Professional Documents
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Pari Synopsis
Pari Synopsis
By
Master of Science
In
NURSING
2020
1
0.1. INTRODUCTION
(Genesis 1:26-27)
important that for a mother to have a healthy baby, she gives her baby the best
nutrition. Breast milk is the best food for babies as breastfed babies are generally
Given the strong evidence of the benefits of breastfeeding for women and babies the
WHO recommends that, in all parts of the world, babies should be exclusively
breastfed for the first six months “to achieve optimal growth, development and
health”1
advantages to mother and child are well recognized, there are a number of problems
associated with it. One common problem that is encountered is breast engorgement,
the baby removes less milk from the breast when feeding than the amount that the
mother produces. Breast engorgement is the overfilling of breast milk that causes
3
is important for the baby to latch on to the breast correctly during feeding so that it
can suck effectively. In order to do this the baby needs to be correctly positioned,
and new mothers may need advice on this. Breast engorgement may affect the area
around the nipple and areola only or the entire breast, and may affect one breast
only, or both. Once engorgement occurs, swelling around the nipple may make it
even more difficult for the baby to latch-on and feed successfully, and this may
Breast engorgement usually occurs within a week of the birth, but can occur
later. Primary engorgement occurs in the first few days after the baby is born, and it
occurs when the mother’s body is still trying to adjust to the amount of milk that the
baby demands. 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.4
tender breasts which may result in women needing analgesia, developing mastitis or
breast engorgement may mean that women initiating breastfeeding may not
This problem may be compounded if concern that the baby is not getting
enough milk, or breast pain and swelling, discourage women from continuing
breastfeeding. Women may also receive limited advice and support from health
professionals; lack of knowledge in managing this condition could be the reason for
shower before breastfeeding, cold compresses for 10 minutes after feedings, gentle
massage and compress the breast when the baby pauses between sucks, frequent
feeding, correct positioning, jasmine flower, frozen pea and warm compresses to the
breast have been advocated to relieve symptoms along with analgesia to relieve
pain4.
Many literatures have been supported that cabbage leaves application and hot
application are effective on breast engorgement. It is not known which ones are
effective compared to the others. It is important that this topic be reviewed as the
Breast feeding is one of the first bonding experiences between mother and child.
Breastfeeding her child is the most natural thing for every mother.
important that for a mother to have a healthy baby; she gives her baby the best
nutrition. Breast milk is the best food for babies as breastfed babies are healthier
the Baby-Friendly Hospital Initiative was launched by UNICEF and WHO in 1991.1
The chief editor of “The Nursing Journal of India” in her key address on the
quarters
The most often stated reason for cessation of breastfeeding in the first two
weeks of postpartum is pain 5. Breast engorgement is a painful problem that can lead
usually occurs between 3-6 days after delivery 6. Dr. Ruth Lawrence defines
engorgement as “the swelling and distension of breasts usually in the early days of
5
initiation of lactation, due to vascular dilation as well as the early arrival of milk”
The incidence rate of breast engorgement all over the world is 1:8000 and in
and 5, with more than two – thirds of women with tenderness on day 5 but some as
late as days 9 – 10. Two – third of women experience least moderate symptoms.
More time spent breastfeeding in the first 48 hours is associated with less
Engorgement can develop if the baby’s demand for breast milk decreases
suddenly or the mother is unable to empty her breast resulting in her breasts
becoming overly full. Immediately after birth the mother produces colostrum which
happen if lactating
women misses several nursings and not enough milk is expressed from breasts.
When the milk oozes out for the first time there will be swelling of breast tissue
occurs due to flooding of lymph fluid and blood. The swelling around the areola
may cause the nipple to become flat and making it difficult for the baby to latch-on
postpartum. During a time when mothers are coping with demands of the baby it
in a rural community and to know the reason for starting top feeds in infants less
method 420 mother-infant pairs was enrolled from 224 villages of central
Karnataka. Out of them, 80.5% were practising exclusive breastfeeding; 19.5% had
started top feeds; and 1.7% mothers had completely stopped breastfeeding. Maximal
onset of breastfeeding problems was noted in the first two weeks of the neonatal
of Mangalore was conducted in 2004. The study revealed that only 7% of the
sample
instructed the mother to start breastfeeding soon after delivery whereas the majority
of the subject (93%) perceived that for the first 3 days there will not be any milk.
82% mother’s milk is not sufficient,18% religious practice. The study recommended
the need of education and how this faulty practice can bring breast engorgement in
Numerous strategies have been adopted over the years in the treatment of
breast engorgement. But very few researches have been conducted to monitor the
effect of cabbage leaves on breast engorgement. Cabbage leaves have been used for
centuries as a folk remedy for a wide variety of ailments and received much
renewed interest from lactation professionals over the past ten years. 13 The common
Herbalists believe that cabbage has both antibiotic and anti irritant properties. It
blood vessels), which improves the blood flow in and out of the area, allowing the
body to reabsorb the fluid trapped in the breasts. Cabbage may also have a type of
Hot application reduces pain and causes relaxation of blood vessels, there
by opening vessels and increasing blood flow to the area. It causes vasodilatation
dispersion of fluid and decreasing the fluid accumulation in the local tissue. Rise in
temperature also causes circulation so necessary oxygen and nutritive materials are
supplied and waste products are removed which in turn removes pain .15
A quasi experimental study was conducted in AIIMS, New Delhi to assess
and compares the efficacy of cold cabbage leaves and hot and cold application in
experimental group and 30 in the control group. The control group received
alternate hot and cold compresses and experimental group received cold cabbage
leaf for relieving breast engorgement. Both the treatment i.e., hot and cold
mothers (p≤0.001). Cold cabbage leaves and hot and cold application were equally
clinical work in maternal and child health observed that breast engorgement and
throbbing breast pain were the most frequent complaints during the postpartum
phase. In order to understand the factors affecting the discomfort and to devise
appropriate nursing care these complaints were experimented (n=62) during June 5th
to July 15th, 2001 at the Severanu Hospital. The study concluded that proper breast
care during antenatal period is needed for preventing postnatal breast complications
.17
being posted in clinical setting motivated the investigator to use cold cabbage leaves
and hot application for relieving breast engorgement. The investigator is also
interested in comparing the effectiveness of cold cabbage leaves and hot application
assess the breast engorgement before and after cold cabbage leaves and hot
postnatal mothers.
find an association between the pre test breast engorgement level with
H1: There will be a significant difference between mean pre test and post test
postnatal mothers.
H2: There will be a significant difference between mean pre test and post test
postnatal mothers.
mothers.
Operational definitions:
Effectiveness:
In this study effectiveness refers to the extent to which cabbage leaves and
hot application has produced desired effect on breast engorgement among postnatal
In this study cold cabbage leaves refers to cabbage leaves which are
refrigerated in the freezer for 20-30 minutes before application. The cabbage leaves
contains sulfa compound which pass through the skin and constrict the vessels and
reduces inflammation. This reduction in inflammation and swelling allows the milk
to flow. Place the freezed cold cabbage leaves on the engorged breast, leaving the
nipple
exposed. Wrap bandage on the top of the leaves to keep them in place. Change leaves
Hot application:
In this study hot application refers to applying hot compress using the
water with temperature 43-46 degree Celsius. The warm moist sponge cloth is
applied to engorged breast and the clothes are replaced frequently after 2 minutes,
Breast engorgement:
breast, redness ,shiny skin ,prominent vein over breast ,flattened nipple ,firm
breast ,hard areola ,warmth in breast ,generalized malaise, rise of body temperature,
Postnatal mothers:
In this study postnatal mothers refers to women who have delivered a baby
within three to five days of postnatal period and have the evidence of bilateral breast
engorgement.
Assumptions:
2. REVIEW OF LITERATURE
work for further study. When the researcher is able to find the right number quality
of resource article to guide the study a door way is opened. This key group articles
may include research findings, theory articles and published review of literature.21
topic in order to gain deeper insight in to the problem and collect maximum relevant
desired results. The literature review has been organised and presented under
following headings:
breastfeeding among 327 rural women in Jammu and Kashmir revealed that
about one-quarter of mothers had lactational problems. The study found 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.22
in rural Karnataka among 420 mother-infant pairs showed that the onset of
breastfeeding problems occurred in 31.7% of women during the first month of life
and 76.9% in the first week, 7.7% in the second and 15.4% in the third week
respectively. Insufficient milk was reported by 53.6% while 23.1% of the mothers
had other problems like sore nipple, mastitis, breast engorgement, and breast
abscess. The study showed that the onset of breastfeeding problems was alarmingly
20% of the mothers were found to have breast complications. Breast engorgement
(17.8%), retracted nipples (10%), cracked and sore nipples (8.33%), cracked and
retracted nipple (7.5%), failing lactation (7.5%) and breast abscess (3.33%).23
engorgement, and 12% knew that hot fomentation will relieve breast
engorgement. The above findings revealed that the mothers still lacked
engorgement, mastitis and infantile colic was conducted on two groups of subjects
emptying of one breast at each feed) was 150 and that in the control group
(both breasts equally drained at each feed) was 152. Both the groups were
followed prospectively to six months after delivery. The study revealed that the
experimental group had lower incidence of breast engorgement in the first week
(61.4% v/s 74.3%, p < 0.002) and infantile colic over first six months 91.20%
v/s 23.4%, p < 0.02). In both groups perceived insufficient milk syndrome was
the main reason for cessation of breastfeeding. The study concluded that the
the reasons for starting top feeds in infants less than six months was conducted
in rural Karnataka among 420 mother-infant pairs of 224 villages. The findings
the first month of life. Further analysis showed that 76.9% occurred in the first week
of life, 7.7% in the and 15.4% in the third week. Not enough milk was responsible
for starting feeds in 53.6% of cases, and 23.1% of mothers had other problems
like sore nipples, , breast engorgement, breast abscess and other illnesses. The
study revealed that the onset of breastfeeding problems was alarmingly high in
breastfeeding problems.26
occurrence of breast engorgement during the first 3 days of postpartum ,the study
(p<0.0001).2
A study was conducted in china to rate the level of breast engorgement for
first 14 days following child birth .Study comprise of 114 breast feeding mothers
and it is assessed by using six point breast engorgement scale. The study concluded
that engorged mother experience either a bell shaped pattern, a multi –modal
Institute of Child Health, Karachi to assess the breast feeding problems. The result
shows that inadequate milk production was the commonest reason as stated by 71%
variables and variables amenable to nursing intervention. The focus of the study
was to identify variables that correlate significantly with breast engorgement and
duration, rate
of milk maturation and supplementation were obtained from 54 women. These
conducted with caesarean section in the year 2007. Among this 45% to 50% have
first time vaginal delivery and second time caesarean section delivery breastfeeding
mothers. Most mothers reported experiencing their most intense engorgement after
variables than the parity in predicting engorgement. Result showed that second time
breast- feeding mother experience engorgement sooner and more severely than the
application of cabbage leaves on their breasts and to a control the group received
routine breast care. The experimental group reported less breast engorgement than
control group. At six weeks, the women who received cabbage leaves application
chilled cabbage leaves and cold gel packs in reducing breast engorgement in
postpartum mothers. Thirty four lactating mothers with breast engorgement received
chilled cabbage leaves on one breast and chilled gel packs on the other breast up to
eight hours. Their pain levels were established pre treatment and compared post
treatment for both conditions. Both the treatment was equally effective in reducing
breast engorgement and pain. 68% obtained relief within one to two hours and the
cream containing cabbage leaf extract while 18 received placebo cream. The study
mothers. The study comprises of twenty four mothers selected by using purposive
sampling method. Pre treatment level of breast engorgement is compared with post
engorgement among postnatal mothers. Twenty eight lactating women with breast
engorgement used chilled cabbage leaves on one breast and room temperature
cabbage leaves on the other breast for a two hour period. Pre treatment pain levels
were compared with post treatment levels for both the conditions. Mothers reported
less pain with both the conditions and majority of the mothers preferred cold
cabbage leaves36.
treatment for women who experience breast engorgement. They identified studies
for inclusion through the Cochrane Pregnancy and Childbirth Group's Trials
with 744 women. Trials examined a range of different treatments for breast
engorgement: acupuncture (two studies), cabbage leaves (two studies), cold gel
packs (one study), pharmacological treatments (two studies) and ultrasound (one
study). For several interventions (ultrasound, cabbage leaves, and oxytocin) there
was no statistically significant evidence but in these studies women tended to have
improvements in pain and other symptoms. The study concluded that more research
Breast engorgement was assessed by using Storr scale. Result revealed that the
were extracted by one reviewer and verified by a second reviewer. Eight trials,
involving 424 women, were included. Three different studies were identified ,which
used cabbage leaves or cabbage leaf extracts and gel packs, ultrasound treatment
like cabbage and broccoli on breast cancer. Researchers found that women who
consumed vegetables like broccoli and cabbage were 62 percent less likely to die of
breast cancer and 35 percent less likely to have a recurrence of the disease,
compared with those who consumed the least. This study suggests that cruciferous
vegetables and the bioactive compounds in them may be protective against breast
cancer.40
vegetables on breast cancer. The study involved almost 5,000 women between 20
and
75 years age who were part of the Shanghai Breast Cancer Survival Study.
Researchers interviewed the women within six months of their diagnosis to gather
information about diet, lifestyle and such clinical factors as tumour stage. They also
asked about their intake of cruciferous vegetables at 18 and 36 months after their
percent less likely to die of breast cancer during the roughly five-year study period
than women in the bottom 25 percent. Recurrence was 35 percent less likely among
women in the top consumption compared to those in the bottom 25 percent. The
researchers also found
that women in the top quarter for consumption were 62 percent less likely to die of
Vellore to compare the effectiveness of manual expression of milk and warm bottle
mothers with breast engorgement on whom moist compress was applied and then
breast milk was manually expressed. Group II consisted of 30 mothers for whom
breast milk was expressed with a warm bottle. The findings of the study showed
that both the methods were effective in reducing the breast engorgement as well as
the pain expressed by the mother. On comparing both methods, it was found that
mothers in group II where breast milk was expressed using a bottle had significant
reduction of breast engorgement (p value < 0.01) than the mothers in Group I who
had a moist compress application and manual expression of milk. Pain was
chart, observation checklist and visual analogue scale The pre test mean score
related to peripheral intravenous infiltration were 61.23 and post test mean pain
scores were
13.27 in treatment with warm application which was found to be most effective than
fomentation versus cold compress for reducing intravenous infiltration. The sample
size was sixty patients (30 for hot fomentation and 30 for cold compress) with mild
to moderate degree of infiltration stayed in hospital for 8-14 days and data was
analyzed using descriptive and inferential statistics. Findings prove that the pre-
treatment mean score was 7.1667 reduced to 0.7071 on the third day of treatment
with hot fomentation. In cold compress pre-treatment mean score 6.9333 reduced to
0.70571. The study concluded that both hot fomentation and cold compress were
study concluded that effect of warmth versus cold on infiltration showed that
the infiltrate.45
METHODOLOGY
“Thinking well is wise; planning well is wiser, doing well is best of all”
problem. It explains the various steps that are generally adopted in studying the
research problem along with the logic behind it. It deals with defining the problem,
techniques used for analyzing the data with logical reason behind it. 46
Research approach
natural phenomena guided by theory and hypothesis about the relation among such
phenomena.46
The focus of the study was to compare the effect of two different modalities
of treatment for the management of breast engorgement and find out which will be
the most effective. The investigator keeping in mind the objectives of the study and
The research design provides the backbone structure of the study .It is the
researchers overall plan for obtaining answer to the research questions or for testing
the research hypothesis.47 The research design selected for the study is quasi
Setting refers to the area where the study is conducted. It is the physical
location and condition in which data collection takes place in a study. The selection
completion.47
situations that change or vary. Variables are attributes that vary. Variability in the
variable.47
cause or influence the dependent variable 46. In this study, cold cabbage leaves and
Population
hospital khargone.
Sample
Sample size
Sample size refers to the number of sampling units included in the study. In
other words, the sample size refers to a decision on how many items from the
2. The sample was divided in to two groups. 15 mothers in cold cabbage leaves
application group (group 1) and remaining 15 in hot application group (group 2).
Sampling technique
represent the entire population 47. The sample was selected using non probability
Sampling criteria:
Inclusion criteria
Pilot study
A pilot study is a small scale version or trial run of the main study. The pilot
study was conducted with the purpose of testing and refining the research process. It
is conducted to obtain information for improving the project or for assessing its
The investigator conducted the pilot study among six postnatal mothers with
Permission from the DMO of the hospital was obtained before conducting the
study .The purpose and the usefulness of the study were explained to the concerned
authorities before taking permission. The investigator carried out the pilot study
with one-tenth of the total sample. The non probability purposive sampling
technique was used for the selection of sample. A total six postnatal mothers were
taken for the pilot study. Three postnatal with breast engorgement were selected for
each intervention.
selected hospital, khargone. The permission from the DMO of the hospital will be
obtained before conducting the study. Based on inclusion criteria, thirty samples
were selected and fifteen samples were assigned in cold cabbage
application group (Group 1) and fifteen in hot application group (Group 2) using
The investigator planned to analyze the data on the basis of the objective and
independent‘t’ test.
Chi-square test will be used to find out association between pre-test breast