Research study pdf

I
A STUDY TO ASSESS THE KNOWLEDGE OF STAFF NURSES
REGARDING PREVENTION AND MANAGEMENT OF
PERINEAL TEAR DURING NORMAL DELIVERY AT
SELECTED HOSPITALS OF LUCKNOW (U.P.) WITH A VIEW
TO DEVELOP SELF INSTRUCTIONAL MODULE (SIM)”
A
THESIS
SUBMITTED TO THE
SARVEPALLI RADHAKRISHNAN UNIVERSITY, BHOPAL
FOR THE DEGREE
OF
DOCTOR OFPHILOSOPHY
IN
NURSING
BY
ANJALATCHI
Registration No. 66004405
UNDER THE GUIDANCE OF
DR. P. SHANTHI SOPHIA IDA
SARVEPALLI RADHAKRISHNAN UNIVERSITY, BHOPAL
YEAR 2021

II
DECLARATION BY THE CANDIDATE
I declare that the thesis entitled “A study to assess the knowledge of staff
nurses regarding prevention and management of perineal tear during normal delivery
at selected hospitals of Lucknow (U.P.) with a view to develop self instructional
module (SIM)” is my own work conducted under the supervision of Dr. P Shanthi
Sophia Ida at RKDF College of Nursing, Bhopal approved by the Research Degree
Committee. I have put in more than 240 days of attendance with the supervisor at the
center.
I further declare that to the best of my knowledge, this thesis does not contain
any part of any work which has been submitted for the award of any degree either by
this university or by any other university without proper citation.
(Signature of the candidate)
Anjalatchi
Registration Number: 66004405
Date: ………………
Place: Bhopal

III
CERTIFICATE OF THE SUPERVISOR
This is to certified that this work entitled “A study to assess the
knowledge of staff nurses regarding prevention and management of perineal tear
during normal delivery at selected hospitals of Lucknow (U.P.) with a view to
develop self instructional module (SIM)” is a piece of research work done by Ms.
Anjalatchi under my/ our guidance and supervision for the degree of Doctor of
philosophy of Nursing Sarvepalli Radhakrishnan University, Bhopal (M.P.) India. I
certify that the candidate has put in an attendance of more than 240 days with me. To
the best of my knowledge and belief the thesis:
I. Embodies the work of candidate himself/ herself,
II. Has duly been completed
III. Fulfills the requirement of the ordinance related to Ph.D. degree of the
University.
Signature of the Co – Supervisor Signature of the Supervisor
Dr. Mohammed Umar Khan Dr. P. Shanthi Sophia Ida
Date: ……………………… Date: …………………..

IV
ACKNOWLEDGEMENT
I would like to express my hurtful gratitude to the following persons who
contributed to accomplishments of this research study.
Firstly, I am grateful to Almighty God whose grace, unconditional love and
blessings accompanied me throughout the study.
I indebted to honourable Chancellor, Sarvepalli Radhakrishnan University,
Bhopal for allowing me to carry my research work in this university.
I would like to give specisl thanks to Principal Dr. Archana Salvan RKDF
College of Nursing for continuous support and guidance through out the study.
I would like to express my hurtful gratitude to my guide Dr. P. Shanthi
Sophia Ida, research guide of Sarvepalli Radhakrishnan University, Bhopal for
proving me an opportunity to conduct this study as a part of my fulfilments of
doctorate degree in Nursing.
Special acknowledge goes to my co Guide Dr. Mohammed Umar Khan,
Associate Professor, HOD, Medical Surgical Nursing, Upchar College of Nursing,
Jaipur for continuous guidance, support and suggestion.
I would like to express my sincere gratitude to faculty member of Sarvepalli
Radhakrishnan University, Bhopal, for their co-operation & their support.
I would like to express my sincere thanks to faculty member of Research
Committee for their co-operation and necessary arrangement and solve the problem
throughout my study.
I express my heartfelt gratitude to all the Experts for validating the tool and
giving necessary correction.
My sincere thanks go to Era‟s Lucknow Medical College and Hospital, K.K.
Hospital, Lucknow, Unity Hospital, Lucknow who give permit to conduct the study.

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I would like to thanks to My Father C. Dhanasekaran and my Mother D.
Pushpavali for continuous encouragement and prayer for me during my study.
In the same way, I would like to give my sincere thanks to all those who have
directly or indirectly helped in successful completion of thesis.
With Gratitude
Date: Signature of the Candidate
Anjalatchi

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ABSTRACT
A study to assess the knowledge of staff nurses regarding prevention and
management of perineal tear during normal delivery at selected hospitals of Lucknow
(U.P.) with a view to develop self instructional module (SIM)” was conducted by Ms.
Anjalatchi followed by following objectives:
The objectives of the study were
1. To assess knowledge of staff nurses regarding prevention and management of
perineal tear during normal delivery.
2. To find association between knowledge regarding prevention and management
of perineal tear with selected demographic variables.
Conceptual framework refers to interrelated concepts or abstractions that are
assembled together in some rational scheme by virtue of their relevance to a common
theme; they serve as a spring board for the generation of hypothesis to be tested.
One of the important purposes of conceptual framework is to communicate
clearly the interrelationship of various concepts. It guides an investigator to know
what data needs to be collected and give directions to the entire research process.
The present study aims to assess the knowledge of staff nurses regarding
prevention and management of perineal tear during normal delivery. The conceptual
frame work of the present studies based on Halls care, core, cure model which
provides the basis of care.
The halls model consists of three interlocking circles core circle, care circle
and cure circle.
ResearchMethodology
The research approach used for present study was descriptive research
approach. The research design adopted for the present study was non experimental
research design. The group consisted of 250 staff nurses mothers that were selected on
the basis of the sampling criteria and purposive sampling technique set for the study.

VII
The Demographic variables selected for this study are age, gender, education
qualification, work experience, work experience in labour room, previous knowledge.
The tool developed and used for the data collection constituted for two parts:
Section – I: This section is the first section seeking information on demographic
information of the staff nurses and Section-II: This section is the second part of
structured knowledge questionnaire, which consists of questions assessing knowledge
about perineal tear.
The pilot study was done on 20 mothers from Era‟s Lucknow Medical College
and Hospital. The content validity of the tool was determined by 11 experts and the
value of reliability co efficient was 0.88 which suggested that tool is highly reliable.
The data collection for main study was conducted from 25/06/2019 to 18/08/2019 at
Era‟s Lucknow Medical College and Hospital, K.K. Hospital, Lucknow, Unity
Hospital, Lucknow.
With regard to scores, 70 (28%) staff nurses had poor knowledge, 85 (34%)
staff nurses had average knowledge and 95 (38%) staff nurses had good knowledge
regarding prevention and management of perineal tear.
The mean, mean percentage, median and standard deviation of first part that
was related to concept of perineal tear, were 7.94, 72.18%, 8 and 2.00 respectively.
Regarding pre-vention of perineal tear the mean, mean percentage, median and
standard deviation were 3.70, 61.66%, 4, and 1.04 respectively. About management of
perineal tear the mean, mean percentage, median and standard deviation was 10.76,
82.76%, 11 and 1.68 respectively. The overall level of knowledge of staff nurses
regarding prevention and management of perineal tear the mean, mean percentage,
median and standard deviation were 22.40, 74.66%, 22 and 2.91 respectively.
Conclusion
On the basis of results it is conclude that maximum number of staff nurses
were had average knowledge and minimum had good knowledge regarding
prevention and management of perineal tear. The maximum mean score of s

VIII
Staff nurses was in the area of management of perineal tear with 1.68 SD. The
overall knowledge score of staff nurses was 22.40 mean, 74.66% mean percentage, 22
median with 2.91 SD.
On the basis of results it is can also conclude that the knowledge level of staff
nurses were significant associated with demographic variables like educational
qualification, work experience, experience in labour room and previous knowledge
because here the calculate value was more than tabulate value. Some demographic
variables like age and gender was not significant associated with level of knowledge.
It is recommended
 A study can be replicated on a larger sample thereby findings can
b
egeneralized for a larger population.
 A comparative study can be conducted to evaluate the effectiveness o
f
a
planned teaching programme.
 A similar study can be conducted in community setting.
An experimental study can be undertaken with control group.

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TABLE OF CONTENTS
CHAPTER CONTENT PAGE NO.
CHAPTER I
INTRODUCTION
Introduction
Need for the study
Statement of the problem
Objectives of the study
Operational definitions
Assumption
Hypotheses
Delimitations
Conceptual framework
CHAPTER II REVIEW OF LITERATURE
CHAPTER III
RESEARCH METHODOLOGY
Research approach
Research Design
Variables under investigation
Setting of the study
Population
Sample
Sampling Technique
Sample size
Data collection technique and instrument
Description of the tool
Pre testing of tool & Reliability
Pilot study
Ethical consideration
Procedure for Data collection
Plan for data analysis

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CHAPTER IV
DATA ANALYSIS AND INTERPRETATION
OF FINDINGS
Section I: Description of demographic variables of
the staff nurses
Section II: Assess the knowledge levels of staff
nurses regarding perineal tear
Section III: Association between knowledge levels
of staff nurses with demographic variables
regarding perineal tear
CHAPTER – V DISCUSSION
CHAPTER VI
SUMMARY AND CONCLUSION
Summary
Conclusion
Nursing Implication
Limitations
Recommendations
BIBLIOGRAPHY
ANNEXURE

XI
LIST OF FIGURES
S. NO. FIGURE NO. TITLE PAGE NO.
1. 1.1 Conceptual Framework Based On Hall‟s Theory –
Core Care And Cure Model
2. 3.1 Schematic Representation of Research
Methodology
3. 4.1 Column Diagram Showing Percentage Distribution
Of Staff Nurses According To Their Age
4. 4.2 Pie Diagram Showing Percentage Distribution Of
Staff Nurse According To Their Gender
5. 4.3 Cylindrical Diagram Showing Percentage
Distribution Of Staff Nurses According To Their
Educational Qualification
6. 4.4 Cone Diagram Showing Percentage Distribution
Of Staff Nurses According To Their Work
Experience
7. 4.5 Pyramid Diagram Showing Percentage
Distribution Of Staff Nurses According To Their
Experience In Labour Room
8. 4.6 Pie Diagram Showing Percentage Distribution Of
Staff Nurses According To Their Previous
Knowledge

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LIST OF TABLES
S. NO. TABLE NO. TITLE PAGE NO.
1. 4.1 Distribution Of Staff Nurses According To Age
2. 4.2 Distribution Of Staff Nurses According To Gender
3. 4.3 Distribution Of Staff Nurses According To
4. 4.4 Distribution Of Staff Nurses According To Work
Experience
5. 4.5 Distribution Of Staff Nurses According To Work
Experience In Labor Room
6. 4.6 Distribution Of Staff Nurses According To
Previous Knowledge
7. 4.7 Comparison Of Level Of Knowledge Score Of
Staff Nurses Regarding Prevention And
Management Of Perineal Tear
8. 4.8 Area Wise Level Of Knowledge Score Of Staff
Nurses
9. 4.9 Association Between Knowledge Levels Of Staff
Nurses With Demographic Variable

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LIST OF ABBREVIATIONS
OASI : Obstetrical Anal Sphincter Injuries
WHO : World Health Organization
NSW : New South Wales
ANC : Ante Natal Care
OB/GYN : Obstetrics and Gynecology
H : Hypothesis
SD : Standard Deviation
df : Degree of Freedom
χ2 : Chi Square
FIG. : Figure

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CHAPTER – I
INTRODUCTION
INTRODUCTION
“There is such a special sweetness in being able to participate in creation”
–Pamela S. Nadav
Pregnancy and child births are a cherished dream for mother and bring joy to
the whole family. It is one of the vital events which need special care from conception
to postnatal period. Every mother wants to enjoy the nine months period with the
baby inside her. The onset of motherhood presents a unique set of physical, emotional
and psychological challenges. The challenges become even more when the new
mother experience genital tract trauma as a result of child birth. Maternal injuries
following childbirth process is quite common and contributes significantly to maternal
morbidity and even to death. Early detection, prompt and effective management not
only minimizes the morbidity but prevent many gynecological problems developing
in later life. Therefore caring the women during pregnancy and delivery is
tremendously significant in health care delivery system.1
The term trauma is defined as a physical wound or injury. Genital trauma is
one of the traumas which occur during vaginal birth. It involves trauma or injuries at
vulva, vagina, perineum, cervix, and uterus. Most acute injuries and lacerations of the
perineum, vagina, uterus, and their support tissues occur during childbirth.2
Nature has the best owed women with the capacity of producing children the
process that makes her mother. For this she has to undergo a very painful process of
labour. The delivery of a child can take place either through the vagina or through the
abdomen. 99% of delivery takes place through the vagina which can be called as
normal labour. Normal labour is a series of events that takes place in the birth canal
with an effort of expelling the viable product of conception through the birth canal to
outside world. In this process the fetus, placenta and membrane are expelled from the

15
mother‟s uterus. Labour is an appropriate term for the process because it involves a
great deal of work.3
During the process of normal delivery, laceration of the perineum and vagina
may be caused by rapid and sudden expulsion of the head, excessive size of the
newborn and friable maternal tissues. In other circumstances, they may be caused by
difficult forceps deliveries, breech extractions, or contraction of the pelvic outlet in
with the head is forced posterior. Some tears are unavoidable, even in the most skilled
hands, but control of this extremely important.4
The genital tract and the adjacent pelvic organs are subjected to strain of
delivery spontaneous or aided. The injury is more in areas of inadequate antenatal
and intranatal care. The patients may have full recovery from the injuries but a
substantial number may produce permanent legacies which lead to major gynecologic
problems.5
When birth occurs normally and naturally, with the mother remaining upright
and active, and not rushing the process, severe tearing rarely occurs such as perineal
injuries are the major obstetric legacies. If the tear is very small, many mothers find
that if they simply stay in bed for a couple of weeks with their legs together, the tear
heals on its own without any care at all, because the edges naturally come together
where they are supposed to anyway. If the tear is larger, these are the products most
often by mothers who have used them at home. If tears are repair at home, this repair
must be done immediately or within a few hours at the most. If too much time passes,
the edges will no longer be living tissue and will not bond back together. At that
point, one should be seen by a doctor because in order to repair the tear, the dead
tissue must be removed to make a new living "edge”. This can be painful the mothers
not want to do this without anesthesia.6
To prevent perineal lacerations during delivery, the nurse should control
delivery of the head; avoid early extension of head and spontaneous forcible delivery
of the head, deliver the head in between contractions, perform timely episiotomy, take
care during delivery of the shoulders.7
Perineum is the tissues between the anus and external genitals. Anatomically
the perineum is bounded above by the interior surface of the pelvic floor, below by

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the skin between the buttock and thighs. Laterally it is bounded by the Ischio pubic
ramii, Ischial tuberosities and Sacrotuberous ligaments and posteriorly by the coccyx.
Obstetrically, it is pyramidal shaped tissue where the pelvic floor and perineal
muscles and fascia meet in between vagina and anal canal. It involves musculo-fascial
structures. It mainly supports the vaginal wall, bladder and uterus.8
As the perineum is a muscular area, it is easily stretched during childbirth to
allow for enlargement of vagina and passage of fetal head. At this time the perineal
tissues must be more relaxed and expandable to allow easy expansion during birth
without tearing perineum. During the process of normal delivery, laceration of the
perineum may be caused by rapid and sudden expulsion of the head. This is very
common in primigravidae.9
A perineal tear is a laceration of the skin and other soft tissue structures which,
in women, separate the vagina from the anus. Perineal tears mainly occur in women as
a result of vaginal childbirth, which strains the perineum. It the most common form
of obstetric injury. Tears vary widely in severity. The majorities are superficial and
may require no treatment, but severe tears can cause significant bleeding, long-term
pain or dysfunction. A perineal tear is distinct from an episiotomy, in which the
perineum is intentionally incised to facilitate delivery. Episiotomy, a very rapid birth,
or large fetal size can lead to more severe tears which may require surgical
intervention.10
Tears are classified into five categories:
1. First – Degree Tear: The most superficial tears involve the skin of the
perineum and the tissue around the opening of the vagina or the outermost
layer of the vagina itself, but no muscles. These tears, called first-degree
lacerations, are often so small that few or no stitches are required. They
usually heal quickly and cause little or no discomfort. Laceration is limited to
the fourchette and superficial perineal skin or vaginal mucosa.

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2. Second – Degree Tear: These tears need to be stitched closed, layer by
layer. They'll cause you some discomfort and usually take a few weeks to heal.
The stitches dissolve on their own during the healing period. Laceration
extends beyond fourchette, perineal skin and vaginal mucosa to perineal
muscles and fascia, but not the anal sphincter
3. Third – Degree Tear: Women who deliver vaginally end up with a more
serious tear in their perineum that extend to or through the rectum. This kind
of tear can cause considerable pain for many months and increases the risk
of anal incontinence. Fourchette, perineal skin, vaginal mucosa, muscles,

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and anal sphincter are torn; third-degree tears may be further subdivided into
three sub categories:
i.) 3a: partial tear of the external anal sphincter involving less than 50%
thickness
ii.) 3b: greater than 50% tear of the external anal sphincter
iii.) 3c: internal sphincter is torn
4. Fourth – Degree Tear: It's also possible to tear in other places. Some
women tear at the top of the vagina, near the urethra. (This is known as a peri
– urethral laceration.) These tears are often quite small, and if someone get
one, they'll probably need only a few stitches or none at all. Fourchette,
perineal skin, vaginal mucosa, muscles, anal sphincter, and rectal mucosa are
torn.

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5. Button – Hole Tear: A “buttonhole” tear is a type of perineal injury
occurring during vaginal delivery which involves the rectal mucosa and an
intact anal sphincter.
In humans and some other primates, the head of the term fetus is so large in
comparison to the size of the birth canal that delivery may result in some degree of
trauma. As the head passes through the pelvis, the soft tissues are stretched and
compressed. The risk of severe tear is greatly increased if the fetal head is oriented
occipital posterior (face forward), if the mother has not given birth before or if the
fetus is large.11
A surgical incision on the perineum skin called an episiotomy was historically
used routinely in order to reduce perineal tears. However, its routine use has declined
as there is some evidence it increases the severity of tears when it is not indicated.11
Several other techniques are used to reduce the risk of tearing, but with little
evidence for efficacy. Antenatal digital perineal massage is often advocated, and may
reduce the risk of trauma only in nulliparous women. Hands on‟ techniques employed
by midwives, in whom the foetal head is guided through the vagina at a controlled
rate, have been widely advocated, but their efficacy is unclear. Water-birth and
labouring in water are popular for several reasons, and it has been suggested that by
softening the perineum they might reduce the rate of tearing. However, this effect has
never been clearly demonstrated.12

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First and second degree tears rarely cause long-term problems. Among women
who experience a third or fourth degree tear, 60-80% are asymptomatic after 12
months. Faecal incontinence, faecal urgency, chronic perineal pain, pain with sex, and
fistula formation occur in a minority of people, but may be permanent. The symptoms
associated with perineal tear are not always due to the tear itself, since there are often
other injuries, such as avulsion of pelvic floor muscles that are not evident on
examination.13
Numerous risk factors contribute to birth related perineal trauma and these
include, maternal age, parity, birth weight of the infant, precipitous birth, operative
delivery and episiotomy. Obstetrical anal sphincter injuries (OASIS) which
encompasses birth related perineal trauma are not uncommon in obstetrical practice
and based on the World Health Organization (WHO) International Classification of
Diseases, has an incidence of 4% to 6.6% in women following vaginal delivery.
Therefore, great care and support need to be instituted to ensure safe vaginal
deliveries and overcome the problem of spontaneous perineal lacerations.14

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NEED OF THE STUDY
“A nice clean cut is better than a jagged tear”
Perineal trauma is damage to the genitalia during childbirth that occurs
spontaneously or intentionally by surgical incision (episiotomy). Anterior perineal
trauma is injury to the labia, anterior vagina, urethra, or clitoris, and is usually
associated with little morbidity. Posterior perineal trauma is any injury to the posterior
vaginal wall, perineal muscles, or anal sphincter. Spontaneous tears are defined as
first degree when they involve the perineal skin only; second-degree tears involve the
perineal muscles and skin; third-degree tears involve the anal sphincter complex
(classified as 3a where less than 50% of the external anal sphincter is torn; 3b where
more than 50% of the external anal sphincter is torn; 3c where the internal and
external anal sphincter is torn); fourth-degree tears involve the anal sphincter complex
and anal epithelium and fifth degree also called button hole tear which involves the
rectal mucosa and an intact anal sphincter.15
Perineal trauma during child birth is very common, occurring in about 40% of
women during their first birth and about 20% in subsequent births. Any laceration
involving more than the perineal skin and the subcutaneous tissue must be regarded as
an obstetric complication. Severe perineal tears which involve the anal sphincters and
the rectal mucosa are identified in 0.6-0.9% of vaginal deliveries. Genital trauma
during childbirth can occur either spontaneously as a laceration or intentionally as an
episiotomy. Rates of trauma are estimated between 30% and 85% of childbearing
women, and can lead to significant short term and long term morbidity, such as
perineal pain, incontinence, sexual problems and varying degrees of functional
impairment.16
In Australia, the average rate of episiotomy was 15%. The rate of women who
had no tears or small tears that may not require stitches was on average about 55%.
On a worldwide level, Australia compares quite well when it comes to performing
episiotomies, considering that the episiotomy rate in the United States is currently
around 35%. In some Latin American countries and also Taiwan, it is accepted
practice to do an episiotomy on all first time mothers; here the rates are close to 90%.
China, Spain, South Africa and Turkey also report extremely high episiotomy rates

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ranging from 60% to almost 90%. Whereas Sweden's rate is a low 9.7%. New South
Wales (NSW) health department actually publishes the individual statistics of every
maternity hospital in the state. Episiotomy rates can vary from 3% to 43% depending
on the hospital.17
The study was conducted to evaluate the effectiveness of an information
booklet on knowledge among staff nurses regarding the prevention and management
of perineal tear during normal delivery at Justice K.S. Hegde Charitable hospital,
Mangalore. 40 samples were selected using simple random sampling method. An
evaluative approach with one group Pre test Post test design was used for the study
and data were analyzed using descriptive and inferential statistics. Findings of the
study reveals that 60% of the staff nurses had average knowledge, 37.5% had poor
knowledge, and only 2.5% had good knowledge in the pre test measure. Post test
knowledge scores revealed 57.5% that had good knowledge and 42.5% of them had
very good knowledge. There was a significant increase in the knowledge scores
(t=23.09, p<0.05). The study findings showed that the information booklet was
effective in improving knowledge of staff nurses regarding prevention and
management of perineal tear during labour. There was no significant association
between the level of knowledge and demographic variables.18
A case series study was conducted to determine the frequency, types and
complications of genital tract trauma during child birth at Department of Obstetrics
and Gynecology. The sample included all women who sustained genital tract trauma.
The result of the study has showed that out of total 9216 cases, 467 (5.06%) had
sustained genital tract trauma. The most frequent obstetrical trauma seen in
primiparous referral cases were vaginal tears in 16 cases (25.39%) and perineal tears
in 12 cases (19.04%). Multiparous women were 196 (41.97%) and cervical tears were
the most frequent obstetrical trauma in them (26.53%). Grand multiparous women
were 208 having cervical tears (44.4%) and uterine rupture in 77 cases (37.01%) each.
Most frequent early morbidities were postpartum haemorrhage (75.37%),
hypovolemic shock (47.10%) and infection (33.83%). The mortality rate was 16.05%.
Conclusion of the study revealed that to genital tract trauma is a common
complication of vaginal birth mostly seen in grand multipara, leading to haemorrhage,
shock and infection.19

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A prospective observational study was conducted to observe the type,
incidence and severity of maternal genital tract injuries during vaginal birth in Bharati
Hospital, Pune (Maharashtra). Sample included 2064 patients who delivered during
two years period. Among them 255 cases had perineal injuries. Result of the study
revealed the incidence of maternal injuries was 12.35%. All the birth injuries were
found to increase when episiotomy was not given. It was also found that instrumental
delivery is significantly more associated with maternal birth injuries as compared to
vaginal deliveries. Birth weight >3 kg is associated with more maternal birth injuries,
in the form of vulval lacerations (69.5%), vaginal lacerations (84.8%), cervical tears
(70.9%), para-urethral tears (62.5%). A higher incidence of 2nd degree perineal tear
was observed in multipara 0.77%. In primipara, there was 0.53% of the total
incidence of 2nd as well as 3rd degree perineal tears whereas in Multipara it was
1.58% which is more and statistically significant. Soft tissue injuries of genital tract as
rupture uterus was seen more with cases of previous LSCS (3.8%) while the incidence
of rupture uterus in unscarred uterus was significantly less (0.04%). The study
concluded that the risk factors of injuries are birth weight >3 kg, instrumental
delivery, VBAC, age <20 and >30, women with scarred uterus.20

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STATEMENTOF THE PROBLEM
“A study to assess the knowledge of staff nurses regarding prevention and
management of perineal tear during normal delivery at selected hospitals of Lucknow
(U.P.) with a view to develop self instructional module (SIM).”
OBJECTIVESOF THE STUDY
OPERATIONALDEFINITIONS
ASSESS: Refers to find out the knowledge and practice level of staff nurses
regarding prevention and management of perineal tear by using self-administered
knowledge questionnaire.
KNOWLEDGE: Refers to correct responses of staff nurses to the items listed in the
questionnaire regarding prevention and management of perineal tear.
STAFF NURSES: Trained registered nurses who are working in selected hospitals,
who have completed prescribed course of General nursing and Midwifery or Post
certificate B.Sc. Nursing or Basic B.Sc. Nursing course and licensed to practice in the
given country or registered with state nursing council.
PREVENTION: Includes primary and secondary measures adopted by staff nurses to
avoid perineal tear while conducting normal delivery.
PERINEAL TEAR: Refers to the injury to the perineum during the process of
normal delivery.
NORMAL DELIVERY: It refers to birth of a baby without the application of
external force or any damage to perineal area through the vagina.

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ASSUMPTIONS
 Staff nurses will have some knowledge regarding prevention of perineal
t
e
a
rduring normal delivery.
 Staff nurses will have some knowledge regarding management of perineal
t
e
a
rduring normal delivery.
HYPOTHESIS
 H0: There is no significant association between the knowledge scores of s
t
a
f
f
nurses in terms of perineal tear and selected demographic variables.
 H1: There is significant association between the knowledge scores of s
t
a
f
f
DELIMITATIONS
 Staff nurses working in selected hospitals at Lucknow.
 Staff nurses who are willing to participate in research study.
 Staff nurses who will be present at the time of study.
CONCEPTUALFRAMEWORK
and cure circle.

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CORE CIRCLE
Refers to the knowledge of staff nurses regarding prevention and management
of perineal tear during normal delivery which helps them to prevent themselves of
control from the threatening problems. Practices also helps or control to reduce the
complications. Knowledge regarding perineal tear also helps to reduce tear.
CARE CIRCLE
Refers to the practices or care which provide to the patient during the delivery.
To reduce the perineal tear the practices of intentionally incision called episiotomy
should be performed. The practice of regular checkup helps to reduce the risk and
complication of perineal tear.
CURE CIRCLE
Refers to the use of control and preventive aspects to prevent the perineal tear.
Antenatal digital perineal massage, water birth, or in other complicated cases
episiotomy done for reducing the risk of perineal tear.

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CORE KNOWLEDGE OF STAFF NURSES
CARE PRACTICES OF PATIENTS CURE CONTROL & PREVENTION
OF PERINEAL TEAR
Fig. 1.1:- Conceptual Framework Based On Hall‟s Theory – Core Care And
Cure Model

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CHAPTER – II
REVIEW OF LITERATURE
The review of literature is defined as a broad, comprehensive, in depth,
systematic and critical review of scholarly publications, unpublished scholarly print
material, audio visual materials and personal communications.21
Review of literature refers to an extensive, executive and systematic
examination of publication relevant to the research project. The term literature review
is used in two ways by research community. The first refers to the activities involved
in identifying and searching for information on a topic and second is developing a
comprehensive picture of state of knowledge on that topic. Researcher may thus say
that he or she is doing literature review before conducting the study. The term is also
used to designate a written summary of the state of the art on the research problem.21
Review of literature is the key step in the research process. A literature review
helps to lay the foundation for a study and can also inspire new research ideas. It can
help with orientation to what is known and not known about an area of inquiry, to
ascertain what research can best make a contribution to the existing base of evidence.
Review of literature is a major aspect of any research process. The view of
literature for the present study has been taken from different sources like texts books,
journals, articles, & published & unpublished research studies and also online
sources.21
Before any research can be started whether it is single study or extended
project, a literature review of previous studies and experiences related to the proposed
investigation should be done. Literature review makes contribution to new knowledge
and scholarship of researcher. So Literature review is important aspect while doing
research.
Based on the objectives of the study, literature from various sources had been
reviewed & arranged under as following categories-
 Studies related to perineal tear
 Studies related to prevention of perineal tear

29
Studies Related To Perineal Tear
Taithongchai A, Veiga SI, Sultan AH (2018) was conducted a retrospective
cohort study on The consequences of undiagnosed obstetric anal sphincter injuries
(OASIS) following vaginal delivery. The aimed to compare anal and urinary
incontinence symptoms and anal manometry between women with undiagnosed
obstetric anal sphincter injuries (OASIS) and women who had OASIS diagnosed and
repaired. The results of the study was that forty missed OASIS were matched with 40
recognised OASIS (16 3a/b; 24 3c). The median modified St Mark's scores were
higher for missed tears [11 (4, 15) vs. 1 (0, 4), p < 0.001] as well as the urinary
incontinence scores [4 (0, 6) vs. 0 (0, 2), p = 0.01] than for the control group. Missed
OASIS patients had a shorter perineal body [1.6 ± 1.3 vs. 2.4 ± 0.8, p = 0.009]. A
l
l missed
OASIS had larger defects on endoanal ultrasound. One in four missed OASIS required
further surgery [aOR 4.1 (95% CI 1.0-16.3), p = 0.04] and almost all needed colorectal
input [aOR 24.1 (95% CI 7.3-80.0). it is concluded that Women with symptomatic
missed OASIS are compromised in terms of anal and urinary incontinence symptoms,
sphincter defect size and perineal body size requiring additional colorectal input. This
highlights the importance of preventing OASIS and perseverance with training to
diagnose OASIS.22
Leombroni M, Buca D (2017) et al were conducted a prospective study on
women with first- and second-degree perineal tears and episiotomy. The purpose of
the study was to evaluate the morphology and biometry of pelvic floor structures 3
months after birth in women experiencing first- or second-degree perineal tears or
undergoing episiotomy during labor. In this study including nulliparous women
delivering at term with a clinical diagnosis of first- or second-
degree perineal tears after birth or undergoing episiotomy. The results show that 115
women assessed 3 months after delivery were enrolled in the study. Compared with
controls, women who experienced first-degree perineal tears had higher bladder neck-
symphysis (versus 20.9 ± 4.9 versus 16.1 ± 4.9 mm, p = .017), bladder wal
l
-pubi
c
symphysis (22.4 ± 7.4 versus 14.2 ± 9.5 mm, p = .02) and anorectal angle-symphysis
distance (12.5 ± 4.7 versus 9.3 ± 4.3 mm, p = .018). Furthermore, they have thi
cker internal
and external anal sphincter. The incidence of partial right and left puborectalis
muscle avulsion was higher in women experiencing first-degree

30
vaginal tear during labor (16.2 versus 0%, p = .004 for both). In women affected by
second-degree tears, the occurrence of partial avulsion of the right and left pubo-
rectalis muscle was 16.2%, while Oasis was detected in 10.8% of the cases. Women
receiving Kristeller maneuver during labor had a higher incidence of either right or
left puborectalis muscle avulsion. It is concluded that women who had either first- and
second-degree perineal tears or episiotomy show signs of abnormal pelvic
morphometry on 3D rotational ultrasound 3 months after birth.23
Morávková P, Hruban L (2017) et al were conducted a prospective case-
control study analysis on operative vaginal deliveries and their impact on maternal
and neonatal outcomes. The objective of the study was evaluation of maternal and
neonatal outcomes in operative vaginal deliveries in prospective study analysis. Type
and frequency of maternal and neonatal trauma occurence was observed in connection
with using vacuum-assisted delivery and forceps delivery, mainly the
cephalohematomas and their complications. Collected data were statistically analysed.
The results shows that overall 6056 deliveries there were 216 vacuumextractions
(3.6%) and 72 forceps deliveries (1.2%) performed. Both methods were used in four
patients (VEX and forceps). The most frequent trauma in newborns were
cephalohematomas. Remarkable cephalohematoma, requiring further observation has
occured in 40 newborns (18.5%) after vacuum-assisted delivery and in 5 newborns
(6.9%), (p = 0,017) after forceps delivery. Consequential punction of
cephalohematoma occured only after vacuumextraction delivery and in 6 newborns
(15.0 %). The third degree perineal rupture occured after vacuumextraction in 20
patients (9.3%) and after forceps delivery in 12 patients (16.7%), (p = 0,091). The
fourth degree perineal rupture occured only after vacuumextraction and in 1 case
(0.5%). It is concluded that vacuumextraction compared with forceps is more likely to
be associated with the statistically significant incidence of cephalohematomas and
their further treatment. Forceps deliveries compared with vacuumextraction are more
likely to be associated with the maternal perineal trauma, but the diference was not
statistically significant.24
Aasheim V, Nilsen AB (2017) was conducted a review on published and
unpublished randomized and quasi- randomized to assess the effect of perineal
techniques during the second stage of labour on the incidence of perineal trauma. The

31
study included 8 trials involving 11,651 randamised women .The result of the study
revealed that there was a significant effect of warm compresses on reduction of third
and fourth degree tears (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.28 to
0.84 (two studies, 1525 women)). There was also a significant effect towards
favouring massage vs hands off to reduce third and fourth degree tears (RR 0.52, 95%
CI 0.29 to 0.94 (two studies, 2147 women)). Hands off vs hand on showed no effect
on third and fourth degree tears, but it observed a significant effect of hands off on
reduced rate of episiotomy (RR 0.69, 95% CI 0.50 to 0.96 (two studies, 6547 women).
The study concluded that the use of warm compresses on the perineum is associated
with a decreased occurrence of perineal trauma.25
Kudish B, Blackwell S, (2016) et al were conducted a study to determine the
impact of operative vaginal delivery and midline episiotomy on the risk of severe
perineal tear. Retrospective cohort study was done. Among nulliparous women,
12.1% had operative vaginal delivery, 22.4% had midline episiotmy,8.1%
experienced severe perineal tear. Among multiparous women, 3.4% had operative
vaginal delivery 4.2% had midline episiotomy and 1.2% had severe perineal tear. The
use of operative vaginal delivery, particularly in combination with midline
episiotomy, was associated with a significant increase in the risk of anal sphincter
trauma in both primigravidae and multigravidae women.26
Jansson MH, Nilsson K, Franzén K (2016) was conducted a study on
Development and validation of a protocol for documentation of
obstetric perineal lacerations. The aim of this study was to develop a new protocol for
documentation of perineal lacerations and to validate the latter against the most
common obstetric record system in Sweden. The results shows that a total of 187
women were included. The coverage of documentation regarding perineal laceration
was significantly higher (p < 0.001) in the new protocol (89%) compared with
ObstetriX (18%). Incidence of second-degree perineal tears was 26% according to the
new protocol and 11% according to ObstetriX. The incidence of third-
degree perineal tears A, B, and C was 2.7%, 2.1%, and 2.1%, respectively, according
to the new protocol, and 3.2%, 2.7%, and 1.1%. It is concluded that this validation
study of a new documentation protocol showed that it delivered significantly more

32
comprehensive information regarding perineal lacerations than the most common
obstetric record system in Sweden.27
Kimmich N, Grauwiler V (2016) were conducted a Prospective
Observational Study on Birth Lacerations in Different Genital Compartments and
their Effect on Maternal Subjective Outcome. This study aimed to evaluate the
frequency and distribution of birth lacerations and their association with maternal
discomfort. 140 women with singletons in vertex presentation at term, who gave birth
vaginally in our center and were affected by a laceration were selected as respondents.
The results was that the number of affected compartments was 1.33 objectively and
2.99 at T2 and 1.27 at T3 subjectively. The most affected compartment was the
right perineum (73%) followed by the right inner posterior (21%) and the right outer
anterior (14%) compartment. Subjective and objective assessment concurred in 83%
at T2 and 69% of cases at T3. Overall, impairment of women was low, reversible, and
not directly associated with the location of lacerations, although women were
psychologically affected. It is concluded that birth lacerations predominantly appear
at the right perineum. Physical impairment from these lacerations is generally low,
reversible, and not directly associated with the location of lacerations, although
psychological impairment is not negligible.28
Williams A, Herron-Marx S, (2016) et al conducted a retrospective cross-
sectional community survey of postnatal women to investigate the prevalence of
enduring postnatal perineal morbidity and its relationship to perineal trauma. The total
sample size was 2100 women form two maternity units in Birmingham. Findings of
the study showed that perineal morbidity was reported (53.8%) stress urinary
incontinence, 36.6% urge urinary incontinence, 9.9% liquid faecal incontinence,
54.5% with at least one index of sexual morbidity. Women with perineal trauma
reported significantly more morbidity (sexual morbidity, dyspareunia, stress and urge
urinary incontinence) than women with an intact perineum. Women with perineal
trauma also resumed sexual intercourse later than women with an intact perineum.
Study concluded that post natal perineal morbidity is common in women with all
types and grades of perineal trauma.29
Alexander JW, Karantanis E (2016) was conducted a study on Patient
attitude and acceptance towards episiotomy during pregnancy before and after

33
information provision. The data was collected through the structured knowledge
questionnaire. The results revealed that there were 105 responses, with 88% accepting
episiotomy, 2% declining and 10% seeking more information to decide. Eighty-one
percent of women agreed that the information provided helped them to understand
more about childbirth and 62% agreed that they felt more comfortable with the
birthing process after reading the material. There was a reduction in anxiety levels
regarding episiotomies after reading information (p = 0.002) and perineal tears
(p = 0.02). It is concluded that most women will accept an episiotomy if required.
Antenatal education about episiotomies is important to women and helps them feel
more comfortable with the birthing process. Written information increases acceptance
and reduces anxiety levels regarding episiotomies.30
Soong B, Barnes M (2015) conducted a study aimed to examine the
association between maternal positional at birth and perineal outcome in women who
had midwife attended, spontaneous vaginal birth and an uncomplicated pregnancy at
term. Sample size was 3,756. Most women (65.9%) gave birth in the semi recumbent
position. 44.5% who required perineal suturing semi recumbent was associated with
the need for perineal sutures, Semi recumbent was associated with highest need for
perineal suturing whereas lateral position was associated with reduced need for
suturing.31
Pintucci A, Consonni S (2015) et al were conducted a study on Operative
vacuum vaginal delivery: effect of compliance with recommended checklist. The
purpose of the study was to evaluate the role of a checklist implementation on the
compliance with the recommended rules in operative vacuum vaginal delivery (OVD)
and on maternal and perinatal tear. The results of the study was that introduction of a
checklist for OVD resulted in an increase in the compliance with the rules (83.3 versus
62.8%, p < .001). Cases in which the rules were respected had lower incidence of third-
and fourth-degree perineal lacerations after controlling for episiotomy, nulliparity, and
indication for OVD (OR = 0.4, 95% CI 0.18-0.89), but similar rates of failure of OVD
(2.1 versus 2.2%, p = 1) and adverse neonatal outcome (10.8 versus 11.7%, p=.71). the
results of the study concluded that knowledge and documented compliance with a
checklist of recommended rules in OVD may assist in achieving a

34
lower rate of severe perineal tear and anal sphincter injury but does not alter the
success of the procedure or neonatal outcome.32
Gommesen D, Nohr EA (2015) et al were conducted a prospective cohort
study on Obstetric perineal tears: risk factors, wound infection and dehiscence. The
main purpose of the study was that to assess risk factors for perineal tears, wound
infection and dehiscence among primiparous women. 603 primiparous women
sampled in three groups: 203 with none/labia/1st degree, 200 with 2nd degree, and
200 with 3rd/4th degree tears were included. Results revealed that instrumental
delivery and birthweight > 4000 g increased the risk of 3rd/4th degree tears (adjusted
Odds Ratio [aOR] 13.7, 95% confidence interval [CI] 5.48-34.1 and aOR 3.27, 95%
CI 1.52-7.04, respectively). BMI > 35 kg/m2 increased the risk of wound infection and
dehiscence (aOR 7.66, 95% CI 2.13-27.5 and aOR 3.46, 95% CI 1.10-10.9,
respectively). Episiotomy tripled the risk of infection (aOR 2.97, 95% CI 1.05-8.41).
Treatment with antibiotics during delivery and postpartum seemed to decrease the risk
of dehiscence (aOR 0.32, 95% CI 0.15-0.70). the conclusion was that instrumental
delivery and high birth weight increased the risk of perineal tears. Severe obesity and
episiotomy increased the risk of perineal wound complications. More focus on these
women may be warranted postpartum. The use of prophylactic antibiotics among
women in high risk of wound complications should be further investigated in
interventional studies.33
Woolner AM, Ayansina D (2015) et al were conducted a cohort study on
impact of third- or fourth-degree perineal tears on the second pregnancy. This study
aimed to investigate the reproductive impact of a third- or fourth-degree tear in
primigravid women. The results was that initial third- or fourth-degree tear occurred
in 2.8% women (5174/182445). The percentage of third- or fourth-degree tears in first
vaginal births increased from 1% in 1997 to 4.9% in 2010. There was no difference in
having a second pregnancy (adjusted Odds Ratio (aOR) 0.98 (99%CI 0.89-1.09)) or
the median interpregnancy interval to second pregnancy (adjusted Hazard Ratio
(aHR) 1.01 (99%CI 0.95-1.08)) after an initial third- or fourth-degree tear. Women
were over four times more likely to have a repeat injury in a subsequent vaginal birth
(n = 149/333, aOR 4.68 (99% 3.52-6.23)) and were significantly more likely to have
an elective caesarean section in their second pregnancy (n = 887/3333, 26.6%; 12.75

35
(11.29-14.40). It is concluded that third- and fourth-degree tears are increasing in
Scotland. Women do not delay or avoid childbirth after initial third- or fourth-
degree tear. However, women are more likely to have a repeat third- or fourth-
degree tear or an elective caesarean section in the second pregnancy. Strategies to
prevent third- or fourth-degree tears are needed.34
Martin S, Labrecqua M, (2015) were conducted a retrospective cohort study
to assess whether women who had a perineal trauma at the first delivery were at
increased risk for spontaneous perineal tears at the next delivery, and whether the risk
increases with the severity of previous perineal trauma. Study conducted at Saint-
Sacrement Hospital, Canada. Sample included 1895 women who had their first and
second deliveries at Saint-Sacrement Hospital, between 1985 and 1994. The result of
the study revealed that who have a perineal trauma at the first delivery more than
tripled the risk (relative risk=3.3; 95% confidence interval, 2.6-4.2) of spontaneous
perineal tears at the second delivery. The risk of spontaneous perineal tears at the
second delivery increased with the severity of previous perineal trauma at birth. The
study concluded that the risk of spontaneous perineal tears at subsequent deliveries
increases with the presence and the severity of perineal trauma at the first delivery.35
Hastings TM, Vincent D, (2015) et al were conducted a study on factors
related to perineal trauma in child birth, retrospective descriptive analysis of 510
pregnant women with singleton pregnancy. Results showed that factors related to
laceration with age and marital status .For all women laceration was more likely when
in lithotomy position for birth or when prolonged stage labour occurred. In this study
use of oils or lubricants increased laceration. It is implicated that side lying position
for birth and perineal support and compress use are important interventions for
decreasing perineal trauma.36
Dahlen HG, Ryan M, (2014) et al were conducted a study in Royal Prince
Alfred hospital, Australia to determine the risk factors for the occurrence of severe
perineal tear during child birth. A prospective cohort study was conducted. The study
subject included all women having vaginal births between 1998to2000, sample size
was 65. 95.2% of women experienced severe perineal tear, 122 women had third
degree tears, and 12 had fourth degree tears. Primiparity, instrumental delivery, Asian

36
ethnicity and heavier babies were associated with an elevated risk of severe perineal
tear.37
Sheiner E, Walfisch A, (2014) et al were conducted a study in Israel to
evaluate the possible risk factors for spontaneous and induced perineal damage during
vaginal delivery. A prospective observational study was conducted with 300 patients
at 37 – 42 weeks of singleton gestation. Perineal damage was assessed before repair
and 24 hours postpartum. Episiotomy was performed in 32% of the population.
Spontaneous perineal tear requiring suturing occurred in 28%. Severe perineal tears
occurred in 1%. Risk factors for adverse perineal outcome included younger maternal
age, non Israeli ethnic background, use of epidural analgesia nulliparity shorter
interval since last vaginal delivery, longer active phase and prolonged second stage.
Woman with a prolonged second stage labour and low parity are prone for
spontaneous damage and therefore deserve high attention.38
Uccella S, Manzoni P (2014) et al were conducted a prospective study on
Impact of Sport Activity and Physical Exercise on Obstetrical and Perineal Outcomes
at Delivery. This study was aimed to investigate the effects of physical activity on
perineal outcomes at delivery according to the different levels and types of maternal
physical activity before and during pregnancy. Women were divided into three groups
according to the features of physical activity performed before pregnancy: group 1:
"very sporty women," group 2: "moderately sporty women," and group 3: "inactive
women." The results that a total of 135, 84, and 85 women were included in group 1,
group 2, and group 3, respectively. The demographic characteristics were comparable
among all the groups. Sport activity during pregnancy was more frequent in groups 1
and 2 (59.3 and 53.6%, respectively, vs. 29.4% in group 3; p = 0.003). No differences
among groups were detected in terms of perineal outcomes. A lower rate of
episiotomy/lacerations ≥ 2nd degree was found among women who practiced sports
that specifically involved the perineal muscles and who continued this practice during
pregnancy. It is concluded that perineal outcomes are not influenced by the intensity
of sport activity performed before/during pregnancy. Continuous sports during
pregnancy that specifically train the perineal muscles are associated with a lower rate
of episiotomy and perineal lacerations ≥ 2nd degree.39

37
Albers LL, Selder KD, (2012) et al were conducted a study in Mexico to
identify the maternal and clinical factors related to genital tract trauma in normal
spontaneous vaginal births. A woman who had a first vaginal birth, risk factors for
trauma was maternal education, valsalva pushing, and the infant birth weight. Risk
factors for woman having second or higher vaginal births were prior sutured trauma
and infant birth weight. Delivery technique that is unrushed and controlled may help
to reduce obstetric trauma in normal spontaneous vaginal birth.40
Studies related to prevention of perineal tear
Studies Related To Prevention Of Perineal Tear
Pierce-Williams RAM, Saccone G, Berghella V (2018) were conducted a
meta-analysis of randomized controlled trials on Hands-on versus hands-off
techniques for the prevention of perineal trauma during vaginal delivery. The aim of
this systematic review with meta-analysis was to evaluate whether a hands-on
technique during vaginal delivery results in less incidence of perineal trauma than a
hands-off technique. Randomized controlled trials comparing a hands-on technique
of perineal support during vaginal delivery (i.e. intervention group) with a hands-off
technique (i.e. control group) were included in the meta-analysis. Hands-on was
defined as involving one hand on the fetal head, applying pressure to control
expulsion, with the other hand applying pressure on the maternal perineum. The
results of the study was that five trials, including 7287 women, were analyzed. All
studies included singleton gestations with cephalic presentation at term undergoing
spontaneous vaginal delivery. Women randomized to the hands-on technique had
similar incidence of severe perineal trauma (1.5 versus 1.3%; RR 2.00, 95% CI 0.56-
7.15). There was no significant between-group difference in the incidence of
intact perineum, first-, second- and fourth-degree laceration. Hands-on technique was
associated with increased risk of third-degree lacerations (2.6 versus 0.7%; RR 3.41,
95% CI 1.39-8.37) and of episiotomy (13.6 versus 9.8%, RR 1.59, 95% CI 1.14-2.22)
compared to the hands-off technique. It is concluded that hands-on technique during
spontaneous vaginal delivery of singleton gestations results in similar incidence of
several perinealtraumas compared to a hands-off technique. The incidence of third-
degree lacerations and of episiotomy increases with the hands-on technique. Key
Message A hands-on technique during vaginal delivery results in similar incidence of
severe lacerations compared to hands-off.41

38
Magoga G, Saccone G (2018) et al conducted a meta analysis study on
Warm perineal compresses during the second stage of labor for
reducing perineal trauma. The aim of this systematic review and meta-analysis of
randomized controlled trials was to evaluate the effectiveness of warm compresses
during the second stage of labor in reducing perineal trauma. . Inclusion criteria were
randomized trials comparing warm compresses (i.e. intervention group) with no warm
compresses (i.e. control group) during the second stage of labor. Types of participants
included pregnant women planning to have a spontaneous vaginal birth at term with a
singleton in a cephalic presentation. The primary outcome was the incidence of
intact perineum. Results revealed that seven trials, including 2103 participants, were
included in this meta-analysis. Women assigned to the intervention group received
warm compresses made from clean washcloths or perineal pads immersed in warm
tap water. These were held against the woman's perineum during and in between
pushes in second stage. Warm compresses usually started when the baby's head began
to distend the perineum or when there was active fetal descent in the second stage of
labor. We found a higher rate of intact perineum in the intervention group compared
to the control group (22.4% vs 15.4%; RR 1.46, 95% CI 1.22 to 1.74); a lower rate of
third degree tears (1.9% vs 5.0%; RR 0.38, 95% CI 0.22 to 0.64), fourth
degree tears (0.0% vs 0.9%; RR 0.11, 95% CI 0.01 to 0.86) third and fourth
degree tears combined (1.9% vs 5.8%; RR 0.34, 95% CI 0.20 to 0.56) and episiotomy
(10.4% vs 17.1%; RR 0.61, 95% CI 0.51 to 0.74). it is concluded that warm
compresses applied during the second stage of labor increase the incidence of
intact perineum and lower the risk of episiotomy and severe perineal trauma.42
Ma DM, Hu W, Wang YH (2017) were conducted a study on multicentre
study on the effect of moderate perineal protection technique: a new technique
for perineal management in labour. 31,249 women accepted the traditional technique
were selected as control group, and 57,056 women accepted the
Moderate Perineal Protection technique as the observation group. There was no
significant difference in demographic characteristics between the two groups. The
perineal episiotomy rate decreased (22.913% vs. 32.161%, p < .05), the
perineal integrity significantly increased (43.505% vs. 36.384%, p < .05) and
perineal trauma reduced in the observation group when compared to the control group
(54.630% vs. 61.239% in first degree tears, and 1.826% vs. 2.340% in second degree
tears, p < .05). The neonatal asphyxia rate in the observation group was lower

39
than that in the control group (p < .05). The observation group also had a higher rate of
total satisfaction, lower VAS score for perineal pain, shorter postpartum
hospitalisation days, lower rate of postpartum urinary retention and postpartum
incontinence (p < .05). We concluded that the Moderate Perineal Protection technique is
safe, effective and worth promoting widely.43
Frietman SK, Compagnie E (2017) et al were conducted a retrospective
study on single-stage reconstruction of third-degree perineal lacerations in horses
under general anesthesia: Utrecht repair method. The objective of the study was that
to describe perioperative management, surgical procedure, and outcome in mares with
third-degree perineal lacerations (TDPL) treated with a single-stage repair, the
Utrecht repair method (URM). The results of the study was that mares ranged in age
from 3.5 to 11 years. Long-term follow-up was available for 13 mares. Mean duration
of follow-up was 9 years (median, 9.5; range, 2-215 months (17.9 years)).
Standardized perioperative fasting and postoperative refeeding protocols were used.
Only five mares received supportive gastric medication. Reconstruction of the
rectovestibular shelf was successful in 18 of 20 mares. Two of 20 mares developed a
small rectovestibular fistula after the initial repair, which was successfully repaired
with a second surgery. Other postoperative complications were observed in 13 mares
and consisted of mild postanesthetic myositis, facial nerve paralysis, esophageal
obstruction, rectal obstipation, partial perineal dehiscence, and rectal or vestibular
wind-sucking. Six of seven mares that were subsequently bred became pregnant. It is
concluded that the alternative single-stage reconstruction for TDPL was successful in
18 of 20 mares after a single surgery. No major complications related directly to the
technique were noted.44
Dieb AS, Shoab AY (2017) et al were conducted a randomized controlled
trial on Perineal massage and training reduce perineal trauma in pregnant women
older than 35 years. The aim of this study was to evaluate the effectiveness
of perineal massage, pelvic floor muscle training (PFMT) and a pelvic floor
dysfunction (PFD) prevention educational program in pregnant women above the age
of 35 years to prevent perineal tear and episiotomy. The first group (n = 200) was
educated to do digital perineal massage and pelvic floor muscle training and received
an educational PFD prevention program. The second group (n = 200) received only the
prevention education program. Occurrence of perineallaceration was reported at

40
time of delivery as a primary outcome. The results shows that delivery was
significantly less complicated by perineal tear, episiotomy and postnatal pain in the
first than in the second group (p < 0.05). Grades of perineal tear were mostly of first and
second degree in the first group compared with the second group. We found a
significantly lower need for analgesia and fewer ampoules required during the
hospital stay in the first group (p < 0.001, 0.002, respectively). It is concluded that
performing antenatal digital perineal massage and PFMT in addition to health
education is recommended to reduce perinealcomplications.45
Garcia J, Renfrew M (2017) et al were conducted a descriptive study trial
participants who delivered spontaneously at term. The purpose of the study was to
describe the range and extent of childbirth trauma and related postnatal pain using
data from a large randomized clinical trial of perineal management techniques. Study
included 5471 sample. Data are reported for sites of trauma, and the relation to
episiotomy, suturing, and maternal reports of pain at 2 days, 10 days, and 3 months
after birth. Result of study showed that 85% of all women experienced some form of
trauma, with first- or second-degree perineal lacerations occurring in 2/3 of women
and outer vaginal tears occurring in one-half. Tears to the rectum and vaginal vault
were more common with episiotomy. Pain declined over time, and a gradient in pain
was observed according to the site and complexity of trauma. The study concluded
that genital tract trauma is extremely common with spontaneous vaginal birth.
Effective measures to prevent or reduce its occurrence would benefit many new
mothers.46
De Tayrae R, Panel L, Masson G, Mares P (2017) conducted a study to
assess the efficacy of episiotomy to prevent severe perineal tears, urinary
incontinence, fecal incontinence and genital prolapse. A systematic review on midline
data base was performed finally 43 articles were analyzed. The study showed that
routine use of episiotomy did not prevent severe perineal tears. It decreased the risk of
moderate anterior perineal lacerations. The risk of perineal tears during episiotomy
increased in primiparity Asian woman, forceps or vacuum assisted delivery and
macrosomia. Relevant studies were consistent in demonstrating no benefit for routine
episiotomy to prevent urinary and fecal incontinence or pelvic floor relaxation.47

41
Marko EK, Fausett MB, (2015) was conducted a study on Reducing Perineal
Lacerations Through Team-Based Simulation. The objective of this study was to
evaluate the effectiveness of an interprofessional simulation-based teams-training
program aimed at reducing severe perineal lacerations during childbirth. A quasi-
experimental pre-post single-group design was used to examine the performance of
labor. Results show that during an 18-month period, 675 personnel in 4 hospitals
participated in the program. Significant improvement was noted in pre-post scores of
knowledge (59.86%, 93.87%, P < 0.0001), performance (36.54%, 93.45%, P <
0.0001), and safety culture (3.24, 1.45, 1 = high, 5 = low, P < 0.0001).
Severe perineal laceration rates decreased by 33.38% since initiation. Rates fluctuated
with the addition of new personnel and renewed educational programs. It is concluded
that a multimodal interprofessional simulation program of strategies to prevent
severe perineal lacerations significantly improved knowledge, skills, and attitudes in
labor and delivery personnel within a healthcare system. Severe perineal laceration
rates were reduced.48

42
CHAPTER-III
RESEARCH METHODOLOGY
A methodology is usually a guideline system for solving a problem, with
specific components such as phases, tasks, methods, techniques and tools.
Methodology of research includes the general pattern of organizing the procedure, for
gathering valid and reliable data for the problem under investigation. The
methodology is the most important part of research as it is the frame work for
conducting the study.49
Research method refers to steps, procedures and strategies for gathering
analyzing data in a research involved. Research methodology is a way to
systematically solve the research problem. It is science of studying how research is
done scientifically.
This chapter deals with the type of research approach used, research design,
setting of the study, the population, sampling technique, sample selection, inclusion
and exclusion criteria, the development of the tool, collection of data, pilot study,
procedure of data collection and plan for data analysis. This chapter describes the
methodology adopted for assess the knowledge of staff nurses regarding prevention
and management of perineal tear during normal delivery.
RESEARCHAPPROACH
A research approach tells the researcher what and how to collect the data and
how to analyze the data. As the researcher was interested in assess the knowledge
regarding prevention and management of perineal tear during normal delivery among
staff nurses at selected Hospital of Lucknow.
In this study, descriptive approach was directed towards the prevention and
management of perineal tear during normal delivery among staff nurses at selected
Hospital of Lucknow.

43
RESEARCHDESIGN
The research design is the plan, structure and strategy of investigation for
answering the research question. It is the overall plan or blue print, the researcher
select to carry out their study.49
The term research design refers to the plan or organization of a scientific
investigation. Research design helps the researcher in selection of subjects, control of
extraneous variables, procedure of data collection and the type of statistical analysis
to be used to interpret the data.49
The research design selected for the present study was non experimental
descriptive research design. Keeping in the view the objectives of the study, the
investigator, assess the knowledge regarding prevention and management of perineal
tear during normal delivery among staff nurses at selected Hospital of Lucknow.

44
Fig. No: 3.1 Schematic Representation of Research Methodology
RESEARCH
DESIGN
TARGET POPULATION
Staff nurses working in selected
Hospital, Lucknow
DATA COLLECTION
METHOD
Assess the knowledge regarding perineal tear during normal
delivery
CRITERION MEASURES
Descriptive and Inferential Statistics
PLAN FOR DATA
ANALYSIS
Descriptive Research Approach
RESEARCH APPROACH
Self Administered Questionnaire
Purposive Sampling Technique
SAMPLING
TECHNIQUE
Non Experimental Descriptive Research
Design

45
VARIABLES UNDER INVESTIGATION
A variable is a phenomena or characteristic or attribute under a study.
Variables are the measurable characteristics of a concept and consist of a logical
group of attributes.50
Three types of variables i.e. independent variable, dependent and demographic
variable. In present study demographic variables were found.
DEMOGRAPHIC VARIABLES
An uncontrolled variable that greatly influences the results of the study is
called as the demographic variables.50
Demographic variables selected for this study are age, gender, education
qualification, work experience, work experience in labour room, previous knowledge.
SETTING OF THE STUDY
“Setting” refers to the area where the study is conducted. Quantitative
researchers deliberately strive to study their phenomenon in a variety of natural
context.50
The study was conducted in Era‟s Lucknow Medical College and Hospital,
K.K. Hospital, Lucknow, Unity Hospital, Lucknow.
POPULATION
Population refers to the complete set of observations or measurements about
which the investigator would like to draw conclusions. Population is a group whose
members possess specific attributes that the researcher is interested in studying.50
In the present study the population consist staff nurses working Era‟s
Lucknow Medical College and Hospital, K.K. Hospital, Lucknow, Unity Hospital,
Lucknow.

46
SAMPLE
A sample is a subset or portion of the population that has been selected to
represent the population of interest.50
The present study was conducted among 250 staff nurses working in Era‟s
Lucknow Medical College and Hospital, K.K. Hospital, Lucknow, Unity Hospital,
Lucknow.
SAMPLING TECHNIQUE
Sampling is a process of selecting a group of people, events or position of the
population to represent the entire population.50
Purposive sampling technique was used to select 250 staff nurses working in
Era‟s Lucknow Medical College and Hospital, K.K. Hospital, Lucknow, Unity
Hospital, Lucknow.
SAMPLE SIZE
Sample size of total 250 staff nurses working in Era‟s Lucknow Medical
College and Hospital, K.K. Hospital, Lucknow, Unity Hospital, Lucknow.
DATA COLLECTION TECHNIQUE AND INSTRUMENT
The phenomena in which a researcher is interested must ultimately be
translated into data that can be analyzed. The task of defining the research variable
and selecting or developing appropriate methods for collecting data are amongst the
most challenging work in hand of a researcher. With high quality data collection
methods, the accuracy and robustness of the conclusions are always subject to
challenge. The most important and crucial aspect of any research is data collection,
which provides answers to the questions under study. Data collection relies on
instruments.
The present study aimed at assessing the knowledge of staff nurses regarding
prevention and management of perineal tear during normal delivery at Era‟s Lucknow
Medical College and Hospital, K.K. Hospital, Lucknow, Unity Hospital, Lucknow

47
and development of tool. Although the investigator is accustomed to asking questions,
the proper phrasing of questions in a research study is a delicate task.
Pre-planned set of questions designed to yield specific information to meet a
particular need for research information about a pertinent topic. The research
information is attained from respondents normally from a related interest area. The
dictionary definition gives a clearer definition.
Review of research and non-research literature was conducted in the area
related to perineal tear. Opinion and suggestions were taken from experts, which
helped in determining the important areas to be included. This was done with the help
of literature review and advice from experts.
DESCRIPTION OF THE TOOL
The Structured knowledge questionnaire consists of two sections:
Section I: This section is the first section seeking information on demographic
information of the staff nurses.
Section II: This section is the second part of structured knowledge questionnaire,
which consists of questions assessing knowledge about perineal tear.
There are a total of 30 question regarding perineal tear in which 11 questions
related to concept of perineal tear, 6 questions related to prevention of perineal tear
and remaining 13 questions related to management of perineal tear.
The score for correct answer was „1‟ and for the wrong answers was „0‟. The
scores range from a minimum of 0 to a maximum score of 30. The levels of
knowledge have been classified as follows:
 Poor - <50%
 Average 51% - 65%
 Good >65%
The content of data collection tool was sent for its validity in terms of
relevance and accuracy to a list of experts along with scoring sheet. The data

48
collection tool was send to 11 experts. These were received with their valuable
suggestion and comments on the study tool.
The content validity of tool enclosed, structured knowledge questionnaire
schedule with two sections pertaining to questions on assessing the demographic
information and knowledge assessment questions regarding perineal tear. The validity
was established by the experts from different specialties i.e. obstetric and
gynecological nursing and others. The experts were selected based on their clinical
expertise, experience and interest in the problem being studied. They were requested
to give their opinions on the appropriateness and relevance of the items in the tool.
As a whole the suggestions and comments of the experts included grammatical
corrections of sentences, some questions were not found good so they were removed.
Else the tool was found to be relevant. The necessary modification was done as per the
expert's advice.
PRE-TESTING OF TOOL& RELIABILITY
After establishing the validity of the tool to be used for the study, the final tool
was made and then the reliability of the tool was done.
The reliability was done in Era‟s Lucknow Medical College and Hospital after
obtaining formal administrative permission the tool was administered to 25 samples,
selected as per the set criteria. The scores were calculated and then given for
statistical analysis.
To test the reliability of the tool the method of „spilit half” has been used. This
method is used as the data is of quantitative type and this method gives the exact error
in the reliability scores. The method of „spilit half” stresses internal score relations of
items in the tool as well as correlation of each item with the test as a whole.
The reliability coefficient was calculated and the value is equal to 0.88, if
value of reliability is greater than 0.70 then the test is reliable. As the value of
reliability in this test is 0.88, the test is more reliable.

49
The final form of the tool consisted of questions related to demographic data
and 30 questions pertaining to knowledge assessment regarding perineal tear. The
time taken to conduct one test was 50 minutes.
PILOT STUDY
The pilot study was conducted in Era‟s Lucknow Medical College and
Hospital from 03/03/19 & 18/03/19 on 25 samples to assess the feasibility of the study
and to decide the plan for data analysis.
The investigator approached the subjects, informed them regarding the
objectives of the study and obtained their consent after assuring the subjects about the
confidentiality of the data. The data was collected through a structured demographic
data and knowledge questionnaire.
ETHICAL CONSIDERATION
The research was ethically approved by institutional ethical committee and it
has no harm on living being. The superintendent of the hospital was informed about
the study and the formal administrative approval was taken. The introduction of the
study was given to the participant and verbal consent/ written consent was taken. The
confidentially of the subject and their response were assured.
PROCEDUREFOR DATA COLLECTION
A formal permission was obtained from the concerned authority. The final
study was conducted in Era‟s Lucknow Medical College and Hospital, K.K. Hospital,
Lucknow, Unity Hospital, Lucknow; from 25/06/2019 to 18/08/2019.The following
schedule was followed for data collection.
Objectives of the study were discussed and consent for participation in the
study was taken from the selected group. The investigator assured the subjects about
the confidentiality of the data. The investigator himself administered the structured
questionnaire schedule for assess the knowledge of staff nurses regarding perineal
tear. The duration of data collection for each sample was 40 – 50 minutes and
approximately 15 samples per day were approached.

50
PLAN FOR DATA ANALYSIS
The statistical analysis was made on the basis of objectives and hypothesis.
The data analysis was planned to include descriptive and inferential statistics. The
following plan was developed for data analysis on the basis of the opinion of experts.
 For the analysis of demographic data frequencies and percentage
w
a
scalculated.
 The significance was calculated by using mean, mean percentage, m
e
d
i
a
n
,
standard deviation was used to find the co-relation with every item & the
findings were documented in tables, graphs & diagrams.

51
CHAPTER- IV
DATA ANALYSIS AND INTERPRETATION OF
FINDINGS
Data analysis is the process of organizing and synthesizing data in such a way
that research question can be answered and tested.
This chapter deals with the data analysis and interpretation of the data
collected through structured knowledge questionnaire. Analysis and interpretation of
data obtained from structured knowledge questionnaire regarding prevention and
management of perineal tear during normal delivery. Then the findings were printed
in different graphs and tables of percentage.
Analysis defined as the “categorizing” ordering manipulating & summarizing
of data to obtain access to research questions. The purpose of analysis is to reduce
data to on intelligible & interpretable form, so that the relation of research problem
can be studied and tested.
This chapter presents the analysis and interpretation of the data collected to
assess the knowledge of staff nurses regarding prevention and management of
perineal tear during normal delivery at selected Hospitals of Lucknow. The data was
analyzed based on the following objectives.
Objectives Of The Study

52
Hypotheses
To achieve the stated objective, the following hypothesis were formulated:
t
a
f
f
t
a
f
f
ORGANIZATION OF THE STUDY FINDING
The data was analyzed, interpreted and presented in the table and graph. Both
descriptive and inferential statistics was used for data analysis. The finding of the
study was organized and presented in the following section:
Section I: Description of demographic variables of the staff nurses.
Section II: Assess the knowledge levels of staff nurses regarding perineal tear.
Section III: Association between knowledge levels of staff nurses with demographic
variables regarding perineal tear.

53
SECTION I: DESCRIPTION OF DEMOGRAPHIC VARIABLES
OF THE STAFF NURSES
Frequency and percentage distribution of staff nurses according to socio
demographic variables
Table No.: 4.1 Distribution Of Staff Nurses According To Age
N = 250
S. No. Demographic Variable Frequency Percentage (%)
1.
Age (In years)
21 – 30 65 26%
31 – 40 110 44%
41 – 50 45 18%
51 – 60 30 12%
Fig. 4.1: Column Diagram Showing Percentage Distribution Of Staff Nurses
According To Their Age
The most of samples were from age of 31 – 40 years 110 (44%), followed by
from 21 – 30 years 65 (26%), some of them 41 – 50 years was 45 (18%) and
remaining from 51 – 60 years was 30 (12%).

54
Table No.: 4.2 Distribution Of Staff Nurses According To Gender
N = 250
2.
Gender
Male 130 52%
Female 120 48%
Fig. 4.2: Pie Diagram Showing Percentage Distribution Of Staff Nurse According
To Their Gender
The majority of samples was male 1300 (52%) and remaining were female
120 (48%).

55
Table No.: 4.3 Distribution Of Staff Nurses According To Educational
Qualification
N = 250
3.
GNM 75 30%
PB B.Sc. Nursing 65 26%
B. Sc. Nursing 90 36%
M.Sc. Nursing 20 08%
Fig. 4.3: Cylindrical Diagram Showing Percentage Distribution Of Staff Nurses
According To Their Educational Qualification
The most of samples 90 (36%) have done B.Sc. Nursing followed by 75 (30%)
have done G.N.M., 65 (26%) have done PB B.Sc. nursing and remaining 20 (08%)
was M.Sc. nursing.

56
Table No.: 4.4 Distribution Of Staff Nurses According To Work Experience
N = 250
4.
Work Experience
< 5 years 55 22%
5 – 15 years 110 44%
16 – 25 years 50 20%
> 25 years 35 14%
Fig. 4.4: Cone Diagram Showing Percentage Distribution Of Staff Nurses
According To Their Work Experience
Most of samples 110 (44%) have 5 to 15 years experience and other was 55
(22%) have less than 5 years experience and remaining 50 (20%) have 16 – 25 years
of experience and remaining 35 (14%) have more than 25 years experience.

57
Table No.: 4.5 Distribution Of Staff Nurses According To Work Experience In
Labor Room
N = 250
5.
Work Experience in Labor Room
< 5 years 75 30%
5 – 15 years 115 46%
16 – 20 years 40 16%
> 20 years 20 08%
Fig. 4.5: Pyramid Diagram Showing Percentage Distribution Of Staff Nurses
According To Their Experience In Labour Room
Most of samples 115 (46%) from 5 to 15 years work experience in labour
room following by 75 (30%) have less than 5 years work experience in labour room
and some of them 40 (16%) have 16 to 20 years and remaining 20 (08%) have more
than 20 years work experience in labour room

58
Table No.: 4.6 Distribution Of Staff Nurses According To Previous Knowledge
N = 250
6.
Previous knowledge
Yes 140 56%
No 110 44%
Fig. 4.6: Pie Diagram Showing Percentage Distribution Of Staff Nurses
According To Their Previous Knowledge
Most of samples about 140 (56%) have previous knowledge regarding perineal
tear and remaining 110 (44%) have not previous knowledge

59
SECTION II: ASSESS THE KNOWLEDGE LEVELS OF STAFF
NURSES REGARDING PERINEALTEAR
There were 250 staff nurses taken for the study. Each of them had to answer
30 questions. The level of knowledge assess by given the questionnaire and take
response to questionnaire and correct answers were recorded and the mean, mean
percentage, median and standard deviation of the test scores were obtained as below:
a) Table – 4.7: Comparison Of Level Of Knowledge Score Of Staff Nurses
Regarding Prevention And Management Of Perineal Tear
S. No. Level Of Knowledge Frequency Percentage
1. Poor (<50%) 70 28%
2. Average (51% to 65%) 85 34%
3. Good (> 65%) 95 38%
The table no. 4.7 showed the comparison of level of knowledge of staff nurses
regarding prevention and management of perineal tear. With regard to scores, 70
(28%) staff nurses had poor knowledge, 85 (34%) staff nurses had average knowledge
and 95 (38%) staff nurses had good knowledge regarding prevention and management
of perineal tear.

60
b) Area Wise Level Of Knowledge Score Of Staff Nurses Regarding
Prevention And Management Of Perineal Tear
Table – 4.8: Area Wise Level Of Knowledge Score Of Staff Nurses
S.
No.
Aspect Of Knowledge
Max.
Score
Mean
Mean%
Median
Standard
Deviation
1.
Questionnaires related to
concept of perineal tear
11 7.94 72.18% 8 2.00
2.
prevention of perineal
tear
06 3.70 61.66% 4 1.04
3.
management of perineal
tear
13 10.76 82.76% 11 1.68
Total 30 22.40 74.66% 22 2.91
The above table no. 4.8 shows the summary of statistical outcomes of level of
knowledge scores of staff nurses regarding prevention and management of perineal
tear. The structured knowledge questionnaire consists of three parts i.e.
Questionnaires related to concept of perineal tear, Questionnaires related to
prevention of perineal tear and Questionnaires related to management of perineal tear.
The mean, mean percentage, median and standard deviation of first part that was
related to concept of perineal tear, were 7.94, 72.18%, 8 and 2.00 respectively.
Regarding pre-vention of perineal tear the mean, mean percentage, median and
standard deviation were 3.70, 61.66%, 4, and 1.04 respectively. About management of
perineal tear the mean, mean percentage, median and standard deviation was 10.76,
82.76%, 11 and 1.68 respectively. The overall level of knowledge of staff nurses
regarding prevention and management of perineal tear the mean, mean percentage,
median and standard deviation were 22.40, 74.66%, 22 and 2.91 respectively.

61
SECTION III: ASSOCIATION BETWEEN KNOWLEDGE
LEVELS OF STAFF NURSES WITH DEMOGRAPHIC
VARIABLES REGARDING PERINEAL TEAR
Table No. 4.9: Association Between Knowledge Levels Of Staff Nurses
With Demographic Variable
N = 250
S. No. Variables Level ofknowledge Df X2
Value
Table
Value
Remarks
Poor Average Good
1.
Age
6 7.06 12.59 NS
21 – 30 32 19 14
31 – 40 55 44 11
41 – 50 22 15 6
51 – 60 17 8 7
2.
Gender
2 3.70 5.99 NS
Male 70 35 25
Female 60 25 35
3.
Educational qualification
6 23.16 12.59 S
GNM 35 24 16
PB B.Sc. nursing 18 15 32
B.Sc. nursing 18 22 50
M.Sc. nursing 6 5 9
4.
Work experience
6 19.11 12.59 S
< 5 years 12 13 30
5 – 15 year 28 45 37
16 – 25 years 18 9 23
> 25 years 5 8 22
5.
Experience in labour room
6 13.67 12.59 S
< 5 years 32 18 25
5 – 15 years 48 36 31
16 – 20 years 9 15 16
> 20 years 5 3 12

62
6.
Previous Knowledge
2 6.47 5.99 S
Yes 30 40 70
No 35 37 38
Table no. 4.9 revealed that:
 The tabulated value of chi square at 6 df was 12.59 and calculated value was
7.06. So there was not significance association between the levels of
knowledge with age of staff nurses at 0.05 level of significance.
3.70. So there was no significance association between the levels of
knowledge with gender of staff nurses at 0.05 level of significance.
23.16. So there was significance association between the levels of knowledge
with educational qualification of staff nurses at 0.05 level of significance.
with work experience of staff nurses at 0.05 level of significance.
with work experience in labour room of staff nurses at 0.05 level of
significance.
with previous knowledge of staff nurses at 0.05 level of significance.
SUMMARY
This chapter dealt with the data analysis and interpretation of data collected
through structured questionnaire on prevention and management of perineal tear
among staff nurses, the research hypothesis was tested. The association between
knowledge level of staff nurses on perineal tear with selected demographic variables
were assessed.

63
CHAPTER – V
DISCUSSION
DISCUSSION
Major finding of the study are as follows:
 The most of samples were from age of 31 – 40 years 110 (44%), followed
b
yfrom 21 – 30 years 65 (26%), some of them 41 – 50 years was 45 (18%)
and
remaining from 51 – 60 years was 30 (12%).
 The majority of samples was male 1300 (52%) and remaining were f
e
m
a
l
e
120 (48%).
 The most of samples 90 (36%) have done B.Sc. Nursing followed by 75 (
3
0
%
)
have done G.N.M., 65 (26%) have done PB B.Sc. nursing and remaining 20
(08%) was M.Sc. nursing.
 Most of samples 110 (44%) have 5 to 15 years experience and other was 55
(22%) have less than 5 years experience and remaining 50 (20%) have 16 – 25
years of experience and remaining 35 (14%) have more than 25 years
experience.
 Most of samples 115 (46%) from 5 to 15 years work experience in l
a
b
o
u
r
room following by 75 (30%) have less than 5 years work experience in labour
room and some of them 40 (16%) have 16 to 20 years and remaining 20 (08%)
have more than 20 years work experience in labour room.
 Most of samples about 140 (56%) have previous knowledge regarding per
i
n
eal
tear and remaining 110 (44%) have not previous knowledge.
Description Of Knowledge Score Of Staff Nurses Regarding
Prevention And ManagementOf Perineal Tear
Here we can discuss about the level of knowledge of staff nurse as per set the
criteria for poor, average and good. With regard to scores, 70 (28%) staff nurses had
poor knowledge, 85 (34%) staff nurses had average knowledge and 95 (38%) staff
nurses had good knowledge regarding prevention and management of perineal tear.

64
The knowledge score of the staff nurses as different area of questionnaire
regarding prevention and management of perineal tear explain with their mean, mean
percentage, median and SD. The mean, mean percentage, median and standard
deviation of first part that was related to concept of perineal tear, were 7.94, 72.18%,
8 and 2.00 respectively. Regarding prevention of perineal tear the mean, mean
percentage, median and standard deviation were 3.70, 61.66%, 4, and 1.04
respectively. About management of perineal tear the mean, mean percentage, median
and standard deviation was 10.76, 82.76%, 11 and 1.68 respectively. The overall level
of knowledge of staff nurses regarding prevention and management of perineal tear
the mean, mean percentage, median and standard deviation were 22.40, 74.66%, 22
and 2.91 respectively.
Association Of Level Of Knowledge Score With Selected
Demographic Variables
7.06. So there was not significance association between the levels of
knowledge with age of staff nurses at 0.05 level of significance.
3.70. So there was no significance association between the levels of
knowledge with gender of staff nurses at 0.05 level of significance.
with educational qualification of staff nurses at 0.05 level of significance.
with work experience of staff nurses at 0.05 level of significance.
with work experience in labour room of staff nurses at 0.05 level of
significance.
with previous knowledge of staff nurses at 0.05 level of significance.

65
CHAPTER – VI
SUMMARY CONCLUSION
SUMMARY
The objective of the study was assessing knowledge of staff nurses regarding
prevention and management of perineal tear during normal delivery. The review of
exiting discloses a dearth in research on actual hands on nursing which would be
because of the methodological difficulties associated with investing actual knowledge.
Objectives Of The Study Are
Hypothesis
t
a
f
f
t
a
f
f
Conceptual Framework

66
and cure circle.
A review of related research and non-research literature helped the
investigator to develop the tool and content for questionnaire. The literature reviewed
further enabled the investigator to develop a conceptual framework, methodology of
the study and to decide plan for data analysis.
The research approach adopted for the study was descriptive research
approach. The research design was non experimental descriptive research design. The
dependent variable was the knowledge of staff nurses. The study was conducted in the
selected hospitals, Lucknow i. e. Era‟s Lucknow Medical College and Hospital, K.K.
Hospital, Lucknow, Unity Hospital, Lucknow (U.P.). The sampling technique used to
choose the subjects was by purposive sampling technique. The sample comprised of
250 staff nurses working in Era‟s Lucknow Medical College and Hospital, K.K.
Hospital, Lucknow, Unity Hospital, Lucknow.
CONCLUSION
On the basis of results it is conclude that maximum number of staff nurses
were had average knowledge and minimum had good knowledge regarding
prevention and management of perineal tear. The maximum mean score of s
Staff nurses was in the area of management of perineal tear with 1.68 SD. The
overall knowledge score of staff nurses was 22.40 mean, 74.66% mean percentage, 22
median with 2.91 SD.
On the basis of results it is can also conclude that the knowledge level of staff
nurses were significant associated with demographic variables like educational
qualification, work experience, experience in labour room and previous knowledge
because here the calculate value was more than tabulate value. Some demographic
variables like age and gender was not significant associated with level of knowledge.

67
NURSING IMPLICATIONS
The findings of the study have implications on the field of nursing practices,
nursing education, nursing research and nursing administration.
NURSING PRACTICE
Nursing is an art and science. As a science, nursing is based upon a body of
knowledge that is always changing with the new discoveries and innovations. When
nurses integrate the science and art of nursing into their practice, the quality of care
provided to the patients is at a level of excellence that benefits patients in numerous
ways. They are the key person of the health team, who plays a vital role in the
promotion and maintenance of health. They can identify the problems as early as
possible and to provide the need based care to promote optimum helping in providing
the patient needs.
The present study has revealed the gap between the knowledge of perineal tear
and prevention of perineal tear during the normal delivery. This indicates that there is
a great scope for patients teaching in this area.
NURSING EDUCATION
Education is the key component to update and improve the knowledge and
attitude of an individual. In the present scenario, knowledge regarding prevention of
perineal tear to prevent the future complications is much deficient among staff nurses
and is still on the path of expansion. Health teaching is one of the areas in which nurse
need preparation and practice with component role models because it involves
transmitting information at the prevention of perineal tear during normal delivery.
Hence there is a need to include these components into the entire educational
curriculum. Awareness programme and other teaching programme will be conducted
to aware the staff nurses about importance or prevention of perineal tear during the
normal delivery. So that life and complication can be saved.

68
NURSING ADMINISTRATION
Nurse administrators should identify prevailing health problems, demands and
organize in-service education programme for the nurse working in various
departments. This will enhance their ability in identifying the learning needs of the
clients people, in planning and conducting an educative programme for prevention of
perineal tear.
Health administrators can develop certain policies concerning periodic survey
to identify the perineal tear importance of prevention of perineal tear; to conduct
education and innovative methods of teaching should be encouraged to aware the
knowledge of staff nurse related to perineal tear.
NURSING RESEARCH
Research should be directed for exploring and updating staff nurses
knowledge, ability regarding prevention and management of perineal tear to provide
quality nursing care.
Nursing research should be conducted to prepare various education materials
for staff nurses who are facing the risk of perineal tear.
LIMITATIONS
The study was limited to:
1. Staff nurses working in Era‟s Lucknow Medical College and Hospital, K.K.
Hospital, Lucknow, Unity Hospital, Lucknow.
2. Staff nurses who are willing to participate in research study.
3. Staff nurses who will be present at the time of study.
RECOMMENDATION
 A study can be replicated on a larger sample thereby findings can
b
egeneralized for a larger population.
 A comparative study can be conducted to evaluate the effectiveness o
f
a
planned teaching programme.
 A similar study can be conducted in community setting.
 An experimental study can be undertaken with control group.

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