Rajiv Gandhi University of Health Sciences Karnataka



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BENGALURU, KARNATAKA.

PROFORMA FOR REGISTRATION OF

SUBJECT FOR DISSERTATION

| | | | |

|1. |NAME AND ADDRESS OF THE CANDIDATE | |MS. ALEENA BABU THOMAS |

| | | |I YEAR M.SC. NURSING, |

| | | |DAYANANDA SAGAR COLLEGE OF NURSING, BENGALURU. |

| | | | |

|2. |NAME AND ADDRESS OF THE COLLEGE | |DAYANANDA SAGAR COLLEGE OF NURSING. |

| | | |SHAVIGE MALLESHWARA, HILLS, KUMARSWAMY LAYOUT, BANGALORE -560078. |

| | | | |

|3. |COURSE OF STUDY AND SUBJECT | |IST YEAR M.SC. NURSING, |

| | | |OBSTETRICS AND GYNECOLOGICAL NURSING. |

|4. |DATE OF ADMISSION | | |

| | | |: 06/06/2011 |

|5. |TITLE OF THE TOPIC | | : “EFFECTIVENESS OF STRUCTURED |

| | | |TEACHING PROGRAMME ON |

| | | |KNOWLEDGE REGARDING SELECTED |

| | | |NEWBORN DANGER SIGNS AMONG |

| | | |POSTNATAL MOTHERS IN SELECTED |

| | | |HOSPITALS, BENGALURU”. |

| | | | |

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“A sweet new blossom of humanity, fresh fallen from god’s own home to flower on earth” (Gerald Massey)

Birth of a baby brings in joy into the family. The most exciting affair in the lives of a couple is having a newborn baby. Caring for a newborn, especially your first is one of life's biggest challenges. The partner may feel overwhelmed at the beginning-after all, there's so much to learn. As soon as the little darling arrives, the life will be changed forever. It's a good idea to start preparing for that change early. As we find out that she is pregnant, before delivery it is time for her to prepare for facing the changes1.

A newborn is an infant who is within hours, days, or up to a few weeks from birth. Newborn or neonate (from Latin, neonatus, newborn) refers to an infant in the first 28 days after birth. The normal newborn characteristics are head represents one-fourth of his total body length. Its circumference is equal to that of his abdomen or chest. The average size is 13" to 14" (33-35 cm). Some newborns have a fine, downy body hair called lanugos. The newborn may also have Mongolian spots and various other birthmarks. Newborn's genitals are enlarged and reddened. Normal apgar score is 7 to 102.

Becoming the parent of a new life, a responsibility of protection is important to the health and safety of the little, defenceless person. It is very important that the child is healthy. The symptoms of illness in a new born baby are very subtle. You as a mother should be watchful for any signs of illness in your new born baby in an endeavour to prevent further complication. Some of the new born problems are jaundice, constipation, watery eyes, dyper rashes, dry skin etc and complications like thrush, birth injuries transient tachepenia and the most common causes of death newborn are due to infection, hypothermia, asphyxia, prematurity and congenital malformation3.

Most first time parents don’t find comfort in being told how a sick baby reacts compared to a healthy baby. This is because everything about their baby is unfamiliar and new so that they don’t have any experience with what is normal and what isn’t. Many a times a parent is told that if the baby is constantly crying for days on end they might be sick, but this isn’t always the case considering many healthy babies cry long period of time4.

An estimated 130 million babies are born each year and about 4 million of them die in the neonatal period. Nearly 99% of all neonatal deaths occur in low- and middle-income countries. A quarter of the global neonatal deaths occur in India and little progress has been made in reducing it in the last decade. Current new born mortality rate is 34 per 1000 live births and current world wide new born mortality rate is 16.19 per live births. A combination of universal outreach and family-community care intervention at 90% coverage has been estimated to avoid 18 to 37% of neonatal deaths. These interventions include family care of the new born, essential new born care, resuscitation of the new born, care for low birth weight babies, emergency new born care and early detection of danger signs5

The important danger signs in new born are: lethargy, breathing problems, temperature instability, failure to pass meconium and/or urine, vomiting, diarrhoea, cyanosis, jaundice, abdominal distension, convulsions, bleeding, tracheo- oesophageal fistula, cardiac problems, and excessive loss of weight . It is very important that you check the newborn for the danger signs, as the actions you take to help the new born are crucial to ensure prompt and safe care. You also need to teach the mother to look for these signs in the newborn and advise her to seek care promptly if she observes any one of the danger signs. Studies say an increase 1% in female literacy is associated with a 23% drop in newborn mortality rates on average6.

Nurses are the instruments in educating women and her partner about preparation of new born and care, preparing for breast feeding, new born illnesses, danger signs and symptoms and available management. Child birth education is not an isolated series of classes in the last trimester of pregnancy, health care professionals in contact with pregnancy or parenting women or men must view themselves as educational resources for these clients and provide them with the most evidenced based information desired by the clients at that time7.

6.1 NEED FOR THE STUDY

“A new baby is like the beginning of all things- wonder, hope, a dream of possibilities” Eda .J.Leshan

Many communities keep mothers and babies indoor for the first month after birth. If the mother or baby become ill during the period of seclusion, seeking health care is often delayed, yet sick babies often die within a few hours or delays can be fatal.Poor knowledge on part of mothers can lead to disastrous results in the field of care giving. Mother has to regulate the child’s behaviour, attitudes, outlook and home environment in family, since these are the basic factors that influence the growth of newborn. If the mothers are not acquainted with a recognition and referral of newborn danger signs, it might affect the rearing of their children. Providing timely education in the form of intervention to mothers could fill these gaps in knowledge8.

A cross sectional study was under taken in three of the 27 primary health centres of Wardha district with a population of 88187 to know mothers' knowledge and explore their perceptions about newborn danger signs and health care seeking behaviour. Out of 1675 expected mothers, 1160 mothers in the area were interviewed by house-to-house visits. Data was entered and analysed in statistical package for the social sciences is 12.0.The finding revealed that 67.2 % mothers knew at least one newborn danger sign. Majority of mothers (87.4%) responded that the sick child should be immediately taken to the doctor but only 41.8% of such sick newborns got treatment either from government hospital (21.8%) or from private hospital (20%) and 46.1% of sick babies received no treatment. The result shows that the reasons for not taking actions even in presence of danger signs/symptoms were ignorance of parents, lack of money, faith in supernatural causes, non-availability of transport, home remedy, non-availability of doctor and absence of responsible person at home. The study concluded that the present study found gap between mothers' knowledge and their health seeking behaviour for sick newborn and explored their deep perceptions, constraints and various traditional treatments. Further it revealed that comprehensive intervention strategies are required to change behaviour of caregivers along with improvement in capacity of Government health care services and National Health Programs to ensure newborn survival in rural area9.

The number of newborn deaths is roughly equivalent to the number of children born annually in the U.S or in the 23 largest countries of Western Europe. Newborns born in developing countries are at least 14 times more likely to die during this period than newborn born in developed countries. Neonatal death comprises 41% of all child death. Nearly all (98%) of neonatal deaths each year occur in developing countries and more than half of neonatal deaths occur in four large countries: India, China, Pakistan, and Nigeria.Current mortality rate of newborn in Karnataka is 45 per 1000 live births and the main causes of newborn death are infectious disease (30-40%), preterm delivery, birth asphyxia, low birth weight, hypothermia10.

A study was undertaken to assess the pattern of reported neonatal morbidity and the care-seeking behaviour for neonates in rural Bangladesh. The samples were 1151 mothers and data was collected using structured knowledge questionnaire. The study revealed that 49% of their neonates were reported to have suffered from the some kind of morbidity. Fever was the most common morbidity reported in the study population (21%), followed by breathing difficulty (11%). Birth order, complications during pregnancy and delivery, and death of sibling were found to be significantly associated with reported neonatal morbidity. 87% of the mothers sought care for their newborns. Some were taken to several different providers, the commonest being homeopaths (38%) and village doctors (37%). Seventeen percent were taken to trained providers, and only 5% to government health facilities. The study concluded that these types of studies will help in educating the women regarding newborn fatal problems11.

In order to improve basic health indicators for maternal and child health in the country, the Ministry of Health is implementing the Strategy for the Accelerated Reduction of Maternal and Child Mortality during the 2008 to 2015 period. The national strategy for Essential Obstetric and Newborn Care is being implemented for this purpose. Included among its lines of action is increasing demand and access to Essential Obstetric and Newborn Care services by means of community action development and by health care providers. The community strategy shown here responds to national efforts aimed at improving maternal and neonatal health.12

A retrospective study was conducted on the main illness and establishment of association between certain conditions and severity of diseases in paediatric emergency department in Portugal. The samples 200 health personals and were collected by random sampling and data was collected by interview method. The result shows that the chief complaints noted were jaundice, excessive crying, and rash. Diagnostic tests were requested in 27.2% cases. The major diagnoses were non apparent diseases, like infant colic’s and physiologic jaundice. In 13.0%, hospital admission was necessary. The study concluded that most paediatric emergency department visits were because of non-serious diseases, mainly because of insufficient caretaker knowledge and information. This highlights the great need for care takers education by health staff. It is also important that physicians are aware of the main illnesses in the newborn period and know how to correctly identify the conditions associated to serious pathology.13

Children are the future for any nation. From them the future develops. In order to have a healthy generation we need a healthy child. Hence the researcher realize the importance of the problem in current situation and created an intention to administer structured teaching programme to assess the knowledge of post natal mothers regarding newborn danger signs, thereby enhancing their awareness on newborn danger sign in order to bring out a healthy baby in the society.

6.2 REVIEW OF LITERATURE

The review of literature for the present study is organized as follows:

6.2.1 Studies related to general information about newborn danger signs.

6.2.2 Studies related to knowledge of mothers regarding newborn danger signs.

6.2.3 Studies related to management of newborn danger signs.

6.2.4 Studies related prevention of newborn danger signs.

6.2.1 Studies related to general information about new born danger signs.

A descriptive study was conducted on prevalence of heart disease in Mysore. Samples were collected and analysed from the three major hospitals of Mysore, Cheluvamba Hospital, CSI Holds worth Memorial Hospital and J.S.S Hospital. The result revealed that the prevalence of coronary heart diseases for five years in Mysore Hospitals range from 6.6 to 13.06 per 1000 live births. The most frequent type of Coronary heart disease was found to be ventricular septal defect (40.47%) followed by arterial septal defect (19.06%), tetrology of fallot (13.38%) and patent ductus arteriosis (9.53%). It is clear that the maximum coronary heart diseases were detected in the first year of life when compared to the later years of life. The prevalence of Coronary heart diseases in Mysore is increasing which might be due to the improvement of diagnosis, attention or awareness among the medical authorities on the disease. The study concluded that the prevalence of Coronary heart disease in Mysore is not very high as reported in other parts of the country, however; it is an important disease which needs an immediate medical attention14.

A surveillance study was conducted to estimate the incidence of neonatal jaundice and hyperbilirubinemia in a poor urban community in Karachi. The samples were collected from 1690 newborns with 59 days of life and data was collected by clinical assessment. The result of the study shows that out of 1690 young infants during the study period, 466 infants (27.6%) were found to have jaundice. Overall detected rate of hyperbilirubinemia (bilirubin >5 mg/dl) among 1690 newborns was 39.7/1000 live births (95% CI 29.3–47.6). Rate of plasma bilirubin levels in the range of 15–20 mg/dl was 13/1000 live births (95% CI 7.6–18.4); levels >20 mg/dl were observed in 3.5/1000 live births (95% CI 0.4–5.5). The proportion of newborns with bilirubin≥15 mg/dl was significantly higher. The study concluded that a significant burden of untreated severe neonatal jaundice, causing potential neurological sequelae, exists in developing countries such as Pakistan. WHO guidelines are needed for screening and appropriate management of neonatal jaundice in developing countries15

A study was conducted on the incidence of neonatal liver and biliary tract disorders, main causes, clinical presentation, treatment and outcome in intensive care unit of five tertiary medical centres in Portugal. The data were collected in 77 neonates by clinical, imagiological, laboratory, pathological and autopsy. The study reported that Jaundice was the most frequent clinical sign (92%), Cholestasis occurred in 67 (87%) patients. Autopsy study was done in 8 cases (10%). The study concluded that nosocomial and intrauterine infection were the most common causes of liver and biliary tract disease. Several other rare causes represented an important challenge in diagnosis and treatment, and some were fatal. Awareness of the spectrum of liver and bile duct disorders in the neonate and recognition of the key clinical features are essential to optimize outcome.16

6.2.2 Studies related to knowledge of mothers regarding newborn danger signs

A triangulated quantitative and qualitative study was conducted on awareness of mothers about newborn danger signs and their health care seeking behaviour for sick newborns in the peri urban wardha. The sample was 72 identified mothers and data was collected by interview by using pre-designed and pre-tested questionnaire. The result revealed that out of 72 mothers, 29 (40.3%), 16 (22.2%) and 10 (13.9%) identified difficulty in breathing, poor sucking and lethargy/unconsciousness as newborn danger signs respectively. Only 7(9.7%) and 2 (2.8%) identified convulsion and hypothermia as newborn danger signs respectively. About 27 (37.5%) babies were sick during newborn period. About 11(15.3%) and 8 (11.1%) were reported to have poor sucking and difficulty in breathing respectively. All sick newborns with danger signs were taken to the doctor and only two mothers consulted faith healer for treatment. The study concluded that considering the poor awareness of mothers regarding newborn danger signs, there is need for raising awareness building which required for early recognition and prompt treatment. Apart from strengthening government health facilities, the capacity of intermediate non-government health care providers should be developed for newborn care17.

A qualitative and quantitative study was conducted on the danger signs of neonatal illness: perceptions of caregivers and health workers in a rural community in Sarojininagar block, Uttar Pradesh, India. Participants were mothers, grandmothers, grandfathers, fathers or nannies and recognised health care providers serving the area and data were collected by structured questionnaire. The result of this study showed that among 210 caregivers, 30% recognised fever, irritability, weakness, abdominal distension breathing and diarrhoea as danger signs in neonates. Seventy nine (39.5%) of the caregivers had seen a sick neonate in the family in the past two years, with 30.38% in whom illness manifested as continuous crying. Healthcare was sought for 46 (23%) neonates. The study concluded that most of the caregivers were not aware of the danger signs of illness18.

A cross sectional study was conducted on assessment of mother’s knowledge, attitude and practices on symptoms and signs of newborn illness. The samples were 336 mothers selected by random sampling and data collection were done by the use of close ended Swahili version of the questionnaire. The result of the study revealed that mothers recognized symptoms of childhood diseases as fever, cough, inability to play, irritability and restlessness and diarrhoea by 92.5%, 85.3%, 83.5%, 81.1% and 80.8% respectively fatal symptoms of childhood diseases cited were convulsions, difficulty in breathing, unconsciousness, breastfeeding or eating difficulties and drowsiness by 92.5%, 90%, 89.8%, 88.0% and 88.0% respectively. Most mothers (89.2%) found no factor preventing them from seeking care, 98.2% and 99.4% of mothers took their children to health facilities once sick or developed any symptom of severe childhood disease. The study concluded that symptom recognition, attitude and practices were appropriate and directed towards proper management of childhood illnesses. Therefore implementation of maternal and child health programmes in government health facilities have improved health seeking for childhood disease19

6.2.3Studies related to management of newborn danger signs.

A study was conducted on treatment of asphyxiated newborns with moderate hypothermia in routine clinical practice in UK. Samples were 120 infants at the median of 40 weeks of gestation were taken for the study and data were collected by interview method about patient characteristics, condition at birth, resuscitation details, severity of encephalopathy, hourly temperature record,clinical complications and outcomes before hospital discharge. The result of the study revealed that cooling

was started at a median of 3 h 54 min (IQR 2 h–5 h 32 min) after birth. All but three Infants underwent whole body cooling. The mean (SD) rectal temperature from 6 to 72 h of the cooling period was 33.57°C (0.51°C). The daily encephalopathy score fell from 11 (6–15), 9.7 (5–14), 8 (5–13) and 7 (2–12) on days 1–4 days after birth, respectively. 51% of the infants established full oral feeding by 9 (4–24) days. 26%

of the study infants died. Clinical complications were not considered to be due to hypothermia. The study concluded that in the UK, therapeutic hypothermia following perinatal asphyxia is increasingly being provided. The target body temperature is successfully achieved and the clinical complications observed were not attributed to hypothermia. Treatment with hypothermia may have prevented the worsening of the encephalopathy that is commonly observed following asphyxia20.

A systematic review study was conducted on zinc for the treatment of diarrhoea, effect on diarrhoea morbidity, mortality and incidence of future episode in US. Data was collected from 13 samples by standardized and grading format. The result of the study revealed that Zinc supplementation decreased the proportion of diarrhoeal episodes which lasted beyond 7 days, risk of hospitalization, all-cause mortality and diarrhoea mortality. Using diarrhoea hospitalizations as the closest and most conservative possible proxy for diarrhoea mortality, zinc for the treatment of diarrhoea is estimated to decrease diarrhoea mortality by 23%. The study concluded that Zinc is an effective therapy for diarrhoea and will decrease diarrhoea morbidity and mortality when introduced and scaled-up in low-income countries21

A retrospective study was conducted on management of Hypothermia in Neonates with a locally made resuscitations trolley system in pre and post-operative newborn. Samples were 510 neonates with hypothermia. A four hourly record of axillary temperature of all the babies under study was kept. The warmer rods were operated at 750 watts maximum till the surface temperature of the babies was normal. The result revealed that out of 510 neonates 108 neonates suffered hypothermia during some phase of pre-operative period. 87% hypothermic babies were managed post-operatively. 15% normothermic babies were also managed on this automatic system. All the neonates with hypothermia preoperative and post-operative were managed successfully on this system. Of the fifteen normothermic neonates who were also managed on this resuscitation system, only two developed hypothermia of 1 degree C. The study concluded that proper warming system can prevent hypothermia in neonates and many lives can be saved22.

6.2.4 Studies related to prevention of newborn danger signs:

. A meta-analysis study was conducted on role of zinc administration in prevention of childhood diarrhoea and respiratory illnesses. Samples were 17 newborns and data collected by clinical assessment. The result revealed those children who received zinc supplement had fewer episodes of diarrhoea (rate ratio: 0.86) and respiratory tract infections (rate ratio: 0.92) and significantly fewer attacks of severe diarrhoea or dysentery (rate ratio: 0.85), persistent diarrhoea (rate ratio: 0.75), and lower respiratory tract infection or pneumonia (rate ratio: 0.80) than did those who received placebo. They also had significantly fewer total days with diarrhoea (rate ratio: 0.86) but not days with respiratory illness (rate ratio: 0.95). The study concluded that Zinc supplementation reduced significantly the frequency and severity of diarrhoea and respiratory illnesses and the duration of diarrheal morbidity23.

A time trend analysis study was conducted on prevalence of severe congenital heart disease after folic acid fortification in Canada.  Data analysed in two time periods (before and after fortification). Birth prevalence measured annually as infants (live and stillbirths) with severe congenital heart defects per 1000 births in Quebec. The result revealed that changes in the birth prevalence from the period before to the period after fortification were estimated with Poisson regression among the 324440 births in Quebec there were 2083 infants born with severe congenital heart defects, corresponding to an average birth prevalence of 1.57/1000 births. Time trend analysis showed no change in the birth prevalence of severe birth defects before fortification (rate ratio 1.01, 95% confidence interval 0.99 to 1.03), while after fortification there was a significant 6% decrease per year (0.94, 0.90 to 0.97). The study concluded that public health measures are needed to increase folic acid intake were followed by a decrease in the birth prevalence of severe congenital heart defects. These findings support the hypothesis that folic acid has a preventive effect on heart defects24.

A Systematic Review and Meta-analysis study was conducted on the role of phenobarbitone in the prevention and management of unconjugated hyperbilirubinemia during first two weeks of life in preterm neonates. Samples were 497 neonates. The result reported that peak serum bilirubin was significantly lower after phenobarbitone administration (2.29 to –1.27 – 95%). Duration of phototherapy was shorter (mean difference (26.67 to –2.83). Need of phototherapy (0.13 to 0.81) and exchange transfusion (0.14 to 0.64) were also reduced in phenobarbitone group. The study concluded that phenobarbitone reduces peak serum bilirubin and need of phototherapy and need of exchange transfusion in preterm very low birth weight neonates25.

STATEMENT OF THE PROBLEM:

A study to assess the Effectiveness of Structured Teaching Programme on Knowledge regarding selected Newborn Danger Signs among Post natal mothers in selected hospitals, Bengaluru.

6.3 OBJECTIVES OF THE STUDY:

1. To assess the pretest and posttest knowledge scores of postnatal mothers regarding newborn danger signs.

2. To determine the effectiveness of structured teaching programme on newborn danger signs.

3. To determine the association between pretest and posttest knowledge scores of postnatal mothers with selected socio demographic variables.

6.4 NULL HYPOTHESIS:

H01 –There will not be statistically significant difference between pretest and posttest knowledge scores on newborn danger signs.

H02-There will not be a significant association between pretest and posttest knowledge scores of the women with selected socio demographic variables.

6.5 RESEARCH VARIABLES:

INDEPENDENT VARIABLE: Structured teaching programme on newborn danger signs.

DEPENDENT VARIABLE: Knowledge of mother during postnatal period regarding newborn danger signs.

6. OPERATIONAL DEFINITIONS:

▪ EFFECTIVENESS: Refers to the extent to which the structured teaching programme has achieved the desired outcome as measured in terms of knowledge scores of postnatal mother.

▪ STRUCTURED TEACHING PROGRAMME:

▪ Refers to systematically developed teaching module designed for educating postnatal mother on newborn danger signs.

▪ KNOWLEDGE: Refers to the appropriate response received from the mother to the item elicited through a structured questionnaire schedule.

▪ NEWBORN DANGER SIGNS: Refers to danger signs which occur in the newborn within 30 days of life in selected areas such as pathological jaundice, vomiting, diarrhea, respiratory problem, poor feeding, and excessive weight loss.

▪ POSTNATAL MOTHER: Refers to the mother those who are in the period beginning immediately after the birth of a child and extending for about 6 weeks.

6.7 ASSUMPTIONS:

1. Postnatal mother may have some knowledge regarding newborn danger signs.

2. Postnatal mother may be more interested to know about the newborn danger signs.

6.8 DELIMITATION:

The study is delimited to the postnatal mother available at hospital during the period of data collection.

7.0 MATERIALS AND METHODS:

7.1 SOURCES OF DATA:

Data will be collected from the postnatal mother during postnatal period in selected hospitals, Bengaluru.

7.2 METHOD OF DATA COLLECTION:

The data for the study will be collected using a structured questionnaire schedule on newborn danger signs. That content will be validated by the experts and will be pretested and standardized through pilot study.

7.2.1 RESEARCH DESIGN:

Quasi experimental, one group pretest-posttest design.

7.2.2 RESEARCH APPROACH:

Evaluative approach will be adopted.

7.2.3 RESEARCH SETTING:

Study will be conducted in selected hospitals, Bengaluru.

7.2.4 POPULATION:

Population present study comprises of all the postnatal mothers during postnatal period in selected hospital.

7.2.5 SAMPLE:

It is a subset of the population selected for the study comprising of postnatal mothers during postnatal period in selected hospital, Bengaluru.

7.2.6 SAMPLE SIZE:

The sample size of present study consists of 50 postnatal mothers.

7.2.7 SAMPLING TECNIQUE:

Purposive sampling technique will be adopted.

7.2.8 SAMPLING CRITERIA:

Inclusion criteria:

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

2. Who are available at the time of data collection.

7.2.9 TOOLS FOR DATA COLLECTION:

Structured questionnaire schedule, it has two parts.

PART 1: Consists of items in the demographic variables such as age, education, religion, number of parity, occupation, income, previous knowledge yes or no, if yes source of information.

PART 2: Consist of knowledge items on newborn danger signs.

7.2.10 DATA ANALYSIS METHOD:

Data analysis is done through descriptive and inferential statistics.

DESCRIPTIVE STATISTICS:

Percentage, mean, mean percentage and standard deviation will be used to explain demographic variables and compute pretest and posttest knowledge scores.

INFERENTIAL STATISTICS:

1. PARAMETRIC TEST:

Paired‘t’ test will be used to compare pretest and posttest knowledge scores.

2. NON-PARAMETRIC TEST:

Chi-square test will be used to study the association between pretest and posttest knowledge scores with selected demographic variables. The results are statistically interpreted at the level of significance, P< 0.05.

7.3 DOES THE STUDY REQUIRE ANY INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR ANY OTHER HUMANS OR ANIMALS?

Yes, structured teaching programme is scheduled among postnatal mothers in selected hospital, Bengaluru.

7.4 HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION?

Permission will be obtained from the institutional ethical research committee of Dayananda Sagar College of nursing, Bengaluru.

Permission will be obtained from the hospital medical director.

Informed consent will be obtained from the postnatal mothers who are willing to participate in the study.

8. LIST OF REFERENCES

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3. Vincent Lannelli. M.D. Common newborn problem [online] 2011;march 27[cited Nov 3 2011]. Available from URL: http:// pediatric.cs/ agesstages/a/two- weeks-3htm.

4. Francis Blonde. Signs of illness in a Newborn [Online] [Cited Nov 5 2011].Available from URL: . Com/? signs-of-illness-in-a-New born& id = 4393922.

5. A.sen; D Mahalanabis; A.K. Singh; T.K. Bandypadhyay. Impact of a district level sick newborn care unit on neonatal mortality rate 2-year follow up. [Serial online] 2009; 29(2):150-155 [Cited Nov 4 2011]. Available from URL: articles/588984.

6. Shruthi Kapoor. Infant mortality rate in India. District level variation and correlation. [Online] 2010; may 22[cited nov23 2011]. Available from URL: http:// Sid. ac.in /pu/conference/ dec- 10- cof paper/ shruthikapoorpdf.

7. Susan.A. maternity, newborn and women health nursing: comprehensive care across. [Online] [Cited nov 25 2011].Available from URL: http;//Books.google.co.in/books?

8. Charlotte Warren, Pat Dally, LallaToure, Pyanade Mongi. Postnatal care. [Serial online] pp.80[cited2011nov23].AvailablefromURL: .

9. A.R. Dongre, P.R.Deshmukh, B.S.Garg. Perception and health seeking about newborn danger signs among mothers in rural wardha. Indian journal of paediatrics[Serial online]2008;vol:75,issue:4,pp325-329 [cited nov12 2011] . Available from URL: .

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11. Amy.J.Kesterton & John Cleland. Neonatal care health and harmful practices, the potential for change. [Online] 2009; may 20[cited Nov 13 2011]. Available from URL: http// 147/-2393/9/20.

12. Hondus .maternal and neonatal health. [Online][Cited Nov22]. Available from URL: http:// documents/A-Holistic-community-model for maternal- and-neonatal health-in Hondus .pdf.

13. C.S. Calado. What brings newborns to the emergency department [Serial online] 2009; apr 25 (4):244-8 [cited nov 25 2011]. Available from .

14. R.Smitha, S.C.Karat.D, Narayanappa, B. Krishna Murthy, S.N. Prassanth, N.B. Ramachandra. [Serial online] 2006; Vol: 12, issue: 1, pp.11-16 [cited nov 7 2011]. Available from URL: http:// articles.asp?issn=6886.

15. Shivamsundar Tikmani, Haider Javed, Farrukh Abbasi, Arjumand Rizvi, Garyh Darmstad, Anita.K.M.Zaidi. Incidence of neonatal hyperbilirubinemia: a population based prospective study. Tropical medicine and International health. [Serial online] 2010; may 9 Vol: 15, issue: 5, pp. 502-507. [Cited Nov 22 2011]. Available from URL: .

16. Rocha.G, Rocha.P, Proena.E, Quintas.C, Martine.T, Pissara.SS, GuimaraceM. Disorders of neonatal liver and bile ducts. Acta Med Port. [Serial online] sep-oct 23(5) pp767:7 [cited nov16 2011]. Available from URL: http:// ncbi.nlm.:21144315.

17. Amol. R. Dongre, Pradeep. R. Deshmukh, Bishan.S. Garg. Awareness and health care seeking for newborn danger signs among mothers. Indian Journal of Paediatrics [Serial online] 2009; 76(7), pp.691-693. [Cited Nov 27 2011].

18. Awasthi. S. Verma, Agarwal.M, Danger signs of neonatal illness: perception of care givers and health workers [Serial online] 2006; [cited nov 15]; Oct. 84(10) pp.819-26.

19. WHO and UNICEF. Mothers knowledge, attitude, practices on signs and symptoms of IMCI strategy addressed illness. [Online] 2007; July [cited Nov 5 2011].

20. D. Azzopardi, B. Strohm, A.D. Edwards.etc. Treatment of asphyxiated newborn with moderate hypothermia in routine clinical practice. Adc foetal and neonatal edition. [Online] 2008; dec 5[cited Nov 9 2011].Vol: 94, issue: 4. Available from URL: .

21. Christa. .Fisher Walker, Robert.Black. Zinc for the treatment for diarrhoea: effect on diarrhoea morbidity and incidence of future episodes. [online] [cited nov 27 2011]. Available from URL: 63.

22. KalidMahmood, ShijdHameed, Liaquat Ali. Management of hypothermia in neonates with a locally made resuscitation trolley system. [Online][Cited Nov 14 2011]. Available from URL:

23. Rakesh Agarwal, John Sentz, Mark. A, Millu. Zinc administration prevention of child hood diarrhoea and respiratory illness. Paediatrics [online] 2009; may 22[citednov29].AvailablefromURL:.

24. Raluca.L. Ariane.J.Marelti, Andrew .S, Mackie, Louise Pillote. Prevalence of severe congenital heart disease after folic acid fortification. [Online] [Cited Nov 29 2011]. Available from URL: http:// view articles/703199.

25. Deepak Chawla and Veena Pawar. Phenobarbitone for the prevention and treatment of unconjugated bilirubin in preterm infants. Indian Journal. [Serial online] 2010 may 8; 47(5) pp 401-7 [cited nov 22 2011] Available from URL: .

9. SIGNATURE OF THE STUDENT:

10. REMARKS OF THE GUIDE: The research topic is relevant as the study empowers the knowledge of postnatal mother regarding newborn danger signs.

11. NAME AND DESIGNATION OF THE GUIDE:

11.1 GUIDE NAME AND ADDRESS: Mrs. Laishram Dabashini Devi

Asst. Professor and HOD

Department of OBG nursing

Dayananda Sagar College of Nursing

Kumaraswamy layout

Bengaluru -560078

11.2 SIGNATURE OF THE GUIDE:

11.3 HEAD OF THE DEPARTMENT

NAME AND ADDRESS: Mrs. Laishram Dabashini Devi

Asst. Professor and HOD

Department of OBG Nursing

Dayananda Sagar College of Nursing

Kumaraswamy layout

Bengaluru -560078

11.4 SIGNATURE OF HOD:

12. REMARKS OF THE PRINCIPAL: The study is feasible to be conducted in selected hospitals.

13. SIGNATURE OF THE PRINCIPAL:

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