 hours without missing any feeding or using any supplements. Use both breasts at each feeding.

Apply warmth to the breast prior to each breast feeding to promote milk flow.

Manually express the milk if there is engorging of the areola to soften the area prior to nursing the baby. This will help the baby latch on to the nipple properly and easily.

Use manual expression of milk to empty the breast after the baby has nursed if they are still uncomfortably full and engorged. Maintain good support to the breast without any pressure point. Icepack may be used between feedings to reduce swelling and pain. (Annamma Jacob -2012).

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STUDIES RELATED TO EFFECTIVENESS OF REVERSE PRESSURE SOFTENING TECHNIQUE ON BREAST ENGORGEMENT

Witt A, Bolman M, Kredit S, et al.(2016) performed an observational study in breastfeeding women with symptomatic pain, engorgement, plugged ducts, or mastitis evaluated therapeutic breast massage during lactation (TBML) by a trained provider combined with consultation with a lactation professional. TBML included an average of 30 minutes (range 15–60 minutes) of gentle breast massage toward the axilla alternating with hand expression. Breast pain, tenderness, and engorgement severity were significantly reduced following treatment. Periareolar swelling decreased from 93% to 7% (p < 0.001) and engorgement severity using the 6-point Humenick scale decreased from 5.31 before treatment to 3.48 after TBML.

An evaluative study to assess the effectiveness of reverse pressure softening technique on breast engorgement, pain perception and breast feeding among primipara postnatal mothers in Kerala by Priyanka Nair (2014) was conducted using quasi experimental pre test - post test control group only design among 40 primipara postnatal mothers. Before the intervention there was no significant difference in breast engorgement, pain, maternal comfort level and feed intake of newborns among the two groups. After the intervention in the experimental group all the four aspects had significant improvement, (breast engorgement: overall mean score = 1.88, t = 4.46*;

pain: overall mean score = 0.32, t = 3.02*; maternal discomfort: overall mean score = 9.94, t = 6.72*; newborns feed intake: overall mean score = 19.96, t = 10.22* at df (38) and p≤0.05) compared to control group which indicated the effectiveness of intervention in the improvement of breast engorgement, pain, maternal comfort and newborns feed intake. The study concluded that reverse pressure softening technique

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had a significant effect in improving the breast engorgement, pain, maternal comfort and newborns feed intake among primipara postnatal mothers.

Shiya Jacob(2012) conducted a study on effectiveness of breast massage on breast engorgement among postnatal mothers in Karnataka. The study was conducted among 60 postnatal mothers using one group pre test and post test pre-experimental design.Breast massage was provided to them for 20 minutes thrice daily for three consecutive days. At the end of third day breast engorgement was assessed by using self structured engorgement scale. The study concluded that breast massage was effective by gradual reduction in the level of breast engorgement from 1st day to 3^rd day of intervention.

A study was conducted on “Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching during Engorgement” at Dayton, Ohio. Subareolar tissue resistance increases during engorgement and result in latching difficulty. The subjects were 84 women of immediate postpartum period with breast engorgement.

They concluded that reverse pressure softening before latching significantly reduces resistance of sub areolartissue, temporarily freeing it to interact more efficientlywith the baby’s mouth & triggers the milk ejectionreflex promptly.

Ahn.S.et.al(2010) conducted a study on 60 postpartum mothers who were admitted and had problems with breast feeding. Were selected for the intervention group and received 2 reverse pressure softening breast massage within 10 days of postpartum. The others were assigned to control group. Breast pain was measured using Numerical Pain scale and number of times newborn suckled was observed.

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Compared to control group intervention group reported decrease in pain(p<.001), increases in number of times newborn sucked after first and second massage. Study concluded breast massage may have effects on relieving breast pain and improving newborn suckling and can be used to solve breast problems.

Kim WO (2007) conducted a study among postnatal mothers in Korea, on the effect of reverse pressure softening and manual expression of the breast milk in breast engorgement. The purpose of this study was to compare the effect of reverse pressure softening and manual expression of the breast milk with the time of development of engorgement, throbbing pain in breast, the amount of breast milk produced and involution of the uterus using a true experimental design. The subjects selected for this study were 138 women (experimental group; 69, control group; 69) who were admitted to the Kyung Hee University Hospital. The study showed that the average time of development of breast engorgement in the experimental group (2.1 days+/-0.8) was shortened than the control group (3.3 days +- 1.2) (t=-6.9045, P<0.005). The average amount of breast milk increased more conspicuously in the experimental group (33. 8ml+/-23. 4) than in the control(29. 8ml+/-25. 3) (t= 0.8262, N. S. ). The study concluded that the reverse pressure softening has great effect on reducing breast engorgement, increasing milk production and in faster uterine involution.

Johnson and Myr (2002) conducted a study on ―Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching during Engorgement‖

at Dayton, Ohio. Sub areolar tissue resistance increases during engorgement and result in latching difficulty. The subjects were 84 women of immediate postpartum period

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with breast engorgement. They concluded that reverse pressure softening before latching significantly reduces resistance of sub areolar tissue, temporarily freeing it to interact more efficiently with the baby‘s mouth & triggers the milk ejection reflex promptly.

Bricout (1996) conducted an experimental study on the effect of reverse pressure softening technique and breast massage on the subjective comfort of mother, the skin surface temperature changes in breast & breast engorgement in Oita prefectural university of nursing in Japan. The subjects were 35 mothers & midwife measured breast engorgement using visual analogue scale rating from 0-10. The breast skin surface temperature measurement was assessed by infrared thermometer after 1 minutes, 3 minutes & 5 minutes after breast massage. They concluded that reverse pressure softening technique and breast massage are good for blood circulation and were considered to be an effective way to ease the discomfort of breast engorgement.

Cotterman.K.J. (1993) conducted a randomised control trail study of 400 women with breast engorgement in Philadelphia and found out that for successful breastfeeding requires efficient milk transfer through the nipple-areolar complex, which includes sub areolar tissue. Sub areolar tissue resistance increases during engorgement, when expanded circulation and excess interstitial fluid compete for space with increasing milk volumes. Physiologic and iatrogenic events often combine to produce distortion of breast anatomy. Resulting latch difficulty, delayed milk ejection reflex, poor milk transfer, pain, and nipple damage discourage many mothers.

The rationale and technique for a simple intervention developed in practice are

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described: reverse pressure softening (RPS) before latching significantly reduces resistance of sub areolar tissue, temporarily freeing it to interact more efficiently with the baby's mouth. RPS also triggers the milk ejection reflex promptly. The health care provider can perform RPS or teach the mother and her significant others, even by telephone.

SUMMARY

The review of literature helped the researcher to develop an insight regarding the prevalence of breast engorgement among postnatal mothers. It also provided insight about methods practiced to manage breast engorgement and improve breastfeeding among postnatal mothers. This review helped the researcher to gain deeper knowledge of the research problem, evidence based information and thus guided in designing the study.

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CONCEPTUAL FRAME WORK

“The conceptual framework ‘sets the stage’ for the presentation of the particular research question that drives the investigation being reported based on the problem statement.”

- McGahie et al.(2001)

A conceptual framework represents the researcher’s synthesis of literature on how to explain a phenomenon. It maps out the actions required in the course of the study given his previous knowledge of other researcher’s point of view and his observations on the subject of research.

The conceptual frame work used in this study was Ernestine Wiedenbach‘s – The Helping art of Clinical Nursing. The helping art of clinical nursing was developed for childbirth education; family centered maternity care and nurse midwifery education. This theory defines nursing as the practice of identifying the patients need for help through the observation of presenting behavior and symptoms, exploration of the meaning of those symptoms, determination of the cause of discomfort and determination of the patient‘s ability to resolve the patient‘s discomfort. The art of nursing is when the nurses understood patient’s needs and concerns.

If a nurse’s attitude and belief is what motivates her to act in certain ways she is guided on nursing philosophy. Three components that may affect the nurses’

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philosophy are reverence for life, respect for the dignity and individuality of each human being and resolving to act on personal and professional beliefs.

Weidenbach’s prescriptive theory is based on three factors.

1. The central purpose which the practitioner recognizes as essential to the particular discipline.

2. The prescription for the fulfillment of central purpose.

3. The realities in the immediate situation that influence the central purpose.

The practice of nursing comprises a wide variety of services each directed toward the attainment of one of its three components. When a nurse wants to accomplish through what she does which is primarily identifying a patient’s need for help, it is based on nursing purpose. Observable actions which are affected by the nurse’s beliefs and feelings in meeting the patient’s need show the nursing practice.

In this study, the central purpose was to reduce the breast engorgement and improve breast feeding among the postnatal mothers through appropriate management.

Step 1: Identification of a need for help Step 2: Ministration of the help needed

Step 3: Validation that the need for help was met

31 STEP 1: Identification of a need for help

As per the theory, within the identification component there are four distinct steps. First, the nurse observes the patient, looking for an inconsistency between the expected behavior of the patient and the apparent behavior. Second, she attempts to clarify what the inconsistency means. Third, she determines the cause of inconsistency. Finally, she validate with the patient that her help is needed. In this study, the demographic variables comprise the age of the postnatal mothers, area of living, educational qualification, type of family, monthly income, dietary pattern, social support, parity, indications of cesarean section. Pre assessment showed that most of the postnatal mothers experienced breast engorgement and inadequate breastfeeding. The cause of this inconsistency was the suboptimal postnatal care.

STEP 2: Ministration of the help needed

In ministry of the patient the nurse may give advice or information, make referral, apply a comfort measure or carry out the therapeutic procedure. The nurse will need to identify the cause and if necessary make an adjustment in the plan of action.

Ministration of help needed has two components, a. Prescription

b. Realities

Prescription is a directive activity whereas the realities are the situations in which the nurse is to provide nursing care.