Skill development of Nurses in Managing the fourth stage of Labour

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1 Skill development of Nurses in Managing the fourth stage of Labour Navkiran Kaur, Sukhjit Kaur, P.K. Saha Abstract : The fourth stage of labour is crucial period of labour process. It is crucial because many life threatening complications can accompany this stage of labour. So it is vital to provide the nurses with full fledged knowledge and training for the management of the fourth stage of labour. The current study was undertaken with the objective to develop the skills of the staff nurses in the management of fourth stage of labour by providing them training. The protocol was developed and was validated by the experts for providing training to the nurses. Tools for data collection include Nursing Assessment sheet and observational checklist were developed andvalidated by the experts in nursing and obstetric department. Research setting was Clean labor room at Nehru Hospital, PGIMER, Chandigarh. Total 25 subjects were selected by using total enumerative sampling technique.the first step of the study included assessment of the baseline practices of the staff nurses for the management of fourth stage of labour i.e. Pre observation. In the second step, the nurses were given training in the form of demonstrations by using the developed protocol and nursing assessment sheet was implemented. After that, the performance of the staff nurses was assessed during the subsequent observations by using the observational checklist. On the completion of each observation, reinforcement was done in the form of re-demonstrations on the management of fourth stage of labour. The repeated observations were done (post 1, post 2, post 3, post 4) and repeated demonstrations were given after each observation till the subjects achieved maximum skill. Mean percent performance score (t-test) of pre observation and post 4 observation was 23.9±11.2 and 100, respectively (p<0.0005).in the pre observation, there were maximum (68%) subjects in poor category. Till the observation 3,most of the subjects (76%) were in excellent category. The study findings provide initial insights into the process of successful training of the staff nurses for participation in the care of their patients in fourth stage of labour. It is recommended that the nursing assessment sheet can be used in the clinical setting by the nurses to manage the patients in fourth stage of labour. Keywords Fourth stage of labour, Skill development Correspondence at Dr. Sukhjit Kaur Clinical Instructor National Institute of Nursing Education, PGIMER, Chandigarh Introduction The fourth stage of labour occurs immediately after the delivery of the placenta. It usually lasts for about 1 to 4 hours, and it initiates the postpartum period. During this stage the woman should be monitored closely because her body has just undergone many changes. In this stabilization phase, the uterus makes its Nursing and Midwifery Research Journal, Vol-10, No.1, January

2 initial readjustment to the non-pregnant 1, 2 state. The primary goal is to prevent haemorrhage from the uterine atony and the 2,3 cervical or vaginal lacerations. It is a very crucial time for both mother and the baby. Both are not only recovering from physical process of birth but also becoming 4,5 acquainted with each other. For the caregiver, the 4th stage is a time to frequently check the woman's physical wellbeing, her blood loss, feel if the uterus is contracting, possibly take her blood pressure and pulse as well as check the woman's genitals for any tears or grazes, and put in stitches if necessary.because there can occur some life threatening complications during immediate postpartum period, it is vital that the care during this period be 6, 7 thoroughly planned and provided. A study of postnatal and neonatal health problems and home remedies used during postpartum period by Molly Babu revealed that most of the health problems were found during immediate postpartum and are often ignored. The problem included after pain(68%), backache(48%), perineal discomfort(16%), shivering(14%), pain in 8 legs(12%), lack of sleep(11%), fatigue(7%). Potential complications during fourth stage of labour includes PPH, hypovolemic shock, perineal hematoma formation, urinary retention and infection.pph is responsible for around 35% of maternal mortality worldwide, reaching as high as 9, 10 60% in some countries Nursing care during 4th stage of labour: The goal of nursing of the nursing care in the postpartum period is to assist the women during their initial transition to parenting. It is vital that the care during this period be thoroughly planned and provided. Care is focused on the woman's physiological recovery, her psychological well-being and her ability to care for herself 11, 12 and her new baby. During the first hour in the recovery room, physical assessment of the mother is frequent. It is necessary to take vital signs 9 frequently. Nurse has to keep a pad count and record the number of pads soaked with lochia during recovery. Observe for constant trickle of bright red lochia. This may indicate 13,11, 14 lacerations. Encourage the mother to pass urine within half an hour after delivery. The maintain intake/output record is to be maintained. A volume of at least 150 ml is 15 expected for each voiding. The nurse should ensure the fundus remains firm. She has to chart fundal height.the patient should 14, 16 be evaluated for distended bladder. The nurse needs to evaluate the perineal area for signs of developing oedema and/or hematoma. She must assess the patient's complaints or expression of severe perineal pain and implement non pharmacological and pharmacological methods to relieve 17, 11 pain. The mother is encouraged to breast feed her baby as soon as possible after delivery preferably within half an hour. The mother should be taught about proper positioning and attachment during breast Nursing and Midwifery Research Journal, Vol-10, No.1, January

3 18 feeding. A cross-sectional study conducted in 10 maternity hospitals at Brazil showed that 47.1% of the mothers initiated breast feeding within the first hour after birth. Early initiation of breast feeding was associated with birth at full term pregnancy, mothers who received prenatal guidance regarding the advantages of breast feeding and vaginal 19 delivery. Interventions must be planned to meet the woman's individual needs for sleep and rest.hospital and nursing routines may be 20 adjusted to meet individual needs. After the initial recovery period is over, the mother is 4 encouraged to ambulate frequently. During the clinical posting of the researcher, it was found that, in spite of the fact that the fourth stage is such an important stage to be managed, it is an alien concept to most of the nurses. Many life threatening postpartum complications occurs during the fourth stage of labour which can be prevented by careful and intelligent observation by the nurses. For this they need training and some guidelines by following which, they can provide quality nursing care to the patients. It helps the nurses to provide consistent, continues and planned care to the mothers. So there is a great need for developing the skill of the nurses for the nursing management of fourth stage of labour so as to take care in the immediate postpartum period more effectively. Objective To develop the skill of the nurses for the management of fourth stage of labour after normal vaginal delivery. Materials and Methods An operational design was adopted to develop the skill of the nurses for the management of fourth stage of labour posted a t C l e a n L a b o u r R o o m, N e h r u Hospital,PGIMER, Chandigarh.Clean labour is situated on the 3rd floor of Nehru Hospital. It is 16 bedded. There is pre-labour room(ob-1), induction room(ob-2), PV room, delivery room with nursery attached to it, eclampsia room and postnatal room. The pre-labour and laboring mothers and high risk pregnancy cases are admitted in clean labour room. The postnatal mothers are transferred to labour room extention, maternity ward or gynae ward. Then they get discharge from these wards. Target population for study was staff nurses posted at Clean Labour Room. Total enumerative sampling technique was used to enroll 25 subjects. Protocols and tools were prepared after review of literature, consultation with experts and through informal observations in concerned areas. The prepared drafts of the tools were validated by the experts in the field of nursing and obstetrics. Tools developed and used for collecting data were socio-demographic profile of the nurses, nursing assessment sheet, observational checklist and protocol for nursing management of fourth stage of labour. 1. Nursing assessment Sheet for the management of fourth stage of labour: Researcher developed this sheet to help the nurses to observe and record the condition of the patient during the fourth stage of labour. This sheet was Nursing and Midwifery Research Journal, Vol-10, No.1, January

4 divided into four parts. The first part included the identification data of the mother. The second part consisted of the details about the baby such as sex, date and time of birth, birth weight and presence of any congenital abnormality. The third part contains the details of the events during the third stage of labour like, time of expulsion, method of removal and completeness of placenta. The fourth part of the sheet consisted of the assessment of the patient after the delivery of the placenta i.e. fourth stage of labour. It included assessing the patient for comfort, vital signs, drugs, fundus, lochia, urinary bladder including input and output record, perineal area for episiotomy, any injury, pain and finally assessing patient during ambulation and for initiation of breast feeding. 2. Protocol for management of fourth stage of labour: The researcher used the protocol guidelines to provide information to the nurses regarding the use of nursing assessment sheet for the management of fourth stage of labour. It included the following points: making the mother comfortable, continues observation of the mother i.e. assessment of vital signs frequently, palpating the fundus for firmness, assessing the amount of lochia by keeping a pad count, to inspect the condition of the perineum, to assess the bladder for fullness and maintain intake output record of the mother, to encourage the mother for early ambulation and early initiation of breast feeding. 3. Observational checklist for the management of fourth stage of labour: The observational checklist for evaluation of management of fourth stage of labour was developed. Researcher evaluated the skills of the nurses by using the checklist. The checklist for observing the practice regarding the management of fourth stage of labour was divided into three parts i.e. the care given before shifting m o t h e r t o t h e p o s t n a t a l unit,immediately after shifting mother to the postnatal unit and within one hour of shifting mother to the postnatal unit.the researcher used the same checklist for pre and multiple post observation and compared the skill development on the basis of the same. There were maximum five observations done for the subjects i.e. one pre observation and maximum four post observations (post 1, post 2, post 3, post 4). One score was given for each correct step and 0 score for each missing or incorrect step. The maximum possible score was 23. Ethical clearance for the study was obtained from institute ethical committee & written consent was taken from the subjects. Data was collected in the month of July- August, A written permission for conducting the study was sought from Head of Department of Obstetrics and Gynecology. Nursing sister in charge of concerned area was informed about study. Data collection: The first step of the study included assessment of the baseline practices of the individual staff nurse for the Nursing and Midwifery Research Journal, Vol-10, No.1, January

5 management of fourth stage of labour i.e. Pre observation. This observation was done by using the observational checklist by the researcher. In the second step, the nurses were given training individually by the r e s e a r c h e r w h i c h i n c l u d e d l i v e demonstrations on patients by following the guidelines of protocol for managing the patient during fourth stage of labour and providing information regarding filling the nursing assessment sheet. After that, the performance of the staff nurses was assessed by the researcher during the post 1 observation by using the observational checklist. On the completion of post 1 observation, reinforcement was done in the form of re-demonstrations (especially for the steps which were left by the nurses) on the management of fourth stage of labour. Similarly, the repeated observations were done (post 2, post 3, post 4) and repeated demonstrations were given after each observation to make the corrections till the subjects achieved maximum skill. The nurses were informed about the observations. The frequency of the demonstrations depend upon the duty shifts of the nurses and the availability of the patients had undergone normal vaginal delivery. The training and observation of 25 staff nurses was completed in 2 months. Descriptive and inferential statistics was used for analysis and interpretation of data by applying the various statistical measures such as measures of central tendency, measures of dispersion, percentage, parametric tests like repeated ANOVA, paired t-test. Categorization of performance score of the subjects Performance score of the subjects were categorized as excellent, very good, good, fair and poor as per the scores obtained by the subjects. Table 1: Categorization of performance score of the subjects Results Category Performance Score(%) for the management of fourth stage of labour Poor (<30%) Fair (31-50%) Good (51-70%) Very Good (71-90%) Excellent (91-100%) The study consisted of 25 subjects. One pre and multiple post observations were carried out for each subject. The data was c o l l e c t e d b y u s i n g o b s e r v a t i o n checklist.majority of the subjects were in the age group of year resulting in the mean age of ± 5.3years. More than half of the subjects were Graduate in nursing(60%). Forty percent of the subjects were having experience of 6-10 years resulting in the mean experience of 8.78 ± 5.75 years. Maximum number of subjects (96%) had the designation of Sister grade 2. Nursing and Midwifery Research Journal, Vol-10, No.1, January

6 Table 1: Age and work profile of the subjects (N=25) Variables Group (n=25) f (%) Age category (in years) (16) Mean ±SD = ± 5.334yrs 09 (36) (24) Range=23-40 yrs (24) Professional Qualification G.N.M. 09 (36) BSc. Nursing 15 (60) MSc. Nursing 01 (04) Experience (in years) (32) 6-10 Mean ± SD= ± yrs 10 (40) Range=1-20 yrs 02 (08) (20) Designation Sister grade 1 01 (04) Sister grade 2 24 (96) Table 2 depicts the number of the subjects performed correct steps for the management of fourth stage of labour during subsequent observations before shifting mother to the postnatal unit. In pre observation (baseline), 32% of the subjects had given comfortable position to the mother and assisted her to move from delivery table to the postnatal unit. Whereas, only 4% of the subjects removed the drapes and soiled linen from the delivery table and offered warm blanket to the patient to prevent chills. In post 1 observation, there was significant increase in the number of subjects who had given comfortable position to the mother and helped the mother to change soiled clothings. In post 2 observation, 96% of the subjects had given comfortable position to the mother. In post 3 observation, all the subjects had given comfortable position to the mother and provided sterile perineal pad to the mother. In post 4 observation, all the subjects performed all the steps correctly. Indicating that with regular assessment and reinforcement all the nurses started practicing all the steps of management of forth stage of labour before shifting the mother the post natal unit. Nursing and Midwifery Research Journal, Vol-10, No.1, January

7 Table 2: Subjects performed correct steps for the management of fourth stage of labour during pre and post training observations before shifting mother to the postnatal unit N = 25 Nursing Activities Subjects performed correct steps for th 4 Stage of labour managing Before shifting mother to the Pre Post 1 Post 2 Post 3 Post 4 postnatal unit n (%) n (%) n (%) n (%) n (%) 1. Removed the drapes and 1(4%) 8(32%) 12(48%) 23(92%) 25(100%) soiled linen from the delivery table 2. Given comfortable position 8(32%) 23(92%) 24(96%) 25(100%) 25(100%) to the mother 3. Helped the mother to 15(60%) 22(88%) 22(88%) 24(96%) 25(100%) change soiled clothings 4. Provided sterile perineal 15(60%) 20(80%) 23(92%) 25(100%) 25(100%) pad to the mother 5. Offered warm blanket to 1(4%) 4(16%) 6(24%) 20(80%) 25(100%) the patient to prevent chills 6. Assisted the patient to 8(32%) 17(68%) 17(68%) 23(92%) 25(100%) move from delivery table to the postnatal unit Table 3 depicts the number of the subjects performed correct steps for the management of fourth stage of labour during subsequent observations immediately after shifting mother to the postnatal unit.in pre observation (baseline), none of the subjects had observed the perineal area for discoloration and swelling and assessed the perineal area for injuries and lacerations. Very few subjects had performed other steps. In post 1 observation, there was significant improvement in the number of subjects who had assessed the patient for perineal pain. In post 2 observation, there was decrease in the number of subjects who had offered fluids and light snacks to the mother and provided the prescribed medication to the mother (96% and 92% respectively).in post 4 observation, all the subjects performed all the steps correctly. This has indicated that with regular assessment and reinforcement nurses were able to practice correct steps of management of forth stage of labour immediately after shifting to post natal unit. Nursing and Midwifery Research Journal, Vol-10, No.1, January

8 Table 3: Subjects performed correct steps for the management of fourth stage of labourduring pre and post training observations immediately aftershifting mother to the postnatal unit N = 25 Nursing Activities Subjects performed correct steps for th 4 Stage of labour managing Immediately aftershifting Pre Post 1 Post 2 Post 3 Post 4 mother to the postnatal unit n (%) n (%) n (%) n (%) n (%) 1. Offered fluids and light 23(92%) 25(100%) 24(96%) 25(100%) 25(100%) snacks to the mother 2. Provided the prescribed 23(92%) 25(100%) 23(92%) 25(100%) 25(100%) medication to the mother 3. Monitored and record the 2(8%) 8(32%) 19(76%) 24(96%) 25(100%) vital signs of the patient hourly 4. Observed for bright red 3(12%) 4(16%) 10(40%) 24(96%) 25(100%) bleeding, blood clots 5. Observed the perineal area 0(0%) 4(16%) 6(24%) 20(80%) 25(100%) for discoloration and swelling 6. Assessed the patient for 4(16%) 17(68%) 24(96%) 24(96%) 25(100%) perineal pain 7. Assessed the perineal area 0(0%) 5(20%) 5(20%) 21(84%) 25(100%) for injuries and lacerations Table 4 depicts the number of the subjects performed correct steps for the management of fourth stage of labour during subsequent observations within one hour of shifting mother to the postnatal unit. In pre observation (baseline), some steps like recording the number of pads soaked with bleeding p/v,maintaining intake/ output record and documentation of fundal height before and after the patient urinate were not performed by even a single subject.in post 2 observation,96% of the subjects had followed the steps like palpate the fundus to check the firmness, observe the fundus for deviation from midline and record the number of pads soaked with bleeding p/v.in post 3 observation, maximum subjects followed all the steps. In post 4 observation, all the subjects performed correct steps. This indicated that with regular assessment and reinforcement nurses were able to practice correct steps of management of fourth stage of labour within one hour of shifting into post natal unit. Nursing and Midwifery Research Journal, Vol-10, No.1, January

9 Table 4: Number of the subjects performed correct steps for the management of fourth stage of labour during pre and post training observations within one hour of shifting mother to the postnatal unit N = 25 Nursing Activities Subjects performed correct steps for th 4 Stage of labour managing With one hour of shifting mother Pre Post 1 Post 2 Post 3 Post 4 mother to the postnatal unit n (%) n (%) n (%) n (%) n (%) 1. Palpate the fundus to 2(8%) 22(88%) 24(96%) 25(100%) 25(100%) check the firmness 2. Observed the fundus for 1(4%) 19(76%) 24(96%) 25(100%) 25(100%) deviation from midline 3. Informed physician about 1(4%) 3(12%) 11(44%) 22(88%) 25(100%) the condition of the fundus 4. Recorded the number 0(0%) 18(72%) 24(96%) 25(100%) 25(100%) of pads soaked with bleeding p/v 5. Observed the patient for 1(4%) 7(28%) 11(44%) 23(92%) 25(100%) distended bladder 6. Assisted the patient to 11(44%) 19(76%) 25(100%) 25(100%) 25(100%) empty her bladder within 30 minutes after delivery 7. Maintained intake/ output 0(0%) 19(76%) 22(88%) 25(100%) 25(100%) record 8. Document the fundal 0(0%) 8(32%) 18(72%) 25(100%) 25(100%) height before and after the patient urinate 9. Encouraged the patient 3(12%) 17(68%) 21(84%) 25(100%) 25(100%) for early ambulation 10. Encouraged and ensure 17(68%) 23(92%) 23(92%) 25(100%) 25(100%) that the mother has breast fed her baby within 30 minutes after delivery Nursing and Midwifery Research Journal, Vol-10, No.1, January

10 Table 5 represents the performace score of subjects learning skills while management of fourth stage of labour. In the pre observation, 68% subjects were having poor performance, 28% had fair performance and only one subject had good performance. In post 1 observation, 64% subjects had good performance, 16% had fair performance, 16% had very good performance and only one subject performed poorly. In post 2observation, 48% of the subjects performed very good category, 40% good, 2 subjects performed excellent. Only one subject performed fair. In post 3 observation, most of the subjects (76%) performed excellent, 20% performed very good and only one subject performed good. In the post 4 observation, all the subjects (100%) had excellent performance. Table 5: Performance score of the subjects learning skills for management of fourth stage of labour in pre and post training observations N = 25 Category wise assessment Observations Scores Pre test Post test 1 Post test 2 Post test 3 Post test 4 n (%) n (%) n (%) n (%) n (%) Poor (<30%) 17(68%) 1(4%) Fair (31-50%) 7(28%) 4(16%) 1(4%) - - Good (51-70%) 1(4%) 16(64%) 10(40%) 1(4%) - V. good (71-90%) - 4(16%) 12(48%) 5(20%) - Excellent (91-100%) - - 2(8%) 19(76)% 25 (100%) Maximum performance score 25(100%) Repeated measures ANOVA among all consecutive observations of management of fourth stage of labour Table 6 depicts the comparison of mean performance score of the subjects during subsequent observations. Post 2 observation was significantly better performance score than pre implementation observation. In post 3 observation, the nurse's performance score was significantly lesser than post 4 observation. There was significant difference between the performance score of pre observation with p o s t 3 ( p < ) a n d p o s t 4(p<.001)obser vation.in Post 4 observation, nurses had significantly better performance score than pre, post1, post 2 and post 3 observation. Nursing and Midwifery Research Journal, Vol-10, No.1, January

11 Table 6: A repeated measures ANOVA with mean performance score of the subjects during the management of the fourth stage of labour Measure: Skill Observations Mean Difference Std. Error p-value Pre Post Post Post <.001 Post <.001 Post 1 Pre Post Post Post Post 2 Pre Post Post <.001 Post Post 3 Pre <.001 Post Post <.001 Post <.001 Post 4 Pre <.001 Post Post Post <.001 Discussion The fourth stage of labour is the most crucial time for both the mother and the baby. Both are not only recovering from physical process of birth but also becoming acquainted with each other. During this time the maternal organs undergo initial readjustment to the non pregnant state and the functions of the body begin to stabilize. Meanwhile the newborn continues the transition from intrauterine to extra uterine 1, 4 existence. There can be some potential complications that can occur during the fourth stage of labour like PPH, hypovolemic shock, perineal hematoma formation, urinary retention and infection etc. According to WHO survey of 2010, it was stated that PPH alone is responsible for 35% of maternal mortality in the world reaching as high as 60% in some countries.present Nursing and Midwifery Research Journal, Vol-10, No.1, January

12 study was conducted with the objective of the developing the skills of the staff nurses regarding the management of the fourth stage of labour at CLR, Nehru Hospital, PGIMER, Chandigarh. During the clinical posting of the researcher, it was found that, in spite of the fact that the fourth stage is such an important stage to be managed, the staff nurses were not following the steps for managing the fourth stage of labour properly. So there was a need to develop protocol and some guidelines by following which, they can provide quality nursing care to the patients. The first step of the study included assessment of the baseline practices of the individual staff nurse for the management of fourth stage of labour without giving any training by using the observational checklist. Staff nurses were trained by using the protocol guidelines and information was provided regarding filling the nursing assessment sheet. After that, the performance of the staff nurses was assessed after each training session. On the completion of each training session, reinforcement was done in the form of redemonstrations (especially for the steps which were left by the nurses) on the management of fourth stage of labour. Similarly, the repeated trainings were done (post 2, post 3, post 4) till the subjects achieved maximum skill. The nurses were informed about the observations. In the present study, it was found that during pre observation most of the subjects were not following all the steps of management of the fourth stage of labour. Almost similar results were shown by many studies which stated that many complications during immediate postpartum period occurs as a result of lack of proper nursing management. A study by Molly Babu revealed that most of the health problems were found during immediate postpartum and are often ignored. The problem included after pain (68%), backache (48%), perineal discomfort (16%), shivering (14%), pain in legs (12%), lack of sleep (11%), fatigue 8 (7%). Another similar study revealed that the major causes of maternal death as anemia (21%), hemorrhage after delivery (21%) followed by retained placenta (17%) and puerperal sepsis (11%) occur due to lack of proper management during postnatal 21 period. In the present study, during pre observation, only few subjects had followed the steps of managing the fourth stage of labour and none of the subject had kept a record of the number of pads soaked with bleeding p/v which is one of the most important step in assessing the patient for PPH.None of the subjects maintained intake/ output record of the mother and documented the fundal height before and after the patient urinate. After training in subsequent observations, skill of nurses improved and all of them performed all steps which shows that with training and regular motivation the performance of nurses to manage the fourth stage of labour has been improved. Hence, it is concluded that the skills of the staff nurses can be improved significantly through such type of training programs. Almost all the staff nurses had poor knowledge and skills regarding the Nursing and Midwifery Research Journal, Vol-10, No.1, January

13 management of the fourth stage of labour before demonstration and guidelines. After repeated training, the staff nurses were able to fill the nursing assessment sheet and performed all the steps for the management of fourth stage of labour. It is recommended that further study can be extended to the labour room in other settings.a study can be conducted on a large number of samples for an extended period of time including community setting and further studies can be conducted with improved Nursing Assessment Sheet and protocol with broader concept regarding the fourth stage of labour In nursing practice, the protocol guidelines and nursing assessment sheet can assist the staff nurses to enhance their competences in managing the fourth stage of l a b o u r. Va r i o u s l i f e t h r e a t e n i n g complications during fourth stage can be assessed and can be managed timely. Initiatives can be taken by health team, hospital administrators for the promotion of nursing assessment sheet and management protocol and availability to the staff nurses in the postnatal units. References 1. World Health Organization (WHO) Mother-Baby Package: Implementing Safe Motherhood in Countries. WHO/FHE/MSM/ Geneva: WHO; Bendetti T, Gabbe S, NiebylJ, Simpson J. Obstetrics: Normal and problem pregnancies. th 4 ed. New York. Churchill Livingstone; Marshall M, Buffington ST, Beck D, Clark A. Life th Saving Skills Manual for Midwives, Draft. 4 Ed Module 5: Hemorrhage - Prevent and Manage. American College of Nurse-Midwives Paul I, Phillip T, Widome M, Hollenbeak C. Cost effectiveness of postnatal home nursing visits for prevention of hospital care for jaundice and dehydration. Pediatrics 2004; 114(4): th 5. Dutta DC. Textbook of obstetrics.6 edition. Calcutta.newcwntral book publications; WHO. Working with Individuals, Families and Communities to Improve Maternal and Newborn Health [Internet]. [Geneva] WHO; 2003[cited on 2013 Jan 26]. Available from: www. who. int/ reproductivehealth/publications/ifc/index. 7. Troy N.Is the significance of postpartum fatigue being over looked in the lives of women?american Jounral of Maternal Child Nursing. Dec 2003; 28(4): Babu M. Home remedies used during postpartum period. The Indian journal of nursing and midwifery.1998;1(3): Source: WHO. Managing Complications in pregnancy and childbirth [Internet].[Geneva]: WHO; 2000.[cited 2012 November 26] A v a i l a b l e f r o m : h t t p : / / w w w. w h o. i n t / r e p r o d u c t i v e - health/impac/symptoms/vaginal_bleeding_aft er_s25_s World Health Organization (WHO). Biennial Report : Research on Reproductive Health [Internet]. [Geneva] WHO; 2002 [cited on 2012 December 22]. Available at: h t t p : / / w w w. w h o. i n t / r e p r o d u c t i v e - health/publicationsbiennial_reports/ /chapter_2.pdf. 11. Obstetrics and Newborn care-ii. Stages of labour and nursing care. [online] [cited on 2012 January 26]. Available from: Nursing and Midwifery Research Journal, Vol-10, No.1, January

14 12. Campbell OM, Graham WJ. Lancet Maternal Survival Series Steering Group. Strategies for reducing maternal mortality: getting on with w h a t w o r k s. L a n c e t ; (9543): Luengenbiehl D. American of Maternal Child Nursing. Improving visual estimation of blood volume on peripads. Oct. 1997; 28(2): W o r l d H e a l t h O r g a n i z a t i o n. W H O recommendations for the prevention of postpartum haemorrhage [Internet].[Geneva] WHO; 2007 [cited on 2013 Jan. 12]. Available f r o m : h t t p : / / w h q l i b d o c. who.int/hq/2007/who_mps_07.06_eng.pdf 15. Sampselle C, Wyman J, Thomas K, Newman D, Gray M, Dougherty M. et al Continence for women: Atest of AWHONN's evidence based protocol in clinical practice. Journal of obstetrics, Gynaecologic and Neonatal nursing.2000;29(1): World Health Organization. WHO guidelines for the management of postpartum haemorrhage and retained placenta [Internet]. [Geneva] WHO; 2009 [cited on 2012 December 2 5 ]. A v a i l a b l e f r o m : _eng.pdf 17. World Health Organization. Managing complication in pregnancy and childbirth: a g u i d e f o r m i d w i v e s a n d doctors[internet].[geneva WHO]; 2000 [cited on 2012 November 18]. Available from: tions/maternal_perinatal_health/ e n/index.html 18. Donnelly A. Commercial hospital discharge packs for breastfeeding women (Cochrane Review). In The Cochrane Library, Issue 2, Chichester, UK: John Wiley & Sons. 19. Vieira TO, Vieira GO, Giugliani ER, Mendes CM, Martins CC, Silva LR. Source: State University of Feira de Santana, Bahia, Brazil. BMC Public Health [Internet] Dec. [cited on 2012 Nov 18] Available from: t_vieira@terra.com.br. 20. Schmied V, Cooke M, Gutwein R, Steinlein E, Homer E. Women and birth 2008; 21(3): Skirah H. Puerperal sepsis[internet].[place unknown]: Sakirah and Associates;2004[cited o n D e c 1 2 ]. A v a i l a b l e a t : U R L : i c m r. n i c. i n / a n n u a l / /nims/completed_stud.pdf_ Nursing and Midwifery Research Journal, Vol-10, No.1, January