Effectiveness of education Program in Knowledge and practices for Nurse- Midwife Regarding Psychological Status, Rest and Sleep, Self-Care for Primipara Women with Cesarean Section at Maternity Hospital in Holy
Karbala
AmelKhalafKadhim, MSc. N* ;Rabea Mohsen Ali, PhD**
* Academic Nurse, Karbala Midwifery school
** Professor, Maternal and Neonate Nursing Department, College of Nursing, University of Baghdad.
Abstract
Background: The ability to provide self- care is a fundamental requisite for childbearing women to maintain and improve health during the postpartum period. Promoting women’s self-care during postpartum is part of the nursing care process in the gravid-puerperal cycle.
Objectives: To evaluate nurses-midwifes' knowledge and practices about Psychological Status, and Rest and Sleep, self-care postpartum for primipara women with cesarean section; to determine the effectiveness of the educational program on knowledge and practices for nurses- midwifes';
and to identify the relationship between nurses-midwifes knowledge and practices about postnatal self-care and their demographic, variables ( age and education).
Methodology: Quasi-experimental study design. Non-probability (purposive) sample consists of (60 nurse- midwife) their work at surgical ward in hospital. The sample was exposed to pretest, educational training program, posttest (1and 2). A pilot-study is conducted to determine the reliability of the questionnaire. Data were analyzed through the use of SPSS (24).
Result: Nurse-midwives’ knowledge was poor in pretest; while in posttest was good after implementation the educational program. The intervention highly effective on nurse-midwives’
knowledge and practices evidenced by high significance at p-value=0.001. It is clear out of descriptive the noticeable increasing of mean score on nurses-midwives’ knowledge and practices in post-test 1 and 2 that indicate the effectiveness of educational program; and there is strong positive relationship between knowledge with nurse-midwives’ level of education at p-value=
0.001
Conclusion: The education program was effective in increasing nurse-midwives’ knowledge and practices regarding Psychological Status Rest and Sleep, self-care for primipara women with cesarean section.
Recommendations: Prenatal and postnatal childbirth education should be improved by giving priority to it, improving nurse/ midwife knowledge and practices regard self-care for primipara women with cesarean section and activation of their role as educator in routine prenatal and postnatal.
Keywords: Knowledge, practices, Nurse-Midwife, Psychological Status, Rest and Sleep, Self-Care Introduction
Postpartum period begins after the third stage of delivery and includes first six weeks after delivery. During this time women’s reproductive organs gradually returns to the normal size and shape. Postnatal period is a crucial period in woman’s life and lot of physiological changes used to occur. They are in need of special care during pregnancy, at the time of delivery as well as after delivery of child in order to prove safe motherhood and healthy living (1). Is the period of adjustment after child birth when anatomical and physiological changes of consumption are
reversed to an almost pre pregnancy level (2).
Self-care is the practice of activities that the individual performs for its own benefit, well- being, health and quality of life. This is a regulatory function, a deliberate action to provide or ensure the provision of the information necessary to continue its life, growth, development and maintenance of human health. the nursing professional has a relevant role in who has recently given birth assistance, performing the function of educator, promoting health and contributing to quality of life. The postpartum period assistance must provide an interactive and effective care, consistent with the bio-psychosocial needs of women. In addition, for the woman feel confident and motivated for the practice of self-care, it is necessary that health professionals involved in assistance to encourage women’s empowerment that has recently given birth in the postpartum period (3).
Mothers can have difficulty in adapting to new family order, new baby and changes in their bodies in the postpartum period. They especially reported that they had problems because of insufficient breast feeding education, physical and emotional support (4). When mothers are discharged in the postpartum period, they must feel themselves sufficient and ready for taking responsibility of care of the baby at home. For this reason, mothers must take medical care and education about health of them and their newborn babies in order to be ready for home environment during the time in which they stay in the hospital (5).
Methodology:
A quasi-experimental design was carried out throughout the present study with the application of a pre- post test1 and 2 for their knowledge regarding personal hygiene and wound care through self- care for primipara women with cesarean section and checklist for their practices observation during self-care for primipara women with cesarean section. The education program consists of 2 major part, and it was implemented and introduced with respect to the essential information relative to knowledge and practices for nurse-midwife regarding self-care for primipara women with cesarean section, each session was designed and scheduled for approximately (15-20) for minutes. They were presented from the period 15th April - 6th November 2020 at maternity teaching hospital in Holy Karbala city. The education program sessions were managed by three methods, power point, education videos, education booklets, lectures discussion , direct intervention on the patient and follow up after the implementation of the education program. A questionnaire was used as a tool of data collection to fulfill the objectives of the study and consisted of demographic, knowledge and practices of nurse-midwife about self-care during the postpartum period include Psychological Status, and Rest and Sleep.
Results of the Study
Figure (1): Distribution of Nurse-Midwives according to their Age Group
This figure shows that more than third of nurse-midwives are young with age group of (25-34) years (41.7%) and (36.7%) of them are with age group of (35-44) years
Figure (2): Distribution of Nurse-Midwives according to their Educational levels This figure presents that the highest percentage regarding education level among nurse- midwives is referring to secondary nursing schools and nursing diploma (41.7%).
Table (1a): Evaluation of Nurse-Midwives’ Knowledge Levels about “Psychological Status”
during Postpartum of Primipara Women with Cesarean Section List Item
Pre-test (N=60)
Post-test 1 (N=60)
Post-test 2 (N=60) M.
S R.S Ev a.
M.
S R.
S Ev
a.
M.
S R.S Eva.
Psychological status
1
The psychological state of the mother is not affected after the cesarean section and during the postpartum period
.03 1.5 Poo
r .57 28 .5
Fai
r .55 27.
5 Fair 2 The mother needs her own time to practice
hobbies and personal care .03 1.5 Poo
r 1.0
0 50 Go
od .93 46.
5
Goo d 3 Carrying out family and entertainment visits
.03 1.5 Poo
r .93 46 .5
Go
od .62 31 Fair 4 Exercise does not improve the psychological state
.03 1.5 Poo r
1.0
0 50 Go od
1.0
0 50 Goo d 5 The type of food does not affect the psychological
state .03 1.5 Poo
r .60 30 Fai
r .57 28.
5 Fair 6 Returning the patient to her previous routine
quickly improves her mood .03 1.5 Poo
r .20 10 Poo
r .13 6.5 Poor 7 Getting enough time to sleep (the mother sleeping
while the child sleeps) .03 1.5 Poo
r 1.0
0 50 Go
od .93 46.
5
Goo d 8 The mother should not sit alone and join the
family .54 27 Fai
r 1.0
0 50 Go od
1.0
0 50 Goo d 9 Frequent use of the mobile phone does not affect
the psychological state .03 1.5 Poo
r .58 29 Fai
r .58 29 Fair M.S: Mean of score, R.S: relative sufficiency, Eva: Evaluation, Poor: M.S= 0 – 0.33, Fair: M.S=
0.34 – 0.67, Good: M.S= 0.68 – 1.
This table reveals that nurse-midwives are showing poor to fair knowledge regarding
―psychological status‖ during the pre-test time, while they are showing fair to good level of knowledge during the times of post-test 1 and 2.
Table (1b): Evaluation of Practices’ Levels among Nurse-Midwives regarding “Psychological Status” for Primipara Women with Cesarean Section
List
The nurse explains and clarify the importance of the following points for the patient to adapt to her new condition
Pre-test (N=60)
Post-test 1 (N=60)
Post-test 2 (N=60) M
.S R.
S Ev
a.
M.
S R.
S Ev
a.
M.
S R.
S Eva
.
Psychological status
1 Get enough sleep .0
0 0 Poo r
2.0 0
66 .7
Go od
1.8
0 60 Goo d
2 Eat healthy foods .0
0 0 Poo r
2.0 0
66 .7
Go od
1.6
2 54 Goo d 3 Doing special hobbies and sports, such as walking .0
0 0 Poo r
2.0 0
66 .7
Go od
1.6
8 56 Goo d 4 Express her feelings, fears and new changes (C/ S and
postpartum)
.0
0 0 Poo r
1.4
7 49 Go od
1.4
7 49 Goo d 5 Resorting to family and friends to cope with
motherhood
.0
0 0 Poo r
1.4 0
46 .7
Go od
1.4 0
46 .7
Goo d 6 Talking with mothers who have the same experience
from friends and relatives
.0
0 0 Poo r
1.5 3
50 .7
Go od
1.5 3
50 .7
Goo d 7
Informing the family, the nurse, or the doctor when feeling overwhelming feelings of sadness or the inability to care for oneself or a child
.0
0 0 Poo r
2.0 0
66 .7
Go od
1.7 3
57 .7
Goo d M.S: Mean of score, R.S: relative sufficiency, Eva: Evaluation, Poor: M.S= 0 – 0.66, Fair: M.S=
0.67 – 1.33, Good: M.S= 1.34 – 2.
This table reports that nurse-midwives are showing poor practices regarding ―psychological status‖
during the pre-test time among all items, and they are showing good practices during the post-test 1 and 2 among all items consequently.
Table (2a): Evaluation of Nurse-Midwives’ Knowledge Levels about “Rest and Sleep” during Postpartum of Primipara Women with Cesarean Section
List Item
Pre-test (N=60)
Post-test 1 (N=60)
Post-test 2 (N=60) M
.S R.S Eva. M.
S R.
S Ev
a.
M .S
R.
S Ev
a.
Rest and sleep
1 Encouraging the mother to sleep for a period of at least 8 hours at night, and a nap during the day
.8 7
43.
5
Goo d
1.0
0 50 Go od
.6
8 34 Go od 2 The mother can take care of the baby alone and without
any help
.0
3 1.5 Poor .58 29 Fai r
.5
8 29 Fai r 3 Encouraging the mother to seek the help of the family to
help with household chores
.0
3 1.5 Poor 1.0
0 50 Go od
1.
00 50 Go od 4 Encouraging the mother to receive guests at any time .0
3 1.5 Poor .93 46 .5
Go od
.7 3
36 .5
Go od 5
Encouraging the mother to allocate her own time to watch a program on television or do any activities of her own, such as contacting some friends
.0
3 1.5 Poor .93 46 .5
Go od
.9 3
46 .5
Go od
6 Encouraging the mother not to sleep, taking a break while the child sleeps, and completing the tasks required of them
.2
8 14 Poor 1.0
0 50 Go od
1.
00 50 Go od 7 Early sleep enhances the body's physical, psychological
and mental adequacy
.4 5
22.
5 Fair .53 26 .5
Fai r
.5 3
26 .5
Fai r 8
Using electronic devices for long periods (such as mobile phones, tablets, and calculators), especially at night, improves feelings of comfort and helps sleep.
.0
3 1.5 Poor .93 46 .5
Go od
.7 3
36 .5
Go od M.S: Mean of score, R.S: relative sufficiency, Eva: Evaluation, Poor: M.S= 0 – 0.33, Fair: M.S=
0.34 – 0.67, Good: M.S= 0.68 – 1.
This table presents that nurse-midwives are showing poor to fair knowledge regarding ―sleep and rest‖ during the pre-test time, while during the post-test 1 and 2, they are showing good knowledge among all items except items 2 and 7 that are showing fair knowledge.
Table (2b): Evaluation of Practice Levels among Nurse-Midwives regarding “Rest & Sleep”
for Primipara Women with Cesarean Section List The nurse guides the patient on the importance of
rest and sleep
Pre-test (N=60)
Post-test 1 (N=60)
Post-test 2 (N=60) M.
S R.
S Ev
a.
M.
S R.S Ev a.
M.
S R.
S Eva
.
Rest and sleep
1
Sleeping for at least 8 hours at night, even if interspersed with a period of breastfeeding for the child, and taking a nap during the day
.03 1 Poo r
2.0 0
66.
7 Go
od 1.9
3 64
.3 Goo
d 2 Asking husband or family to help with housework
.00 0 Poo r
2.0 0
66.
7 Go
od 1.6
8 56 Goo d 3 Set a time to visit guests (receive guests) to provide
time for her rest .00 0 Poo
r 2.0
0 66.
7 Go
od 1.9
3 64
.3 Goo
d 4
Allocate her own time to watch a program on TV or do any activity of her own, such as calling some friends
.00 0 Poo r
1.4 0
46.
7 Go
od 1.0
8 36 Goo d 5
Sleeping and taking a break while the child sleeps, and not completing the tasks required of them during the child's sleep period
.00 0 Poo r
2.0 0
66.
7 Go
od 1.8
0 60 Goo d M.S: Mean of score, R.S: relative sufficiency, Eva: Evaluation, Poor: M.S= 0 – 0.66, Fair:
M.S= 0.67 – 1.33, Good: M.S= 1.34 – 2.
This table reports that nurse-midwives are showing poor practices regarding ―sleep and rest‖
during the pre-test time among all items, and they are showing good practices during the post-test 1 and 2 among all items respectively
Table (3a): Overall Evaluation of Knowledge among Nurse-Midwives regardingSelf-Care for Primipara Women with Cesarean Section
Levels of Knowledge
Pre-test Post-test I Post-test II
F % M SD F % M.S SD f % M SD
Poor 58 96.7
1.07 .362
0 0
3.00 .000
0 0
2.93 .252
Fair 2 3.3 0 0 16 26.7
Good 0 0 60 60 44 73.3
Total 60 100 60 100 60 100
f: Frequency, %: Percentage, M: Mean, SD Standard deviation ,Poor= 0-33, Fair= 34-66, Good=67-99
This table shows that most of the nurse-midwives are with poor level of knowledge during the pre-test time regarding self-care of primipara women with cesarean section (96.7%). The nurse- midwives’ knowledge is increased during the time of post-test 1 and post-test 2 to good level (post- test 1= 100% and post-test 2= 73.3%).
Table (3b): Evaluation of Overall Practices among Nurse-Midwives regardingSelf-Care for Primipara Women with Cesarean Section
Levels of Practices
Pre-test Post-test I Post-test II
F % M SD f % M.S SD f % M SD
Poor 60 100
1.00 0.000
0 0
3.00 0.000
0 0
2.73 .443
Fair 0 0 0 0 4 6.7
Good 0 0 60 100 56 93.3
Total 60 100 60 100 60 100
f: Frequency, %: Percentage, M: Mean, SD Standard deviation, Poor= 0-56, Fair= 57-112, Good=113-168
This table refers to evaluation of nurse-midwives’ practices regarding self-care for primipara women with cesarean section; the findings indicates that all nurse-midwives are showing poor practices during the pre-test time (100%), while they are showing good knowledge during the post- test 1 time (100%) and post-test 2 time (93.3%).
Table (4): Pearson Correlation for Nurse-Midwives’ Knowledge with regard to their Demographic Characteristics of Age and Level of Education (N=60)
Knowledge Variables
Pearson
correlation p-value Sig
Age - 0.659 0.001 H.S
Level of Education 0.516 0.001 H.S
P: probability, Sig: Significance, N.S: Not Significant, S: Significant, H.S: High significant This table indicates that there is strong reverse relationship between level of knowledge among nurse-midwives with regard to their age group at p-value =0.001, while there is strong positive relationship between knowledge with nurse-midwives’ level of education at p-value= 0.001.
Table (5): Pearson Correlation for Nurse-Midwives’ Practices with regard to their Demographic Characteristics of Age and Level of Education (N=60)
Practices Variables
Pearson
correlation p-value Sig
Age - 0.699 0.001 H.S
Level of Education 0.627 0.001 H.S
P: probability, Sig: Significance, N.S: Not Significant, S: Significant, H.S: High significant This table reports that there is strong reverse relationship between level of practices among nurse-midwives with regard to their age group at p-value =0.001, and also, there is strong positive relationship between practices with nurse-midwives’ level of education at p-value= 0.001.
Discussion:
The result of study shows that more than third of nurse-midwives are young with age group of (25-34) years (41.7%) and (36.7%) of them are with age group of (35-44).Figure (1).This result in agreement with Mukonka et al (2018) who found that women and newborn in Lusaka District
study shows that more than (41.2%) of nurse-midwives are young with age (20 - 29) years, and (19.6%) were 30 - 39 years(6).A similar study conducted by Elsharkawyetal (2019) on the effect of educational module on nurses knowledge and practices shows that more than half (59.10%) of nurses their age ranged from 30- 35years(7). Nanda et al (2020) in their study showed higher percentage (75%) of nurses their age ranged from (31-40) years(8) .
Regarding educational levels,the result of study presents that the highest percentage regarding education level among nurse-midwives is referring to secondary nursing schools and nursing diploma (41.7%)Figure (2). A similar study conducted by Elsharkawy et al (2019) found in their study that (65.9%) of the nurses had a nursing diploma(7). Also Mukonka et al (2018) showed the education level, majority (66.7%) had diplomas(6). While Mustafa & Al –Mukhtar (2015) in a study in Kirkuk City found that (74%) of the study sample were graduated from the secondary nursing school /midwifery(9). Nanda et al (2020) study also showed, majority (60%) had secondary nursing schools(8).
Regarding evaluation of nurse-midwives’ knowledge about “Rest and Sleep” Table (1a):
The study results presents that nurse-midwives are showing poor to fair knowledge regarding
―sleep and rest‖ during the pre-test time, while during the post-test 1 and 2, they are showing good knowledge among all items except items 2 and 7 that are showing fair knowledge after implementation of educational program.According to Lee & Gay (2017) in similar study to evaluate nurse-midwife knowledge for improving sleep and rest for postpartum women. After intervention of the program found that both groups recorded knowledge but the controls group had fewer knowledge to improving sleep and rest for postpartum women and significantly (P = .015) lower practices to improving sleep and rest for postpartum women (53.1 ± 14.5) than intervention (71.9 ± 18.8). Participant feedback about the intervention was positive(10).
Regarding evaluation of nurse-midwives’ practicesregarding “Rest and Sleep” Table (1b):The result reports that nurse-midwives are showing poor practices regarding ―sleep and rest‖
during the pre-test time among all items, and they are showing good practices during the post-test 1 and 2 among all items respectively after implementation of educational program.A similar study conducted by Ismail &Elgzar (2018) on a sample of 80 nurse-midwife work in surgical ward, after the intervention program , rest and sleep significantly decreased pain severity among study group in pain rating index scale,. The severe physical activities limitation significantly absent from the entire study group, while it was significantly present among (70%) of the control group. About two-thirds (62.5%) of the study group had a good quality of rest and sleep compared to (5%) of the control group(11).
Regarding evaluation of nurse-midwives’ knowledge levels about “Psychological Status”
Table (2a): The result reveals that nurse-midwives are showing poor to fair knowledge regarding
―psychological status‖ during the pre-test time, while they are showing fair to good level of knowledge during the times of post-test 1 and 2 after implementation of educational program. A similar study conducted by Rami et al(2021) found that the nurses and midwives lacked knowledge about various aspects of PPD, including its definition, prevalence, symptoms, risk factors, screening tools, and treatment. Only one third of participants were confident in their ability to provide education for women about PPD. Participants' self-confidence to educate women about PPD was significantly correlated with their level of knowledge about assessment and management of PPD(12).
Regarding evaluation of nurse-midwives’ practices’ levels “Psychological Status” Table (2b): This results reports that nurse-midwives are showing poor practices regarding ―psychological status‖ during the pre-test time among all items, and they are showing good practices during the post-test 1 and 2 among all items consequently after implementation of educational program.
Ghiasvandetal (2017)study showed that the implementation of a self-care program based on the
Teach Back method improves the postpartum quality of life and after the intervention, during postpartum period, (psychological status)(p<0.00). The separate assessment of each group revealed the mean and standard deviation of the psychological status during postpartum quality of life score to be (31.75±3.052) before the intervention and (34.28±3.942) after the intervention in the trial group, and (31.775±3.832) before the intervention and (31±4.403) afterwards in the control group, suggesting a significant difference in each group between the pre- and the post-intervention scores (p<0.001). In the trial group, the mean score of all the dimensions of quality of life differed significantly after the intervention compared(13). Esmkhani et al (2021) found that the post-test mean total score of quality of life had a statistically significant difference between two groups (p = .001), assessment of each group revealed the mean and standard deviation of psychological status during postpartum quality of life score to be (11.07 ± 4.19) before the intervention and (16.11 ± 3.35) after the intervention in the trial group, and (12.59 ± 4.04) before the intervention and (17.97
± 2.20) afterwards in the control group, suggesting a significant difference in each group between the pre- and the post(14).
The overall evaluation of knowledge among nurse-midwives regarding self-care for primipara women with cesarean section. Table (3a): The result shows that most of the nurse- midwives are with poor level of knowledge during the pre-test time regarding self-care of primipara women with cesarean section (96.7%). The nurse-midwives’ knowledge is increased during the time of post-test 1 and post-test 2 to good level (post-test 1= 100% and post-test 2=
73.3%) after the implementation of educational program. According to Nanda et al (2021), Nurses- midwife in this study had a mean pre – test knowledge score of 22.35 (74.50%), the post – test mean value was 26.63 (88.78%) . There was a good effectiveness of Self instructional module on postoperative care after caesarean section. The researcher also found the association between post – test knowledge and age of the samples. Hence self-instructional module is very much effective for staff nurses(8).
Theevaluation of overall practices among nurse-midwives regarding self-care for primipara women with cesarean section. Table (3b): The findings indicates that all nurse- midwives are showing poor practices during the pre-test time (100%), while they are showing good knowledge during the post-test 1 time (100%) and post-test 2 time (93.3%) after the implementation of educational program. It is clear out of descriptive the noticeable rising of mean score on nurses-midwives’ practices post-test 1 and 2 that indicate the effectiveness of educational program. Ghiasvandet al (2017) study showed that the implementation of a self-care program based on the Teach Back method improves the postpartum quality of life and increases the mean(13). El- Khawaga1(2019) findings of study revealed that after implementation of teaching program immediately and 3 months later the post program, there was a significant improvement of knowledge as well as performance among the studied nurses regarding the immediate postpartum care and the immediate newborn care compared to preprogram(15).
The correlation for nurse-midwives’ knowledge with regard to age and level of education Table (4a): The result indicates that there is strong reverse relationship between level of knowledge among nurse-midwives with regard to their age group at p-value =0.001, while there is strong positive relationship between knowledge with nurse-midwives’ level of education at p- value= 0.001. Nanda et al (2020) in their study found the association between post – test knowledge and age of the samples. The chi – square value was 6.0 for the degree of freedom 6 at level of significance 0.000. In current study there was a statistically significant association between post – test knowledge level with age [(χ2 = 6.000, dof = 2 and TV = 5.991)](8).
The correlation for nurse-midwives’ practices with regard to age and level of education Table (4b): The result reports that there is strong reverse relationship between level of practices among nurse-midwives with regard to their age group at p-value =0.001, and also, there is strong
positive relationship between practices with nurse-midwives’ level of education at p-value= 0.001.
Selvam (2017)study found the association of demographic variable (age and level of education ) with post test scores of education program of the experimental group. The x2 value of height was (20.323) at 3 degree of freedom and significant at (0.05) level(16).Saral (2018) study result showed, there was a significant difference between the pre-test and post-test level of practices and attitude regarding breast care and exclusive breast feeding. The obtained t – value (19.67) was greater than the table value at 0.05 level of significance (17).
Conclusion:
The findings of nurse-midwives’ knowledge and practices reveals that overall evaluation of knowledge among nurse-midwives regarding self-care for primipara women with cesarean section are with poor level of knowledge during the pre-test time. The nurse-midwives’ knowledge is increased during the time of post-test 1 and post-test 2 to good level after the intervention of educational program.
Recommendations:
Based on early stated fact, the study recommends that: All maternal and child health center in Iraq should include educational programs for nurse-midwives’ on knowledge regarding self-care of primipara and multipara women with cesarean section on postpartum period . Nurse-midwives’
should teach women delivered by cesarean section primipara and multpara or normal delivery the principal of self-care during postpartum period .
Funding: This research was funded by Author. Moreover, Conflict of interest: None declared.
Ethical approval: Clearance was taken from committee in College of Nursing/ University of Baghdad.
Acknowledgments: We would like to thank all the Nurses/Midwives who participated in this study.
References
1. Missiriya S.: Knowledge and Practice of Postnatal Mothers Regarding Personal Hygiene and Newborn Care. International Journal of Pharmaceutical Sciences Review and Research.
October 2016 ( 18) pp: 89-93
2. Memchoubi K., Kudale A., Lilileima L., Koshy L. and Londhe S.: A study to assess the knowledge of postnatal mothers regarding self-care after childbirth in Bharati hospital and research centre, Pun. International Journal of Applied Research( IJAR) 2019; 3(6)pp: 1115- 1117
3. Barreto B., Moreira MA.: Motherhood experience on puerperium and its interference in self- care practice. ArqCiencSaade. 2014 Jan-Mar; 21(1):29-35. Disponevelem: http:// repositorio- racs.famerp.br/racs_ol/vol-21-1/ID_562_21(1)_(Jan_ Mar_2014).pdf.
4. Barimani, M., Vikström, A.:Successful early postpartum support linked to management, informational, and relational continuity. Midwifery. 2015,(31),pp 811–817
5. Jing, L., Bethancourt, C.N., McDonagh, T.: Assessing infant and maternal readiness for newborn discharge. Current Opinion in Pediatrics. 2018.( 29)pp598-605
6. Mukonka P. ,Mukwato, P. , Kwaleyela, C. , Haruzivishe, C. and Maimbolwa, M.
:Understanding Midwives’ Perspective on Care of Post Cesarean Section Women at the University Teaching Hospital—Women and Newborn, Lusaka. Open Journal of Nursing, 2018, 8, pp918-939.doi: 10.4236/ojn.2018.812069
7. Elsharkawy., Othman A., Attia . and MohamedHasanein .:Effect of Educational Module on Nurses Knowledge and Practices Regarding Cesarean Section. researchgate. December 2019 163(11):201-221
8. Nanda K., Rajamani S. and Priyanka N.:A study to Assess the Effectiveness of Self Instructional Module (SIM) on Knowledge Regarding Post-Operative Care of Cesarean Mothers among Staff Nurses in Selected Government Hospitals of Haryana. International Journal of Nursing Education, April-June 2020, l. (12),
9. Mustafa D. and Al –Mukhtar S.: Evaluation of Knowledge and Practice of Nursing Staff Regarding Immediate Care after Birth in Kirkuk City Hospitals. Mosul Nursing Journal.
2015,(1),3. article_160025_4a167cdae380836d5b89a1f23ed279c5.pdf
10. Lee KA and Gay C.: improving Sleep for Hospitalized Antepartum Patients: A Non- Randomized Controlled Pilot Study .Journal Clin Sleep Med. 2017 Dec 15; 13(12): 1445–
1453 Published online 2017 Dec 15. doi: 10.5664/jcsm.6846PMCID: PMC5695992 PMID: 29117884
11. Ismail N. and Elgzar A.: The Effect of Progressive Muscle Relaxation on Post Cesarean Section Pain, Quality of Sleep and Physical Activities Limitation.International Journal of Studies in Nursing, 2018,l( 3) 3 . ISSN 2424-9653 E-ISSN 2529-7317 Published by July Press Online Published: September 7, 2018 doi:10.20849/ijsn.v3i3.461 12. Rami et al (2021) https://journals.healio.com/doi/abs/10.3928/02793695-20180612-02
available at January 22, 2021https://doi.org/10.3928/02793695-20180612-02
13. GhiasvandF., Riazi H, Hajian S, Kazemi E, Firoozi A.: The effect of a self-care program based on the teach back method on the postpartum quality of life 2017 Apr; 9(4): 4180–4189.
Published online 2017 Apr 25. doi: 10.19082/4180PMCID: PMC5459290 PMID: 28607653 Electronic physician
14. EsmkhaniAhmadi L. and Maleki A.: The Effect of Client Needs Counseling on the Postpartum Quality of Life of Women .Journal Perinat Education.20201Apr 1; 29(2): 95–102
15. El-Khawaga D., Ahmed M. and Elwelely M.: Effect of Implementation of a Teaching Program about Immediate Postpartum Care on Nurses’ Knowledge and Practice. Tanta Scientific Nursing Journal. 2019 ,l(16) 1 May,
16. Selvama S.: Nurses' knowledge, attitudes and practices regarding breast care in the Sousse region of Tunisia: a cross sectional descriptive study. Journal of Clinical Oncology and Cancer. 2017,1(1):pp1-7.
17. Saral G .: Effectiveness of video assisted program on knowledge and Attitude regard exclusive breast feeding among primi mothers in postnatal ward at institute of obstetrics and gynecology government hospital for women and children , channel is a bonafide work done by, College of Nursing, Madras Medical College, Chennai 3, 2018.Thesis
