i

“A STUDY TO ASSESS THE EFFECTIVENESS OF LOWER LIMB MASSAGE ON

PHYSIOLOGICAL LOWER LEG/S EDEMA AND COMFORT DURING THIRD

TRIMESTER AMONG GRAVID MOTHERS IN A SELECTED COMMUNITY,

BENGALURU”

BY

ELIZABETH JOSEPH

Thesis submitted to

Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka

In partial fulfillment of the requirements for the degree of

MASTER OF SCIENCE

IN

OBSTETRICS AND GYNAECOLOGICAL NURSING

Under the guidance of

MRS MARY REXLINE S. M.Sc (N)

Assistant Professor

Department of Obstetrics and Gynaecological Nursing

St.Philomena’s College of Nursing Bengaluru

2018

ii

iii

iv

v

vi

vii

viii

ix

x

LIST OF ABBREVATIONS

Fig Figure

df Degree of freedom

H1 Research Hypothesis one

H2 Research Hypothesis two

H3 Research Hypothesis three

H4 Research Hypothesis four

N Total number of the sample

NS Non- significant

S Significant

SD Standard Deviation

< Lesser than

> Greater than

ꭓ2 Chi square

xi

LIST OF TABLES

TABLES

NO

TITLE PAGE

NO.

1. Comparison of pre and post intervention lower leg edema scores among

gravid mothers during third trimester.

64

2. Comparison of pre and post intervention comfort scores among gravid

mothers during third trimester.

66

3. Association between sample characteristics and pretest Erin edema

scores among gravid mothers with physiological lower leg edema during

third trimester

67-68

4. Association between sample characteristics and pretest Comfort scores

among gravid mothers with physiological lower leg edema during third

trimester.

70-71

xii

LIST OF FIGURES

Figure

No

Title Page

No

1. Conceptual frame work based on Katharine Kolcaba’s theory of comfort.

15

2. Schematic representation of the Research design 48

3. Bar diagram showing percentage distribution of the gravid mothers

according to their age.

53

4. Cylindrical diagram showing percentage distribution of the gravid

mothers according to their Religion

54

5. Bar diagram showing percentage distribution of the gravid mothers

according to their educational status

55

6. Bar diagram showing percentage distribution of the gravid mothers

according to their occupational status.

56

7. Bar diagram showing percentage distribution of the gravid mothers

according to their type of family

57

8. Bar diagram showing percentage distribution of the gravid mothers

according to their weeks of gestation

58

9. Bar diagram showing percentage distribution of the gravid mothers

according to maternal weight gain during pregnancy

59

10. Bar diagram showing percentage distribution of the gravid mothers

according to their pervious number of deliveries.

60

11. Bar diagram showing percentage distribution of the monthly income

of the gravid mothers.

61

12. Bar diagram showing percentage distribution of the gravid mothers

according to their pervious knowledge about lower limb massage.

62

13. Bar diagram showing Frequency and percentage distribution of pre

and post intervention lower leg edema scores among gravid mothers

during third trimester.

63

xiii

14. Bar diagram showing percentage distribution of pre and post

intervention comfort scores among gravid mothers during third

trimester.

65

xv

ABSTRACT

The present study was conducted to assess the effectiveness of lower limb massage on

physiological lower leg/s edema and comfort during third trimester among gravid mothers in

Koramangala community, Bengaluru. The objectives of the study were to assess the level of

physiological lower leg/s edema and comfort during third trimester among gravid mothers, to

evaluate the effectiveness of lower limb massage on physiological lower leg/s edema and

comfort during third trimester among gravid mothers, to find out the association between the

pre interventional physiological lower leg/s edema scores and comfort scores with selected

sample characteristics. The Conceptual frame work was based on Katharine Kolcaba’s theory

of comfort which provides a comprehensive framework for achieving the objectives of the

study.

The research design selected for this study was pre experimental one group pre-test post test

design. Purposive sampling technique was adopted to select 30 samples. Lower limb

massage was performed for 5 continuous days for two times a day (morning and evening) for

a duration of 15 minutes for each leg. Post test was conducted on the fifth day. The mean

post-test physiological leg/s edema scores with a SD (4.23 ± 0.67) was less than pre-test

(10.8 ± 0.96) scores. The calculated paired ‘t’ value (14.52) was greater than the table value

(2.05) at p< 0.05. The mean post – test comfort score with SD (4.1±1.6) was less than the

pre-test score (8 ± 1.26). The calculated paired ‘t’ value (8.9) was greater than the table value

(2.05) at p< 0.05. There is no significant association found between the pre interventional

edema scores and comfort scores with sample characteristics.

xvi

Thus the findings of the study concluded that lower limb massage is effective in the

reduction of physiological lower leg/s edema and promotion of comfort during third

trimester.

KEYWORDS: Physiological lower leg/s edema, lower limb massage, third trimester,

comfort.

1

CHAPTER –I INTRODUCTION

“Pregnancy and childbirth are joyful life events in the life of a woman.”

Pregnancy is a unique, exciting and often joyous time in women’s life, as it highlights the

women’s amazing creative and nurturing powers while providing a bridge to the future.

Pregnancy is carrying fetus or embryo in the womb of the mother. It begins at

fertilization and end at the delivery of the fetus. Pregnancy lasts for 40 weeks.1

Physiological lower leg edema is common in third trimester of pregnancy. During

pregnancy, body produces approximately 50% more blood and body fluids to meet the

needs of the developing baby. Swelling is normal in pregnancy that is caused by this

additional blood and fluid. Normal swelling is also called as edema during pregnancy.

Women may suffer from various discomforts.2

Minor ailments are common during pregnancy and non-pharmacological therapies should

be considered as the first-line treatment, if appropriate such as positioning, exercises, and

lower limb massage. Use of medication during pregnancy is a secondary choice because

it has adverse effect on fetus. Lower leg edema is an almost universal finding in late

pregnancy occurring secondary to increased venous pressure in legs, obstruction of

lymphatic flow and reduced plasma colloid osmotic pressure. Gestational edema is the

development of an excessive accumulation of fluid in the tissues without co-existing

hypertension or proteinuria. Physiological lower leg edema causes discomfort during

pregnancy.3

2

Physiological lower leg edema is one of the cutaneous manifestations of pregnancy. The

weight gain during pregnancy and gravity slow the circulation of blood and body fluids

particularly in lower limbs. The swelling or edema is a common discomfort of pregnancy.

It is estimated that about 75% of women experience this excessive accumulation of fluid

around the leg and ankles during pregnancy.2

Physiological edema results from hormones induced sodium retention. Leg edema in

lower extremities may be unilateral or bilateral. Edema may also be present when the

enlarged uterus intermittently compresses the inferior vena cava during recumbency,

obstructing outflow from both femoral veins. Dorsum of the foot, medial malleolus, and

anterior 2/3rd of tibia are the common sites of physiological edema3.

Growing uterus puts pressure on the pelvic veins and the vena cava (the large vein on the

right side of the body that carries blood from the lower limbs back to the heart). The

pressure slows the return of blood from the legs, causing it to pool, which forces fluid

from the veins into the tissues of the feet and ankles. For this reason, edema is most likely

to double during the third trimester. It may be particularly severe for women

with excessive amniotic fluid or those carrying multiples. Edema also tends to be worse

at the end of the day and during the summer. After the delivery, the swelling will

disappear fairly rapidly as the body eliminates the excess fluid by urinating frequently

and sweating a lot in the first few days following childbirth.4

3

Lower limb massage has been found to decrease the level of physiological lower leg

edema. Lower limb massage means manipulation of superficial and deeper layers of

muscles and connective tissues of the limb by using different massage techniques for a

duration of 20 minutes. Lower limb massage stimulates lymphatic circulation and

decreases swelling. Massaging the leg from toes to calf muscles providing gentle pressure

with the finger tips may help to shift water out of the tissue.2

Excessive fluid retention as evidenced by marked gain in weight or evidence of

preeclampsia has to be excluded. Physiological edema causes pain and difficulty in

walking. Lower limb massage is a non pharmacological method to reduce the

physiological edema and provide comfort to the patient. Pregnancy is presumed to be a

major contributing factor in the increased incidence of varicose veins in women, which

can in-turn lead to venous insufficiency and leg edema.4

Due to venous insufficiency impaired pumping ability of the heart increases hydrostatic

and hydraulic pressure in the extremities caused by poor circulation, and venous pooling

will result in capillary leak and interstitial fluid accumulation in the dependent area such

as lower extremities. Lower limb massage is a non pharmacological method to reduce

the physiological lower leg edema. Lower limb massage stimulates lymphatic circulation

and decreases edema. Massaging the leg from toes to calf muscles providing gentle

pressure with finger tips may help to shift fluid out of the tissue.5

This study aims to reduce physiological lower leg/s edema by lower limb massage and

make the gravid mothers more comfortable during their pregnancy.

4

NEED OF THE STUDY

One of the common and annoying problems during pregnancy is physiological legs

edema that may cause activity restrictions during pregnancy.6 Leg edema from venous

insufficiency is not dangerous but it can cause symptoms such as pain, feeling of

heaviness, night cramps, and paraesthesia4. It is estimated that about 75% of women

experience excessive accumulation of fluid (edema) around the legs and ankles during

pregnancy.2

Oedema in lower limbs, unilateral or bilateral, is described as leg edema. An expansion

of interstitial fluid volume may not be discovered readily , but an excess of numerous

liters shows visible and palpable swelling. Lower limb and foot swelling is known as

peripheral edema. Pitting edema provides way on palpation, leaving persistent

impressions in the skin; brawny edema offers resistance but leaves no impressions. It can

be very normal for leg to swell during pregnancy as released hormones cause the body to

retain fluid and salt. The face may swell, as can the legs. In addition dependent

physiological lower limb oedema which means water retention in the interstitial space of

the lower extremities is a frequent unpleasant accompaniment to pregnancy. Additionally,

Peripheral edema is associated with numeral activity restrictions.4

Edema is usually evident early in the morning and lost during the day. It is important to

differentiate this edema from renal, cardiac, or pre-eclamptic edema. Edema is a common

discomfort during late pregnancy. It typically involves the lower limbs but occasionally

appears as swelling or puffiness in the face or hands. Pregnancy is presumed to be a

5

major contributory factor in the increased incidence of varicose veins in women, which

can in turn lead to venous insufficiency and leg oedema. While this condition is not

painful, it can be uncomfortable and swelling may make it difficult to put on socks or

shoes for them to fit properly. This swelling can be caused by prolonged periods of sitting

or standing and pregnancy.5

Swelling, or edema, during pregnancy is normal but can leave the expectant mother

feeling uncomfortable. In new research, foot massage has been found to decrease lower-

leg edema6.

Swelling (oedema) in pregnancy happens because body is holding onto more fluid than

usual. The increased pressure in the leg veins, and pressure from the growing baby on the

big veins in groin, adds to the problem6. Swelling is common about half of the pregnant

women experience it around their ankles, particularly in the last few months of

pregnancy. It may be found in fingers, face and the lower back may become swollen too7

Edema is a palpable swelling produced by expansion of the interstitial volume or an

increase in extracellular volume. The swelling in the legs usually gets worse towards the

end of the day, especially in feet. Gravity makes fluid collection at the lowest point in the

body. Hot weather and being tired can also make swelling worse.6

Pregnancy is one of the most important periods in human life with hormonal,

psychological, vascular, metabolic and immunologic changes. It occurs as a result of the

6

enlarged uterus intermittently apply pressures on the inferior vena cava during

recumbency, which impedes venous return; prostaglandin- induced vascular relaxation;

and reduced plasma colloid osmotic pressure. Leg oedema could be a benign

inconvenience with unknown etiology. Leg edema is a frequent presenting complaint that

demands diagnostic and referral strategies. In recent years, there has been utilization of

non-pharmacological interventions to complement modern technological medicine. It is

established popular among nurses in clinical practice. Non-pharmacological interventions

of leg oedema comprise mostly symptom reduction rather than cure.8

Pregnancy is often a time when chronic pain is exacerbated, or when acute pain, needs

prescription. Medication cannot correct the cause of the pain; instead it alters the person’s

experimental perception of the pain. In addition, medication exposes both mother and

fetus to risk. Massage during pregnancy should be pleasurable (not painful) and will

promote feeling of calmness, well-being, and relaxation. The incidence of physiological

edema during pregnancy is about 80% in India. It is recommended to provide simple,

evidence-based holistic/ alternative remedies for women who experienced non emergent

pain during pregnancy.7

Massage therapy is a natural and effective way to reduce the symptoms of edema without

any side effects. Foot massage can relieve pain and improve the blood circulation.

Prenatal massage has been used for centuries to reduce stress, improve overall health, and

relieve muscle tension. Pregnant women have often received ambivalent responses from

7

the health committee, regarding the purpose and safety of the massage during pregnancy.

Studies have proved that prenatal massage therapy can be a very instrumental tool in

women’s prenatal care and should be given with careful consideration. Massage therapy

works by directing pressure at the skin and muscle area affected by edema. The

lymphatic system is activated during the process and the fluid drains away naturally.

Prenatal massage is truly beneficial for pregnant women and the baby, while easing the

pain and discomfort of pregnancy, delivering a safe, relaxing, and effective massage.8

Physiologic edema can be reduced by intermittently lying on the left side (which moves

the uterus off the inferior vena cava), by intermittently elevating the lower extremities,

and by wearing elastic compression stockings.9

Changes in blood flow during pregnancy are likely to play a role in development of

venous insufficiency and thrombo embolic events. Venous insufficiency and varicose

disease were observed in 43% and 72.7% of pregnant women, respectively. Additionally,

50% of pregnant women complained of lower limb edema. One mechanical factor that

affects venous return is the growing uterus. In the supine position, the uterus presses on

the inferior vena cava, resulting in reduced venous return. However, the major factors

causing pregnancy-related blood vessel changes are pregnancy-related hormonal and

physiological changes. The total volumes of blood, plasma, and erythrocytes increase

during pregnancy to provide an increased blood supply to the uterus and placenta. The

total blood volume of 4000 ml prior to pregnancy increases to 5300 ml at week 36 of

gestation. During pregnancy, the number of white blood cells and blood coagulation also

increase. Furthermore, a reduction in vein wall tension can cause stagnation of blood and

swelling of the legs and women with a predisposition may develop varicose veins.

8

Additionally, vein dilatation and exposure to collagen fibers can cause endothelial

damage and lead to blood clot formation Foot massage has a positive effect on edema in

late pregnancy. Foot massage is different from reflexology. Foot massage is more general

because the manipulation of soft tissue which involves movement of extravascular fluid

without disturbing intravascular fluid. Twenty minutes of foot massage given for 5 days

to an experimental group proved effective in reducing leg circumference compared to the

control group.10

The researcher observed that gravid mothers experience physiological lower leg(s) edema

and discomforts during third trimester. Researcher’s own interest, in depth reviews and

suggestions from the experts inspired the researcher to undertake the present study to

assess the effectiveness of lower limb massage on physiological lower leg/s edema and

comfort during third trimester among gravid mothers.

9

CHAPTER II

OBJECTIVES

This chapter deals with statement of the problem, objectives of the study, Hypotheses,

operational definitions, assumptions, delimitation and conceptual framework.

STATEMENT OF THE PROBLEM

A Study to Assess the Effectiveness of Lower Limb Massage on Physiological Lower

Leg/S Edema and Comfort during Third Trimester among Gravid Mothers in a Selected

Community, Bengaluru.

OBJECTIVES:

• To assess the level of physiological lower leg/s edema and comfort during third

trimester among gravid mothers.

• To evaluate the effectiveness of lower limb massage on physiological lower leg/s

edema and comfort during third trimester among gravid mothers.

• To find out the association between the pre interventional physiological lower leg/s

edema scores and selected sample characteristics.

• To find out the association between the pre interventional comfort scores and selected

sample characteristics

10

HYPOTHESES

At 0.05 level of significance

• H1: There will be a statistically significant difference in the physiological lower leg/s

edema scores before and after the lower limb massage among gravid mothers during

third trimester as measured by using Erin edema scale.

• H2: There will be a statistically significant difference in the comfort scores before and

after lower limb massage among gravid mothers during third trimester as measured

by using comfort scale.

• H3: There will be a statistically significant association between pre interventional

physiological lower leg/s edema scores among gravid mothers during third trimester

and selected sample characteristics .

• H4: There will be a statistically significant association between pre interventional

comfort scores among gravid mothers during third trimester and selected sample

characteristics.

RESEARCH VARIABLES

Independent variable: Lower limb massage

Dependent variables: Physiological lower leg/s edema and comfort.

Extraneous variables: Age, religion, education status occupation, type of family, weeks

of gestation, maternal weight gain during pregnancy, family income/ month, number of

previous delivery, and previous information about lower limb massage.

11

OPERATIONAL DEFINITIONS

Effectiveness: In this study, it refers to the extent to which lower limb massage

causes a desired effect in terms of physiological leg/s edema and comfort scores

among gravid mothers during 3rd trimester of pregnancy as measured by using Erin

edema scale and comfort scale.

Physiological leg/s edema: In this study it refers to the swelling assessed on dorsum

of the foot, medial malleolus, and anterior lower 2/3rd of tibia among gravid mothers

during 3rd trimester of pregnancy as measured using Erin edema Scale.

Comfort: In this study, it refers to the state of feeling at ease experienced by gravid

mothers during 3rd trimester of pregnancy as measured using comfort scale.

Third trimester: In this study, it refers to the last 3 months of pregnancy.

Gravid mothers: In this study, it refers to female individuals who were pregnant

with the gestational age between 28-40 weeks.

Lower limb massage: In this study it refers to the sequentially articulated

movements applied to the lower extremities comprising of circular massage from the

anterior lower 2/3rd of the tibia to dorsum of foot, circular massage over the medial

malleolus in clockwise and anti clock wise direction and finger walking massage in

the dorsum of the foot (each for five times) twice a day (morning and evening) for a

total duration of 15 minutes for each leg for a period of 5 consecutive days.

ASSUMPTIONS

• Gravid mothers may experience physiological leg/s edema during third trimester.

• Edema may cause discomfort to gravid mothers during third trimester.

12

• Foot massage may have an effect on physiological leg edema.

DELIMITATION

The study is delimited to gravid mothers who:

• had physiological lower leg/s edema during third trimester of pregnancy .

• were in the Koramangala community.

CONCEPTUAL FRAMEWORK

Conceptualization is the process of forming ideas, design and plans. The conceptual

model act as a guide for the research process in each step.11

The Kolcaba’s theory of comfort considers patients to be individuals, families,

institutions or communities in need of health care. Nursing is described as the process of

assessing the patient’s comfort needs’ developing and implementing appropriate nursing

care plans and evaluating the patient’s comfort after the care plans have been carried

out.12

The main concepts of Kolcaba’s Theory of Comfort are

Health care needs

Intervening variables

Health seeking behaviour

Institutional integrity

13

Best policies and procedures

HEALTH CARE NEEDS

Kolcaba includes health care needs which are defined as those needs identified by the

patient and/or family in a particular nursing practice setting.13

In this study health care needs are discomfort during pregnancy due to physiological

lower leg/s edema.

INTERVENING VARIABLES

Intervening variables are factors that are not likely to change, and over which health care

providers have little control.13These variables include prognosis, financial situation,

social support and others. In this study the intervening variables are age, education,

occupation, type of family, number of deliveries, maternal weight gain during pregnancy,

family income/month, number of previous deliveries, week of gestation, and information

obtained regarding lower limb massage.

HEALTH SEEKING BEHAVIOURS

Health- seeking behaviors are the behaviors of a patient in an effort to find health.13 In

this study the heath seeking behavior is the internal behaviour of accepting lower limb

massage to relieve discomfort caused by physiological leg/s edema.

14

INSTITUTIONAL INTERGRITY

The quality or state of health care organization as complete, whole, sound, upright,

professional, and ethical providers of health care.13 In this study foot massage being a

cost effective procedure is recommended in an institution for a large population in reducing

physiological lower leg edema among gravid mothers.

BEST PRACTICES AND POLICIES

Finally, best policies are protocols and procedures developed by an institution for overall

use after the collection of evidence.13 In this study best practice refers to the

incorporation of foot massage for physiological lower leg/s edema among gravid mothers

during third trimester of pregnancy. In this study best policy refers to the motivation of

administrators to frame policies incorporating foot massage in the health care setting on a

large scale.

15

Health care

needs

Discomfort

due to

physiologic

al lower

leg/s

edema.

Nursing

interventions.

-Pretest

-Routine

nursing care

- Lower limb

Massage

Intervening

variables

Age, Education,

Occupation,

Type of family,

Religion,

Family Income

per month in

rupees, Number

of previous

deliveries,

Maternal

weight gain

during

pregnancy,

Weeks of

gestation,

Previous

information

about lower

limb massage

Enhanced comfort

Circular massage

on lower 2/3rd of

the tibia, dorsum

of the foot and

medial malleolus

Health

seeking

Behaviour

Internal

behaviour

Reduction of

lower leg/s

edema due to

lower limb

massage

ERIN EDEMA

SCALE

None, Trace, Mild,

Moderate, Severe.

COMFORT

SCALE.

Very comfortable,

Less comfortable,

Discomfort, Moderate

discomfort, Serious

discomfort, Extreme

discomfort

Post-test

Institutional

integrity

Implementatio

n of lower

limb massage

being a cost

effective

procedure is

recommended

in an

institution for

a large

population.

Best practice

Lower limb massage

being an evidence

based practice can be

recommended in

hospital and

community

Best policies

Framing policies to

incorporate the use of

lower limb massage in

reducing the discomfort

due to physiological

lower leg/s edema

among gravid mothers

in the health care

settings.

External

behaviour

Sample will recommend lower limb massage to other gravid mothers to reduce physiological lower leg/s edema

FIGURE :1 CONCEPTUAL FRAME WORK BASED ON KATHARINE KOLCABA’S THEORY OF COMFORT

Not included in the study

9

16

CHAPTER III

REVIEW OF LITERATURE

A literature is a critical summary of research on the topic of interest . Review of literature

provides a current theoretical and scientific knowledge about a particular problem and

resulting in a synthesis of what is known. Researcher usually undertakes a thorough

literature review to familiarize them with the knowledge base14.

The researcher carried out an extensive review of literature on the research topic in order

to gain deeper insight into the problem as well as to collect maximum relevant

information for building up the present study. This was accomplished by using PubMed,

Google, and survey of the latest journals and books.15

The literature review of the present study is organized and presented under following

headings.

Review of literature for the present study is organized as follows

Literature related to

1. Minor ailments during pregnancy.

2. Physiological leg edema and discomfort during pregnancy.

3. Various complementary therapies used in the reduction of edema

4. Effectiveness of foot massage in reduction of physiological leg edema.

17

Literature related to minor ailments during pregnancy

A descriptive study to assess the prevalence of minor ailments during pregnancy, home

care remedies adopted by primigravida antenatal mothers, and to develop an information

booklet regarding the management of minor ailments was undertaken in a selected

hospital of Delhi. The objectives of the study were to assess prevalence of minor ailments

during pregnancy among primigravida antenatal mothers, to assess the home care

remedies adopted for minor ailments during pregnancy by antenatal primigravida mothers

and to develop an information booklet regarding the management of minor ailments. A

total of 30 antenatal primigravida mothers, were selected from a selected hospital of New

Delhi, using purposive sampling technique. The tools used for data collection were semi-

structured interview schedule to determine the demographic data as well as to assess the

occurrence of minor ailments during pregnancy and home care adopted by them. Data

collection was done on 5 May, 2017 among primigravida antenatal mothers.The study

reveals that, out of 30 antenatal mothers, fatigue was present in 20 (67%) subjects,

micturition was present in 12 (40%) subjects, heartburn was present in 7 (23%) subjects,

anorexia was present in 13 (43%) subjects, backache was present in 18 (60%) subjects,

constipation was present in 10 (33%) subjects, morning sickness was present in 23 (77%)

subjects, headache was present in 15 (50%) subjects, leg cramps were present in 22

(74%) subjects, lack of sleep was present in 11 (37%) subjects, excessive white discharge

was present in 12 (40%) subjects, edema of lower extremities was present in 13 (43%)

subjects, generalized itching was present in 11 (37%) subjects, excessive salivation was

present in 4 (13%) subjects, varicose vein was present in 2 (7%) subjects, carpel tunnel

syndrome was present in 12 (40%) subjects, pruritis vulva was present in 6 (20%)

18

subjects and none of them were having piles. Edema of lower extremities was prevalent

in 43% of primigravid mothers. Significant findings of the study were that all the

antenatal mothers experienced minor ailments during their pregnancy.16

A non-experimental descriptive survey study was conducted on Yenepoya Nursing

College, Mangalore to assess the knowledge on minor ailments of pregnancy and its

management among antenatal mothers. A structured knowledge questionnaire regarding

minor ailments of pregnancy and its management was prepared in order to assess the

knowledge of antenatal mothers. A sample of 100 antenatal mothers were selected by

using non probability purposive sampling technique. The study reveals that 17 percentage

of the mothers had good knowledge, 49 percentage of mothers had average knowledge,34

percentage of the women had poor knowledge. The mean percentage of knowledge of the

antenatal mothers regarding minor ailments of pregnancy and management was 3.33

percentage. The association of the knowledge score with demographic variables were as

follows; age (χ2=0.432,P>0.05), parity (χ2=0.152, P>0.05), religion (χ2=0.005, P>0.05),

education (χ2=0.538, P>0.05), occupation (χ2=0.20, P>0.05), type of family (χ2=0.246,

P>0.05),income (χ2=0.025, P>0.05), and source of information (χ2=0.047, P>0.05). The

result of the study shows that there is no significant association between the knowledge

score with selected demographic variable.17

A cross sectional study was carried out in Anuradhapura district, Sri Lanka. Pregnant

women residing in the Anuradhapura district with a gestational age more than 24 weeks

through 36 weeks were recruited to the study using a two-stage cluster sampling

19

technique. All pregnant women who consented participated in a detailed interview using

a structured questionnaire. Self reported episodes of acute illness during pregnancy were

the main outcome measures. Secondary outcomes were utilization of medical services

and frequency of hospitalizations. The study revealed that Nausea and vomiting during

pregnancy (NVP) was experienced by 325 (69.7%) of the 466 pregnant women studied.

Other common symptoms were backache (152, 32.6%), dizziness (112, 24.0%) and

heartburn/regurgitation (107, 23.0%). Of the 421 pregnant women who reported ill health

conditions 260 (61.8%) women sought medical treatment for these illnesses. Total

number of episodes that needed treatment seeking was 373. Hospitalizations were

reported by 83 (17.8%) pregnant women and the total number of hospitalizations was

109. The leading cause of hospitalization was NVP which accounted for 43.1% of total

admissions and 49.1% of total days spent in hospitals. The study concluded that Minor

maternal ill health conditions affecting day-to-day life have a major burden on pregnancy

period. Evidence based management guidelines and health promotion strategies are

needed to control and prevent these conditions, in order to provide comprehensive, good

quality maternal health care.18

A descriptive study was conducted in Amrita college of Nursing in Kochi to identify the

prevalence of minor ailments of pregnancy and to assess the knowledge

regarding selected minor ailments among antenatal mothers. Descriptive survey design

was used. Sixty antenatal mothers attending Obstetrics and Gynecology OPD, AIMS,

Kochi were selected using quota sampling technique including 30 primigravida and 30

multigravida mothers. Demographic variables and knowledge regarding minor ailments

20

of pregnancy were collected using a semi- structured questionnaire. The prevalence of

minor ailments of pregnancy was identified by a checklist. The study reveals that the

most common minor ailments were frequency of micturition(80%), nausea and vomiting

(80%), fatigue(80%), back pain(70%) and leg cramps(55%). Knowledge regarding minor

ailments of pregnancy was good in 54%, average in 41% and poor in 5%. There was no

significant difference between knowledge and prevalence of minor ailments between

primi and multi gravida. The result of the study suggest that health education should be

provided to all the antenatal mothers regarding minor ailments of pregnancy and

its management.19

A descriptive study was conducted in North Iran to assess the knowledge and practices

of pregnant women regarding minor discomforts during pregnancy. The study was

conducted among 370 healthy pregnant women at four Primary Health Care Centers

(Nazdar bamarni- Nawroz- Brayati- Kurdistan) in Erbil City from October 2014 to

November 2015. Data were collected through interview by using questionnaire.

Questionnaire was designed and divided into four parts; the first part includes socio-

demographic characteristics of pregnant women, the second part contains obstetric

history, the third part deals with knowledge about minor discomforts and the fourth part

comprises ten areas of practical care regarding minor discomforts during pregnancy. The

questionnaire contains 53 items using 3 Likert scales. Reliability was determined by 24

experts. The results showed that the majority of the study sample was between 18-25

years old, secondary school graduates, housewives and nuclear families. The evidence

from this study showed that self management was poor and pregnant women had fair

21

knowledge. Finding of the study revealed that self management practices of pregnant

women regarding minor discomforts were very poor also. The result shows that minor

discomforts were very common, and were reported by 50% - 80% of pregnant women.

Nausea occurred in 80-85% of all pregnancies during the first trimester, heartburn

occurred in 30% to 50% of pregnancies, with prevalence approaching 80% in some

populations. Leg cramps have been reported by 30% of pregnant women, most

commonly in the second and third trimester. They usually affect the calves and occur at

night in 75% of cases. Fifty percent to 70% of all pregnant women may have back pain.

The prevalence of constipation in pregnancy is reported to be between 11% and 38 %.

These minor discomforts might affect the health of mother and fetus lifestyle is affected

by physical and mental functions therefore, if pregnant women are helped to change

behaviors related to lifestyle, it effectively restores their health. 20

A quasi-experimental study was conducted by Nancy College of Nursing, Nainital,

Uttarakhand, India,to find the effectiveness of a structured teaching program on the minor

disorders of pregnancy and their home management. Hundred antenatal mothers were

selected by Consecutive sampling technique. Pre and post test was conducted without

control group. Semi structured interview method was used to collect the reliable data

from the study participants. The tools used for the study were structured demographic

questionnaire and closed-ended questionnaire to assess the knowledge regarding minor

disorders of pregnancy and their home management consecutively recruited from a

selected setting. The study revealed that before the implementation of a planned teaching

program, the antenatal mothers showed a poor knowledge of the common minor

22

disorders (19.56 ± 12.73), whereas after the implementation, the knowledge significantly

improved with the difference of 18.02 ± 0.742 revealing the effectiveness of the planned

teaching program. The study concluded that teaching about minor disorders of pregnancy

and its home management helps the mothers to manage their minor disorders at home

itself and continue their pregnancy more comfortably and securely.21

An Evaluative study was conducted in Karad to assess the knowledge on minor ailments

of pregnancy among primipara mothers, before and after intervention, to assess

effectiveness of Self Instructional Module [SIM] versus health education on minor

ailments of pregnancy and to find an association between knowledge and socio

demographic variables. The study was conducted among 120 Primi para mothers using

pre test post test control group design at Antenatal clinic of Krishna Hospital Karad by

using Random sampling technique. The tool used for gathering data was a structured

interview questionnaire on knowledge of minor ailments of pregnancy and its home

remedies as per trimester wise. The study revealed that all the primipara mothers did not

have 100% knowledge. They require teaching to promote their knowledge and skills

during their pregnancy. Enough knowledge helps them to cope with the minor ailments of

pregnancy. The study reveals that they need SIM on minor ailments of pregnancy and its

home remedies. Study concluded that the Self instructional module (SIM) on minor

ailments of pregnancy and its home remedies was effective.22

23

A descriptive study was conducted in Mangalore to assess the knowledge of primi

mothers on self-management of minor discomfort of pregnancy with a view to develop

information was carried out in Justice K.S Hegde Charitable hospital among 100

primigravida mothers by using purposive sampling technique. The findings of the study

showed that 87% of the Primigravida mothers were in the age group of 21 – 30 years,

37% of the women had high school education, 70% of the subjects were Hindus, 77%

belonged to joint families and 53% were in the gestational age group of 29 – 40 weeks.

Most (59%) of the Primigravida mothers had poor knowledge, 29% had average

knowledge, and 12% had good knowledge regarding minor discomforts of pregnancy and

its self-management. Area wise knowledge of Primigravida mothers reveals deficiency in

most of the areas, but the lowest mean percentage of score is 28.25% with a standard

deviation of 1.74 in the area of knowledge related to Circulatory and Nervous system,

which indicated that the maximum knowledge deficit is in this area. There was significant

association between knowledge of Primigravida mothers age, and educational

qualification. The calculated chi square values were 3.953 and 12.603 respectively which

are more than the table value 3.84 and 7.82 at 0.05% level of significance. The result of

the study proved that Primigravida mothers had poor knowledge regarding minor

discomforts of pregnancy and its self management. The findings of the study showed that

there was a need to educate all women on preparation towards motherhood. 23

24

Literature related to physiological leg edema and comfort during

Pregnancy

A study was conducted in Frontier Nursing University on “comfort over pain in

pregnancy”. Pregnancy is often a time when chronic pain is exacerbated, or when acute

pain appears. Frequently the easiest intervention within reach, for both chronic and acute

pain, is a prescription. However, medication cannot correct the cause of the pain; instead

it alters the person's experiential perception of the pain. In addition, medication exposes

both mother and fetus to risks. To provide simple, evidence-based, holistic/alternative

remedies for women who experienced non emergent pain during pregnancy. The subjects

consisted of 89 primipara and 78 multipara. Holistic/ alternative techniques for increasing

comfort were taught (positioning and massage) to the participants and individualized

during three sessions. Holistic/alternative techniques for increasing comfort were taught

to the participants and individualized during three sessions. Levels of pain and comfort

were measured before and after the treatment, using the validated General Comfort

Questionnaire and Pain Outcomes Profile. Pain scores decreased from an average of

5.8/10 to 3.5/10 (p = .00). Comfort scores increased from an average of 17.5 to 30 (p =

.00 )24

A descriptive, longitudinal correlational study was conducted in Japan. The purpose was

to clarify the relationship between comfort in late pregnancy and maternal role attainment

and childcare during early postpartum. Data was collected using the Prenatal Comfort

Scale, the postpartum Maternal Role Confidence Scale, and the postpartum maternal

satisfaction scale. The sample consisted of 339 participants who had received care at a

25

university hospital located in Sendai city in Japan. Two hundred and fifteen subjects

completed the longitudinal study by answering a questionnaire for the respective Scale

late in their pregnancy or during early postpartum. The subjects consisted of 114

primipara (32±5.4 years) and 101 multipara (33.4 ± 4.9 years ). The result of the study

revealed that in primipara, comfort with motherhood was significantly correlated with

maternal confidence regarding knowledge and childcare skills and maternal satisfaction.

In multipara, comfort in late pregnancy was related to maternal confidence and

satisfaction. Positive effect was related to maternal confidence and maternal satisfaction

in early postpartum. Therefore, a prenatal nursing intervention helps women become

more comfortable with impending motherhood, thereby promoting maternal role

attainment after delivery.25

A study was conducted by Kasturba Hospital, Manipal in India to assess the Prevalence

of Musculoskeletal Dysfunctions among Indian Pregnant Women. Pregnancy triggers a

wide range of changes in a woman’s body leading to various musculoskeletal

dysfunctions. Most commonly reported musculoskeletal discomforts by pregnant women

are low back pain and symphysis pubis pain. The culture and the environmental factors

may influence the discomforts experienced by a pregnant woman. There is a dearth of

literature in India, regarding the common musculoskeletal dysfunctions experienced by a

pregnant woman. A questionnaire method used to identify the musculoskeletal

dysfunction was developed; content was validated and was translated to local languages

through parallel back translation. Two hundred and sixty one primiparous pregnant

women participated in the study and filled the questionnaire in their native language. The

study reveals that among the musculoskeletal dysfunctions reported by the pregnant

26

women, 64.6% reported calf muscle cramps, 37.1% reported foot pain, and 33.7%

experienced low back pain in their third trimester. In the second trimester, common

musculoskeletal dysfunctions experienced by the women were that of calf pain (47.8%),

low back pain (42%), and pelvic girdle pain (37%).The study conclude that

Musculoskeletal dysfunctions and general discomforts very commo nly affect the

activities of daily living of pregnant women. Understanding the common discomforts

during various trimesters of pregnancy will help to develop a comprehensive program for

prevention and cure.26

A survey was conducted in two hospitals (Lahore general hospital and Lady Willington

hospital in Jan. 2015 in Lahore to determine the frequency of lower extremity edema

during third trimester of pregnancy. A self-administered questionnaire was used to check

the lower extremity edema during third trimester of pregnancy in both the hospitals. One

hundred and ten female patients were taken in the beginning of which ten (10) patients

refused to participate whereas one hundred (100) patients willingly opted the inspection.

After collection, data was entered in computers, using SPSS Software, version 20. Data

were cleaned, organized and variables of interest were cross-matched. The majority of

female patients were with the mean age of 26 Years and a standard deviation of 4.00. Out

of 100 women, maximum were Multigravida (65%) and maximum (60%) were in their

9th month of pregnancy. 67% were those in which edema was present and 33% were

without edema. 49% women were having edema around feet, 4% around sacral region,

14% around both regions. 60% women presented with pitting edema, 7% with non-pitting

27

edema. 89% women were having pain in their lower extremities, 76% were having

feeling of heaviness in their lower extremities and 84% were found to have difficulty in

performing functional activities. 58% women were not having prolonged sitting/standing

posture. Maximum women with presence of edema were Multigravida (36%) and parity

status significantly influenced the presence or absence of edema (p-value 0.001).

Maximum frequency of edema (42%) was shown by women of 9th month (p-value 0.68).

Out of 67 women with edema, 34 were having prolonged sitting/standing posture (p-

value 0.10) The study concluded that most of the females suffer from lower extremity

edema during pregnancy especially in 3rd trimester.27

A cross sectional study was conducted in Saudi Arabia to assess the knowledge and

practices of primigravida women regarding minor and common pregnancy discomfort at

Obstetrics & Gynecology Outpatient Department (antenatal clinic) of Maternity &

Children Hospital in Dammam city (MCH) from the beginning of March 2017 to the end

of April 2017. Total of 82 primigravida women have participated in this study, who met

the inclusion criteria. The main result suggests that most of the mothers (59%) had good

knowledge, 32% had excellent knowledge and only 2% of them had poor knowledge.

This study also shows that the overall level of measures practiced by the primigravida

women to relieve their discomforts during pregnancy were with good practice score

(47.0%). The study concluded that primigrvida women show good level of knowledge

scores and also good level of measures practiced by them to relieve their discomforts

during their pregnancy. However, the current study recommends further research to

28

investigate the unsafe practices related to minor discomforts during pregnancy and its

effect on the mother and fetus.28

Literature related to various complementary therapies used in the

reduction of edema

A retrospective study was conducted in Poland to assess the risk factors and to analyze

methods applied in the prevention and treatment of lower limb edema in pregnant women

with a particular focus on compression therapy and exercise. Fifty-four women during the

early 24-hour period following delivery were assigned to two groups—either to a group

with swellings of lower limbs during pregnancy, located mostly in the region of feet and

lower legs (Group A, n = 42), or to a group without edema (Group B, n = 12). Two

subgroups, namely A1 and A2, were additionally distinguished in Group A. Compression

therapy that consisted in wearing circular-knit compression garments, usually at

compression level 1 (ccl1), with three cases of compression level 2 (ccl2) was applied

only in Group A1 (n = 18 women). The study reveals that there is a link between the

occurrence of edema during pregnancy on the one hand and the pre gravidity episodes of

venous conditions (vascular insufficiency and thrombosis, p < 0.05) and the lack of

physical exercise during pregnancy (p = 0.01) on the other hand. However,

interdependence between the occurrence of edema and the number of times a female had

been pregnant, physical activity before gravidity, or body mass index before gravidity has

not been identified. Only 33% of the analyzed women applied compression therapy

during pregnancy; a half of them continued to apply compression during the postpartum

29

period. The study concluded that Compression therapy in combination with proper

physical exercises appears to be an effective means to prevent and treat venous

thrombosis and lower limb edema in pregnant women, yet further research in line with

the principles of evidence-based medicine is required.29

A study was conducted to assess the Response of Pregnancy Leg Edema to a Single

Immersion Exercise Session. Dependent leg edema is not uncommon in pregnant women

and may cause pain with each step. In addition to compression stockings and leg

elevation, immersing the extremities in water is beneficial. This prospective trial

evaluated a single session of immersion exercise in 9 women (32 to 36 years of age) who

had marked edema but otherwise uncomplicated pregnancies at 25 to 39 weeks gestation.

Only one of the women was parous. A few hours after the midday meal, the women had a

45-minute session of upright water immersion exercise. A vest, worn like a backpack,

kept the wearer afloat and immersed to the axillae without the need for extremity

movements. After warming up for 5 minutes, the women performed coordination

exercises for 10 minutes and a range of running sequences for 30 minutes. Lower leg

volume was measured in triplicate by the displacement method using a polyurethane

vessel with an overflow device. Supine lower leg circumference also was measured

before and after immersion exercise. A single session decreased the volume of both legs

by an average of 6.3% on the left and 4.9% on the right. Lower leg circumference

decreased significantly on both sides. Maternal heart rate did not change significantly

after immersion exercise, but during the session, the rate increased by 15 beats per minute

on average. Systolic blood pressure increased significantly 1 minute after exercise, from

124 to 130 mm Hg, and nearly significantly after 5 minutes. Diastolic blood pressure,

30

however, remained unchanged. The women felt very positive about the beneficial effects

of immersion exercise on leg edema. A single 45-minutes session of immersion exercise

effectively and safely improved marked lower leg edema in these women. This form of

exercise could complement or supplant the use of compression stockings as a means of

reducing dependent edema in pregnant women.30

A study was conducted in North America to determine the effectiveness of water

immersion as a means of reducing peripheral edema during the last 6 weeks of

pregnancy. Thirty-two pregnant women in their 34th weeks of a normally progressing

pregnancy were assigned randomly to either standing water immersion (16) or to sitting

upright in a chair with legs elevated at poolside (16). Subjects in the water group (W)

were immersed up to the Xiphoid process for 20 minutes in a swimming pool (85–90°F).

Subjects in the land group (L) sat in a chair with both feet elevated for 20 minutes.

Changes in right foot volume were quantified by foot volumetric immediately pre and

post intervention. The study results reveals that Right foot volume decreased 38 ± 18

ml (mean ± SD) for W and increased 2 ± 14 ml for L (P < .001 for between groups).The

present study concluded that Water immersion for 20 minutes is an effective means of

decreasing pedal edema during pregnancy.31

A quasi experimental, comparative study was conducted on Mansoura university Hospital

to assess the effectiveness of Leg Elevation versus Water Immersion on Leg Edema in

Third Trimester of Pregnancy. Lower extremities edema is a common complaint during

pregnancy and associated with daily activity limitations. Common intervention to reduce

31

edema includes leg elevation and immersion in water which represents potential

interventions to eliminate or minimize some of the functional limitations associated with

legs edema during pregnancy. This study aimed to evaluate effect of leg elevation versus

water immersion on leg edema in third trimester of pregnancy. The study was conducted

in Antenatal Clinics of the Obstetrics and Gynecology Department in Mansoura

University Hospital. The samples are selected through purposive sampling technique

sample of the study consist of 80 pregnant women who were randomly chosen and

divided into two equal groups for sitting upright in a chair with legs elevated or immersed

their legs in water for 20 minutes, Changes in leg volume of edema were assessed by

pitting edema techniques immediately pre and post intervention, immediately and after

two weeks. This study revealed that highly significant variations between pre- and post-

interventions for both groups and equal, non significant differences between both

interventions (leg elevation and water immersion). The study concluded that leg elevation

and water immersion are necessary to alleviate edema in lower extremities during

pregnancy. 32

A study was conducted in Masaryk University Brno Czech Republic on Changes in lower

extremity blood flow during advancing phases of pregnancy and the effects of special

footwear. During pregnancy, a number of changes affecting venous blood flow occur in

the circulatory system, such as reduced vein wall tension or increased exposure to

collagen fibers. These factors may cause blood stagnation, swelling of the legs, or

endothelial damage and consequently lead to development of venous disease. The aim of

this study is to evaluate the effect of special footwear designed to improve blood

circulation in the feet on venous blood flow changes observed during advancing phases

32

of pregnancy. The study consist of Thirty healthy pregnant women participated in this

study at 25, 30, and 35 weeks of gestation. Participants were allocated at random to an

experimental group (n = 15) which was provided with the special footwear, or a control

group (n = 15). At each data collection session, Doppler measurements of peak systolic

blood flow velocity and cross-sectional area of the right popliteal vein were performed

using a MySonoU6 ultrasound machine with a linear transducer (Samsung Medison). The

differences were compared using Cohen’s d test to calculate effect size.The study

revealed that with advancing phases of pregnancy, peak systolic velocity in the popliteal

vein decreased significantly in the control group, whereas it increased significantly in the

experimental group. No significant change in cross-sectional area was observed in any of

the groups. The study findings concluded that the experimental group demonstrated that

wearing the footwear tested may prevent venous blood velocity from reducing during

advanced phases of pregnancy. Nevertheless, there is a need for further investigation of

the beneficial effect on venous flow of the footwear tested and its application.33

Literature related to effectiveness lower limb massage in reduction of

physiological leg edema

A single – blinded randomized controlled trial was conducted to explore the differential

effects of “Two different foot reflexology techniques with a period of rest on edema –

relieving effects and symptoms relief in healthy pregnant women with foot edema”. A

sample of fifty- five women in the third trimester were randomly assigned to one of the

three groups: a period of rest, ‘relaxing’ reflexology techniques or a specific ‘lymphatic’

33

reflexology technique for 15 minutes with pre-and post- therapy ankle and foot

circumference measurements and participant questionnaire. The result of the study

showed that, there was no statistically significant difference in the circumference

measurements between the three groups; however, the lymphatic technique reflexology

groups’ mean circumference measurements were all decreased. A significant reduction in

the women’s symptom mean measurements in all groups (p<0.0001) was apparent. A

‘perceived wellbeing’ score revealed that the lymphatic technique group (p<0.0001)

significantly increased their wellbeing the most, followed closely by relaxing techniques

(p<0.0001) and then the control rest group (p<0.03). Lymphatic reflexology techniques

and a period of rest had a non – significant oedema- relieving effect. From the women’s

viewpoint’ lymphatic reflexology was the preferred therapy with significant increase in

symptom relief.34

A non- randomized clinical trial was performed in 2012, among 120 pregnant women

aged 20 to 35 years who were assigned to treatment and control groups. Treatment group,

received 20 minutes daily foot massage during 5 days. Data were analyzed using SPSS

statistical software, independent t-test and Mann- Whitney U test. Foot edema was

measured by using a measuring non- elastic tape on the leg.10 The results indicates a

statistically significant difference between the average of the feet environments (around

the ankle, heel and metatarsal joints between the bones) in both treatment and control

groups (p<0.001).The results of the study showed that massage therapy was effective in

reducing physiological edema during pregnancy. Therefore the lower limb massage can

be performed by trained midwives and as a useful, low risk and low cost method in

prenatal clinics or pregnant women homes35.

34

A study was conducted to evaluate the effectiveness of foot massage on reduction of

physiological lower leg edema among Primigravid mothers during third trimester in

Elariyampannai, Primary Health Center, Virudhunagar district Tamilnadu. The study

comprised of 60 samples selected by purposive sampling method. Demographic data was

collected through interview method, and pre-test was assessed using Erin Oedema Scale.

Foot massage was given over 20 min for each leg .The results concluded that the mean

value of post test level of physiological lower leg oedema after receiving foot massage

was 2.38 and it was more than the pretest mean value 0.58. The calculated t test value

7.51 showed that there was a significant difference in the effectiveness of foot massage

at p<0.05 level.36

A study titled ”The natural state of pregnancy also has its disorderly side” was conducted

in Australia Hospital midwives in Australia recruited fifty five women in their third

trimester of pregnancy to test the effect of foot massage for the foot and the ankle edema

(2003). The women were assigned to three groups: foot massage focused on relaxation

zones; foot massage focused on reflex on zones to the lymphatic system; and a rest

period. Ankle and foot circumference measure were taken before and after a fifteen –

minutes intervention or rest period and participants completed a symptamatology

questionnaire. The result of the study shows that edema measurements showed a

significant reduction for all groups, but what was more interesting is the step increase in

sense of well-being across groups, with the most significant increase documented for the

35

lymphatic reflexology group. A majority of those receiving the foot massage intervention

reported feeling of profound relaxation.37

A study was conducted in Australia to evaluate the effect of foot massage for decreasing

physiological lower leg edema in late pregnancy, Eighty pregnant women were

randomly divided into two groups; study group had a twenty minute foot massage daily

for five days whereas the control group did not receive any intervention beyond standard

prenatal care. The result obtained from the research, showed that foot massage was found

to have a positive effect on decreasing normal physiological lower leg edema in late

pregnancy.38

A Single- blind trial addressing the differential effect of two reflexology techniques

versus rest, on ankle and foot edema in late pregnancy was conducted to assess if the foot

massage had a positive effect on decreasing the normal physiological ede ma of late

pregnancy. The study group had a 20 minute foot massage daily for five days whereas the

control group did not receive any interventions beyond standard prenatal care. Compared

with the control group, women in the experimental group had a significantly smaller

lower leg circumference (right and left ankle instep and metatarsal- phalanges joint) after

5 days of massage; the control group tended toward increased circumferences. The study

conclude that foot massage is more effective in reduction of physiological foot edema39

A study conducted to assess the effectiveness of self massage on reduction of edema and

pain in lower extremity after completing a nurse’s daily shift was conducted in Korea.

36

Non equivalent control group pretest- post test design was used for the same. There were

81 nurses who took part in self leg massage program developed by the researcher. There

was a statistically significant difference in lower extremity edema and pain in nurses after

the shift and self leg massage.40

A study was conducted in Malta, to evaluate the impact of pregnancy on foot

health. A prospective non-experimental study was conducted. The authors interviewed 40

expectant Maltese mothers using the Bristol Foot Score (BFS). Results showed a

significant difference (p < 0.001) in foot health in the recruited subjects from Time 0 (15

weeks pregnancy) to Time 1 (37 weeks pregnancy), implying that pregnancy imposes a

negative impact on foot health. This finding is of key importance and needs to be taken

into consideration by all health stakeholders if better health care is to be offered to all

expectant mothers. Both locally and internationally, antenatal care aims to monitor

pregnant women’s general health and foetal development. However, very little attention

is given to foot health. The authors highlight the importance of providing all expectant

mothers with foot care education and podiatry services in the Antenatal Clinic.41

A study was conducted in USA to assess any form of intervention used to relieve

the symptoms associated with varicose veins and leg oedema in pregnancy. The study

consists of 356 women who were selected by randomized trial .Two studies were

placebo-controlled trials. The first one compared a phlebotonic (rutoside) with placebo

for the reduction in symptoms of varicose veins; the second study evaluated the efficacy

of troxerutin in comparison to placebo among 30 pregnant women in their second

37

trimester with symptomatic vulvar varicosities and venous insufficiency in their lower

extremities. Two trials compared either compression stockings with resting in left lateral

position or reflexology with rest for 15 minutes for the reduction of leg oedema. One trial

compared standing water immersion for 20 minutes with sitting upright in a chair with

legs elevated for 20 minutes. Foot massage versus routine care One trial, involving 80

women reported a significant difference in lower leg circumference when foot massage

was compared against routine care (MD -0.11, 95% CI -1.02 to 0.80).Women standing in

water were allowed to stand or walk in place. One trial compared 20 minutes of daily foot

massage for five consecutive days and usual prenatal care. The final trial compared three

treatment groups for treating leg oedema in pregnancy. The first group was assigned to

lateral supine bed rest at room temperature, women in the second group were asked to sit

in a bathtub of waist-deep water at 32 ± 0.5 C with their legs horizontal and the third

group included the women who were randomized to sitting immersed in shoulder-deep

water at 32 ± 0.5 C with legs extended downward. One trial, involving 80 women

reported that significant difference in lower leg circumference when foot massage was

compared against routine care (MD -0.11, 95% CI -1.02 to 0.80). so the study conclude

that Foot massage more effective than routine care for treating leg edema in

pregnancy.42

38

CHAPTER IV

METHODOLOGY

Methodology is the most important part of the research study, which enables the research

to achieve the highest possible precision and it should be able to establish trust worthy

relationship between variables.15

Research methodology is a design or a plan or a strategy of a research study that gives

guidelines, which direct the research steps, the research study process and enables in

systematic data collection, accurate data analysis and data interpretation.15

This chapter deals with methodology of the present study which includes research

approach, research design, variables, setting of the study, population, sample and

sampling technique, criteria for sample selection: inclusion and exclusion criteria,

development and description of the tool, pilot study, data collection procedure and data

analysis.

RESEARCH APPROACH:

The main aim of the present study is to assess the effectiveness of lower limb massage on

physiological lower leg/s edema and comfort during third trimester among gravid

mothers. Hence it involves the finding out of how well the intervention of lower limb

massage works among antenatal mothers with physiological lower leg/s edema. A

Quantitative evaluative research approach was adopted to attain the objectives.

39

RESEARCH DESIGN

Research design is also known as a blueprint that researchers select to carry out their

research study.15 A research design is the framework or guide used for the planning,

implementation and analysis of a study, it is a systematic plan of what is to be done, how

it will be done, and how the data will be analyzed

This study is carried out to assess the effectiveness of lower limb massage on

physiological lower leg/s edema and comfort among gravid mothers. The research design

used for the present study is pre experimental one group pre-test post-test design.

• Pre test- Assessment of edema using Erin edema scale and comfort using comfort

scale.

• Intervention- lower limb massage for 5 continuous days

• Post-test – Assessment of edema using Erin edema scale and comfort using comfort

scale on the fifth day after the intervention.

VARIABLES: Characteristics, attributes or phenomena under study are called

variables.15 Three types of variables are identified in the study. These are

Independent variable: Lower limb massage

Dependent variables: Physiological lower leg/s edema and comfort.

PRE TEST INTERVENTION POST TEST

40

Extraneous variables: Age, religion, education status, occupation, type of family,

weeks of gestation, maternal weight gain during pregnancy, family income/ month (in

rupees), number of previous delivery and previous information about lower limb

massage.

RESEARCH SETTING:

The setting is the physical location and condition in which data collection takes place for

the study.14 This study was conducted in Koramangala community. The community

covers a population of 70,000-1, 00,000 consisting of 19000 houses and one Primary

Health Centre (PHC). The PHC records an average of 124 antenatal cases per month.

POPULATION

The accessible population of this study comprised of gravid mothers having physiological

lower leg/s edema during third trimester in a Koramangala community.

SAMPLE

The sample consisted of 30 gravid mothers with physiological lower leg/s edema during

third trimester

SAMPLE SIZE

30 Sample who met the inclusion criteria

SAMPLING TECHNIQUE:

The subjects were selected through purposive sampling technique.

41

SAMPLING CRITERIA:

Inclusion Criteria

Gravid mothers

Between 28-40 weeks of gestation

– with mild to severe physiological lower leg/s edema as per ERIN edema

scale

– Who can understand Kannada/English

Exclusion

Gravid mothers who

– had pathological edema

– were at high risk.

DEVELOPMENT OF THE TOOL

The tool was prepared based on the objectives of the study. The following steps were

carried out before the selection and development of the tool

• Review of literature from electronic media and non electronic media

• Consultation with experts

• Pretesting of instruments by trial run

• Content validity

42

• Reliability

DESCRIPTION OF THE TOOL:

The tool consists of three sections

Section A :Sample Characteristics

Age, religion, education status, occupation, type of family, weeks of gestation, maternal

weight gain during pregnancy, family income/ month (in rupees), number of previous

delivery and previous information about lower limb massage.

Section B: Erin edema scale

Scoring pattern:

Trace 1-3

Mild 4-6

Moderate 7-9

Severe 10-12

Section C: Comfort scale

Scoring pattern:

Very comfortable 0-1

Less comfortable 2-3

Discomfort 4

Moderate discomfort 5-6

Serious discomfort 7-8

43

Extreme discomfort 9-10

CONTENT VALIDITY OF THE TOOL

Content validity of the tool was established by 14 experts.

The validators comprised of

Obstetric and gynecological Nursing faculty 12

Obstetricians 2

The items suggested irrelevant by the validators were removed and final tool was

devised.

RELIABILITY OF THE TOOL

The final tool was tested for reliability among 4 gravid mothers. The reliability of the tool

was established by using Karl Pearson’s Correlation Coefficient.

The reliability score for the Erin edema scale is r= 0.96 and thus the tool was found to be

reliable.

SCORING METHOD

The gravid mothers were examined for their physiological lower leg/s edema, by using

the Erin edema scale. The maximum score is 12 and the minimum score is 0. Higher the

score, severe edema.

44

ETHICAL CLEARANCE

The ethical clearance was obtained from the Institutional Ethical Review Board of St.

Philomena’s hospital, Bengaluru. Permission to conduct the study in Koramangala

community was obtained from, medical officer of the PHC. Written informed consent

was obtained from the gravid mothers with physiological lower leg/s edema who

participated in the study. Assurance was given to them that the anonymity of each

individual would be maintained as well as the confidentiality of the information obtained.

PILOT STUDY

Pilot study was conducted on Koramangala community from 16-11-2017 to 24-11-2017.

The researcher obtained written permission from the concerned authority prior to the

study.

Pilot study helped the researcher to understand the practical utility of the lower limb

massage among gravid mothers with physiological lower leg/s edema. Three subjects

were selected by using purposive sampling technique. Lower limb massage was given to

gravid mothers with physiological lower leg/s edema two times a day for five consecutive

days (total 6 sessions) and each session lasted for 15 minutes. Physiological leg/s edema

was assessed by using Erin edema scale and comfort was measured by using comfort

scale after the last sessions of lower limb massage. The findings of the pilot study

revealed that there was significant change in physiological leg/s edema.

45

PROBLEM FACED

• Getting sample was difficult.

• Less cooperation from the sample

These problems were corrected by following ways

Encouraged them for lower limb massage with explaining the benefit of the lower

limb massage.

Co-operation from the health team of the PHC was sought.

Corrected by visiting the family according to their convenient time.

DATA COLLECTION PROCEDURE

Preparatory phase

The researcher underwent a certified course on lower limb massage in Kottayam, Kerala.

An official written permission was obtained from the Institutional Ethical Review Board

and the medical officer of the PHC, Koramangala. The need and purpose of the study

were explained and a written informed consent was obtained from the gravid mothers

with physiological lower leg/s edema.

DATA COLLECTION PHASE

The data was collected from 30/11/2017 to 22/12 2017

Formal permission was obtained from the PHC

Physiological lower leg(s) edema was assessed by using Erin edema scale and

comfort was assessed by Comfort scale as a pre test.

46

Gravid Mothers were selected based on inclusion and exclusion criteria through

purposive sampling technique.

Sample characteristics were collected through an interview schedule.

Purpose and need for the study were explained to the gravid mothers with

physiological lower leg/s edema

Written informed consent was obtained from the gravid mothers

Intervention in the form of lower limb massage was administered for 30 minutes

(15 minutes/ leg) twice daily for five consecutive days

Assessed the physiological lower leg /s edema by using Erin edema scale and

comfort was measured using comfort scale on the fifth day after the intervention

as a post test.

TERMINATION PHASE:

The physiological lower leg/s edema and comfort among gravid mothers were assessed

by using Erin edema scale and comfort scale on the fifth day after the intervention.

DATA ANALYSIS

The data obtained was analysed in terms of the objectives and hypotheses of the study

using descriptive and inferential statistics.

The steps include

Organisation of the data

Description of sample characteristics

47

Determination of mean and the standard deviation

Determination of effectiveness of lower limb massage in reduction of edema

among gravid mothers with physiological lower leg/s edema.

Determination of effectiveness of lower limb massage in comfort among gravid

mothers with lower leg/s edema.

Determination of association between the sample characteristics and edema scores

using chi-square test.

Determination of association between the sample characteristics and comfort

scores using chi-square test with Yates correction.

48

TARGET POPULATION

Gravid mothers with

physiological lower leg/s

edema

ACCESSIBLE

POPULATION

Gravid mothers with

physiological lower leg/s

edema during third trimester in

Koramangala community

SETTING

KORMANGALA

community at

Bengaluru

SAMPLE

Gravid mothers with physiological

lower leg/s edema from

Koramangala community

SAMPLING

TECHNIQUE

Purposive sampling

technique

SAMPLE SIZE

n= 30

TOOLS

SECTION A Sample

characteristics

SECTION B Erin edema

scale

SECTION C Comfort

scale

VARIABLES

Independent variable: lower limb massage

Dependent variables: physiological lower

leg/s edema and comfort.

Extraneous variables: age, religion, education

status occupation, type of family, weeks of

gestation, maternal weight gain during

pregnancy, family income/ month, number of

previous delivery. Previous information about

lower limb massage

PILOT STUDY

DATE: 16/11/2017-

24/11/2017

MAIN STUDY:

30/11/2017- 22/12/2017

DATA COLLECTION PROCEDURE

Ethical clearance was obtained

Researcher underwent training on lower limb

massage

Subjects where selected based on inclusion and

exclusion criteria.

Assessed the edema and comfort by using Erin

edema and comfort scale. (pre test)

Written informed consent obtained

Interview schedule for sample characteristics

Performed lower limb massage twice a day for 5

consecutive days.

Assessed the physiological lower leg /s edema and

Comfort level as post test on fifth day .

DESCRIPTIVE STATISTICS

Frequency, Percentage, Mean, Standard deviation

INFERENTIAL STATISTICS

Paired t test, Chi square with Yates correction, Fisher’s

Exact test

pair

INTERPRETATION AND PLAN FOR

DISSEMINATION OF RESEARCH FINDING

Seminars, Exhibitions, Poster presentations,

publishing in journal

FIGURE 2: SCHEMATIC REPRESENTATION OF RESEARCH METHODOLOGY

49

49

SAMPLE SIZE ESTIMATION

The sample size was calculated based on comparison of proportions of the pilot study findings

with 80% power at 0.05 level of significance.

n = 1.96( √2*0.93*0.07 + 0.84 √.78*.22 – 0.31*0.69)2

(0.78+ 0.31)2

Though the recommended sample size based on comparison of proportions is 14 the study was

arbitrarily conducted among 30 samples after discussion with experts.

2

1-β 1 1 2 21-α/2

2

1 2

Z 2PQ +Z PQ +PQn =

P -P

1 2

1 1 2 2

P +Pwhere P = , Q =1-P

2

Q =1-P & Q =1-P

=14

50

CHAPTER V

RESULTS

The description of results is the eternity of a research project which enables the

researcher to reduce, summarize, organize, evaluate, interpret and communicate

numerical information. The term analysis refers to the computation of certain measures of

organizing and synthesizing data so as to answer the research question and to test the

hypothesis.15

The study was done to identify the effectiveness of lower limb massage on

physiological lower leg/s oedema and comfort during third trimester among gravid

mothers in a selected community, Bengaluru. In order to interpret a meaningful answer to

the research problem under study, the data was processed and analyzed in a systemic

orderly coherent fashion, so that patterns and relationships that exist between the data

groups can be discerned.

This chapter deals with analysis and interpretation of data obtained from 30

subjects selected from koramangala community, to evaluate the effectiveness of lower

limb massage on physiological lower leg/s and comfort during third trimester among

gravid mothers. The data collected were organized, tabulated, analyzed and interpreted

using descriptive and inferential statistics. MS Excel was used to analyze the data in

addition to manual calculations.

51

OBJECTIVES

To assess the level of physiological lower leg/s oedema and comfort during third

trimester among gravid mothers.

To evaluate the effectiveness of lower limb massage on physiological lower leg/s

edema and comfort during third trimester among gravid mothers.

To find out the association between the pre interventional physiological lower

leg/s oedema scores and selected sample characteristics.

To find out the association between the pre interventional comfort scores and

selected sample characteristics

HYPOTHESES

At 0.05 level of significance:

H1: There will be a statistically significant difference in the physiological lower leg/s

oedema scores before and after the lower limb massage among gravid mothers during

third trimester as measured by using Erin Edema scale

H2: There will be a statistically significant difference in the comfort scores before and

after lower limb massage among gravid mothers during third trimester as measured

by using comfort scale

52

H3: There will be a statistically significant association between pre interventional

physiological lower leg/s edema scores among gravid mothers during third trimester

and selected sample characteristics

H4: There will be a statistically significant association between pre interventional

comfort scores among gravid mothers during third trimester and selected sample

characteristics

ORGANIZATION OF FINDINGS.

The data collected were edited, tabulated, analyzed, interpreted and findings were

presented in the form of tables and graph.

53

Section: I – Description of percentage distribution of sample

characteristics.

Figure 3: Bar diagram showing percentage distribution of the gravid

mothers according to their age.

Data presented in figure 3 shows the percentage distribution of gravid mothers

according to their age in years. Among the gravid mothers, half (50%) of them

belonged to the age group between 23-27 years, 40% of them were between 18-22 years,

6.7% of them belonged to 28-32 years, and 3.3% of them belonged to 33-37 years.

40

50

6.73.3

0

10

20

30

40

50

60

70

80

90

100

18-22 yrs 23-27 yrs 28-32 yrs 33-37 yrs

Perc

enta

ge o

f m

oth

ers

Age in years

18-22 yrs

23-27 yrs

28-32 yrs

33-37 yrs

n=30

54

Figure 4: Cylindrical diagram showing percentage distribution of the

gravid mothers according to their Religion.

Data presented in figure 4 shows the percentage distribution of gravid mothers

according to their religion, where half (50%) of the gravid mothers were Christians, 30%

were Hindus and 20% were Muslims.

0

10

20

30

40

50

60

70

80

90

100

Hindu Christian Muslim

30

50

20

Perc

enta

ge o

f m

oth

ers

Religion

Hindu

Christian

Muslim

n=30

55

Figure 5: Bar diagram showing percentage distribution of the gravid

mothers according to their educational status.

Data presented in Figure 5 shows the percentage distribution of gravid mothers

according to their educational status, where less than half (46.7%) of them completed

their Pre-University, 30% were diploma/ degree holders, 16.6% had completed their

high school education and 6.7% had finished their primary education.

6.716.6

46.7

30

0102030405060708090

100

Primary High school Pre-university Diploma/

graduates and

above

Perc

enta

ge o

f m

oth

ers

Educational status

Primary

High school

Pre-university

Diploma/ graduates

and above

n=30

56

Figure 6: Bar diagram showing percentage distribution of gravid

mothers according to their occupational status.

Data presented in Figure 6 shows the percentage distribution of gravid mothers

according to their occupational status. A little more than half (53.3%) were homemakers,

36.7% were privately employed and 10% were self employed.

10

36.7

53.3

0

10

20

30

40

50

60

70

80

90

100

Self employee Private employee Home maker

Perc

enta

ge o

f m

oth

ers

Occupation

Self employee

Private employee

Home maker

n=30

57

Figure 7: Bar diagram showing percentage distribution of the gravid

mothers according to their type of family

Data presented in figure 7 shows the percentage distribution of gravid mothers

according to their type of family. Most (70%) of the gravid mothers belonged to nuclear

family, and 30% of them belonged to joint family.

70

30

0

10

20

30

40

50

60

70

80

90

100

Nuclear Joint

Perc

enta

ge o

f m

oth

ers

Type of family

Nuclear

Joint

n=30

58

Figure 8: Bar diagram showing percentage distribution of the gravid

mothers according to their weeks of gestation

Data presented in figure 8 shows the percentage distribution of gravid mothers

according to their weeks of gestation. Less than half (43.3%) of the gravid mothers were

in their 28-32 weeks of gestation,33.3% were in 33-36 weeks of gestation and 23.4 %

were in 37-40 weeks of gestation.

43.3

33.3

23.4

0

10

20

30

40

50

60

70

80

90

100

28- 32 weeks 33-36 Weeks 37-40 Weeks

Pe

rce

nta

ge

of

moth

ers

Weeks of gestation

28- 32 weeks

33-36 Weeks

37-40 Weeks

n=30

59

Figure 9: Bar diagram showing percentage distribution of the gravid

mothers according to maternal weight gain during pregnancy.

Data presented in figure 7 shows the percentage distribution of gravid mothers

according to their maternal weight gain during pregnancy. More than half (66.6%) of

gravid mothers gained 7- 9 kg weight, 30% gained 10-12 kg weight, and 3.4% gained

13-15 kg of weight.

66.6

30

3.4

0

10

20

30

40

50

60

70

80

90

100

7-9 Kg 10-12 Kg 13-15 kg

Perc

enta

ge o

f m

oth

ers

Maternal weight gain (kg)

7-9 Kg

10-12 Kg

13-15 kg

n=30

60

Figure 10: Bar diagram showing percentage distribution of the gravid

mothers according to their previous number of deliveries.

Data presented in Figure 10 shows the percentage distribution of gravid mothers

according to their number of previous delivery. More than half (53.4%) of them were

nulliparas, 26.6% of gravid mothers were primiparas, and 20% of them were multiparas.

53.4

26.620

0

10

20

30

40

50

60

70

80

90

100

Nil One Two

Perc

enta

ge o

f m

oth

ers

Numbers of previous delivery

Nil

One

Two

n=30

61

Figure 11: Bar diagram showing percentage distribution of of gravid

mothers according to their monthly income.

Data presented in figure 11 shows the percentage distribution of gravid mothers

according to their monthly income. More than half ( 56.6%)of gravid mothers had their

family income of Rs 10001-15000 per month, 36.7% of them had family income of Rs

5000-10000 per month, and 6.7% had family income of Rs 15001-20000 per month.

36.7

56.6

6.7

0

10

20

30

40

50

60

70

80

90

100

5000-10000 10001-15000 15001-20000

Perc

enta

ge o

f m

oth

ers

Monthly income (in rupees)

5000-10000

10001-15000

15001-20000

n=30

62

Figure 12: Bar diagram showing percentage distribution of the gravid

mothers according to their previous knowledge about lower limb

massage.

Data presented in Figure 12 shows the percentage distribution of gravid mothers

according to their previous information about lower limb massage. Most (73.3%) of them

had previously obtained information about lower limb massage, and 26.7% did not obtain

any previous information about lower limb massage.

73.3

26.7

0

10

20

30

40

50

60

70

80

90

100

Yes No

Perc

enta

ge o

f m

oth

ers

Have you obtained previous information regarding lower limb massage

Previous information obtained regarding lower limb

massage

Yes

No

n=30

63

Section II: Effectiveness of lower limb massage on physiological lower

leg/s edema

Figure 13: Bar diagram showing percentage distribution of pre and post

intervention lower leg/s edema scores among gravid mothers during

third trimester.

Figure 13 depicts the percentage distribution of pre and post interventional lower

leg/s edema scores among gravid mothers during third trimester. In pretest most (76.6%)

of them had severe edema, 20% of them had moderate edema and 3.4% of them had mild

edema. In post test after the intervention of lower limb massage majority (90%) of them

had mild edema and 10% of them had trace edema.

0

10

20

30

40

50

60

70

80

90

100

pre test post test

0

103.4

90

20

0

76.6

0

Perc

enta

ge o

f m

oth

ers

ERIN EDEMA SCORE

Trace

Mild

Moderate

Severe

n=30

64

Table 1: Comparison of mean pre and post intervention lower leg/s

edema scores among gravid mothers during third trimester.

Pretest/ Post test edema scores

Mean SD Mean difference df Paired

t-test p value Inference

Pretest 10.8 0.96 6.6 29 32.49 p<0.05 S*

Post test 4.23 0.67

* Significant at p< 0.05 t

29 =2.05

Data presented in Table 1: reveals the mean, mean difference, standard deviation,

degree of freedom and paired‘t’ test values of pre and post interventional lower leg

edema scores. The mean pre-test score is 10.8 with a standard deviation of 0.96 and the

post test score is 4.23 with a standard deviation of 0.67

The calculated paired‘t’ value is 32.49 which is greater than the table value (2.05). Hence

H1 is accepted stating that there is a statistically significant difference in the physiological

lower leg/s oedema before and after the lower limb massage among gravid mothers

during third trimester as measured using Erin Edema scale

n=30

65

Section III : Effectiveness of lower limb massage on Comfort among

gravid mothers during third trimester.

Figure 14: Bar diagram showing percentage distribution of pre and post

intervention comfort scores among gravid mothers during third

trimester.

The data in figure 14 shows the percentage distribution of pre and post

intervention comfort scores of gravid mothers. In pre test more than half (56.6%) of them

had serious discomfort, 30% of them had extreme discomfort, and 13.4% of them had

moderate discomfort. In post test after the intervention of lower limb massage 63.4 % of

them were less comfortable, 26.6% of them had discomfort and 10% of them felt very

comfortable.

0

10

0

63.4

0

26.6

13.4

0

56.6

0

30

0

10

20

30

40

50

60

70

80

90

100

pre test post test

Pe

rce

nta

ge

of

moth

ers

Percentage of pre and post test comfort scores

Very comfortable

Less comfortable

Discomfort

Moderate discomfort

Serious discomfort

Extreme discomfort

n=30

66

Table 2: Comparison of mean pre and post intervention comfort scores

among gravid mothers during third trimester.

Pretest/ Post test

comfort score

Mean SD Mean difference

df Paired t-test

p value Inference

Pretest 8 1.26 3.9 29 8.9 p<0.05 S*

Post test 4.1 1.6

* Significant at p< 0.05 t

29 =2.05

The data presented in table 2 reveals the mean, mean difference, standard deviation,

degree of freedom and paired‘t’ test values of pre and post interventional comforts

scores. The mean pre-test score is 8 with a standard deviation of 1.26 and the post test

score is 4.1 with a standard deviation of 1.6.

The calculated paired‘t’ value is 8.9 which is greater than the table value (2.05). Hence

H2 is accepted stating that there is a statistically significant difference in the comfort

before and after lower limb massage among gravid mothers during third trimester as

measured using comfort scale.

n=30

67

Section IV: Association between sample characteristics and pretest

intervention scores among gravid mothers with physiological lower leg

Edema during third trimester.

Table 3: Association between sample characteristics and pretest

intervention edema scores among gravid mothers with physiological

lower leg/s Edema during third trimester.

Sample characteristics Mild/Modera

te Severe Chi square/

Fisher exact p value

Age (in years)

≤ 27 5 22 3.035 Yates

0.081 (NS)

> 27 2 1

Type of family

Nuclear 7 13 0.34 Fisher exact

0.34 (NS)

Joint 0 10

Religion

Hindu 1 8

0.531 Fishers exact

0.766 (NS)

Christian 5 10

Muslim 1 5

Occupation

0.041 Yates

0.42 (NS) Employed 4 10

Unemployed 3 13

Education status

High school 1 6 0.24

Fisher exact Table value

5.99

0.883 (NS)

PUC 2 12

Diploma and above 4 5

n=30

68

Weeks of gestation (in

weeks)

28-32 5 8 0.302

Fisher exact

0.85 (NS)

33-36 1 9

37-40 1 6

Maternal weight gain

(kg)

7-9 3 17 0.129

Fisher exact

0.71 (NS)

10-12 3 6

13-15 1 0

Family income/ month

(in rupees)

5000-10000 3 8

0.825

Fisher exact

0.66

(NS)

10001-15000 4 13

150001-20000 0 2

Number of previous

delivery

0 4 12

0.44 Fisher exact

0.97 (NS)

1 0 8

2 3 3

Previous information

obtained about lower

limb massage

Yes 6 16 1.13 Yates

0.35 (NS)

No 1 7

69

The computed chi-square values between the pre intervention oedema scores and the

sample characteristics like age, religion, occupation, type of family, educational status,

weeks of gestation, , maternal weight gain during pregnancy, family income/ month,

number of previous deliveries and previous information obtained about lower limb

massage were less than the corresponding table values at p< 0.05 level. Hence the

research hypothesis H3 is rejected stating that there is no significant association found

between pre interventional edema scores and selected sample characteristics.

70

Table 3.b) Association between sample characteristics and pretest

Comfort scores among gravid mothers with physiological lower leg

Edema during third trimester.

Sample characteristics Moderate Serious Extreme Chi square/ Fisher exact

p

value

Age (in years)

≤ 27 4 16 7 0.63

Yates

0.21

(NS) > 27 0 1 2

Occupation

Employed 2 5 7 0.05

Fisher exact

0.97

(NS) Unemployed 2 12 2

Type of family

Nuclear 3 13 5 0.48

Yates

0.24

(NS) Joint 1 4 4

Education status

High school 0 6 2

0.40

Yates

0.85

(NS) PUC 1 8 5

Diploma and above 3 3 2

Weeks of gestation (in

weeks)

28-32

3 7 3

0.41 Yates

0.85 (NS)

33-36

1 7 2

37-40

0 3 4

n=30

71

Maternal weight gain

(Kg)

7-9 3 14 3

0.60 Yates

0.96 (NS)

10-12 1 3 5

13-15 0 0 1

Family income/ month

(in rupees)

5000-10000 1 7 3

0.67 Yates

0.94 (NS)

10001-15000 3 8 6

15001-20000 0 2 0

Number of previous

delivery

0 4 9 3

3.15

Yates

0.94

(NS) 1 0 4 4

2 0 4 2

Pervious information

obtained about lower

limb massage

Yes 2 13 7 0.13 Yates

0.35 (NS) No 2 4 2

The computed chi-square values between the pre intervention comfort scores and

the sample characteristics like age, religion, occupation, type of family, educational

status, weeks of gestation, maternal weight gain during pregnancy, family income/

month, number of previous deliveries and previous information obtained about lower

limb massage were less than the corresponding table values at p< 0.05 level. Hence the

research hypothesis H4 is rejected stating that there is no association found between the

pre- interventional comfort scores among gravid mothers during third trimester and

selected sample characteristics.

72

SUMMARY

This chapter dealt with the analysis and interpretation of data using descriptive

and inferential statistics. The effectiveness of lower limb massage was identified by

paired‘t’ test. The finding showed that there is a significant difference in the level of

physiological lower leg/s edema scores and comfort scores among pre and post

interventional scores. Hence the study reveals that lower limb massage is effective in the

reduction of physiological lower leg/s edema and promotion of comfort among gravid

mothers during third trimester.

73

CHAPTER VI

DISCUSSION

This chapter deals with the discussion of study findings in accordance with the

objectives of the study and discusses them in relation to similar studies. The study intends

to evaluate the effectiveness of lower limb massage on physiological lower leg/s edema

among gravid mothers during third trimester in a selected community Koramangala,

Bengaluru.

In order to achieve the objectives of the study, a pre experimental one group

pretest post test design was adopted. Purposive sampling technique was used to select the

sample. The data was collected from 30 gravid mothers with physiological lower leg/s

edema. The data was collected using Erin edema scale and Comfort scale; the findings of

the study have been discussed with specific reference to objectives, hypotheses and

related findings of available studies. The data were organized, analysed and presented in

five sections.

74

Section I: Description of sample characteristics

Section II : Description of Pre and post test edema scores after the lower limb massage

Section III: Description of Pre and post test comfort scores after lower limb massage.

Section IV: Association between pre interventional scores and selected sample

characteristics.

MAJOR FINDINGS

SECTION I: Description of gravid mothers with physiological lower leg/s edema

according to their sample characteristics.

Age: Half (50%) of them belonged to the age group between 23-27 years, 40% of them

were between 18-22 years, 6.7% of them belonged to 28-32 years, and 3.3% of them

belonged to 32-37 years.

Religion: Half (50%) of the subjects were Christians, 30% were Hindus and 20% were

Muslims.

Educational status: Less than half (46.7%) of them completed their Pre-University, 30%

of were diploma/ degree holders, 16.6% had completed high school education and 6.7%

had finished their primary education.

Occupational status: A little more than half (53.3%) were homemakers, 36.7% were

privately employed and 10% were self employed.

Type of family: Most (70%) of the gravid mothers belonged to nuclear family, and 30%

of them belonged to joint family.

75

Weeks of gestation: Less than half (43.3%) of the gravid mothers were in their 28-32

weeks of gestation,33.3% were in 33-36 weeks of gestation and 23.4 % were in 37-40

weeks of gestation.

Maternal weight gain during pregnancy: More than half (66.6%) of gravid mothers

gained 7- 9 kg weight, 30% gained 10-12 kg weight, and 3.4% gained 13-15 kg of

weight.

Previous number of deliveries: More than half (53.4%) of them were nulliparas, 26.6%

of gravid mothers were primiparas, and 20% of them were multiparas.

Monthly income of the gravid mothers: More than half (56.6%)of gravid mothers had

their family income of Rs 10001-15000 per month, 36.7% of them had family income of

Rs 5000-10000 per month, and 6.7% had family income of Rs 15001-20000 per month.

Previous knowledge about lower limb massage: Most (73.3%) of them had previously

obtained information about lower limb massage, and 26.7% of d id not obtain any

previous information about lower limb massage.

Section II: Description of Pre and post –test Erin edema scores after the lower limb

massage

a) Percentage distribution of pre and post intervention lower leg/s edema scores

among gravid mothers during third trimester.

In pretest most (76.6%) of them had severe edema, 20% of them had moderate

edema, 3.4% of them had mild edema. In post test after the intervention of lower

76

limb massage majority (90%) of them had mild edema and 10% of them had trace

edema.

b) Comparison of pre and post intervention lower leg/s edema scores among gravid

mothers during third trimester.

The mean pre-test edema score is 10.8 with a standard deviation of 0.96 and the post

test edema score is 4.23 with a standard deviation of 0.67.The calculated paired‘t’

value is 32.49 which is greater than the table value (2.05). Hence H1 is accepted

stating that there is a statistically significant difference in the physiological lower

leg/s oedema before and after the lower limb massage among gravid mothers during

third trimester as measured using Erin Edema scale.

These findings was supported with a study conducted to evaluate the effectiveness of

foot massage on reduction of physiological lower leg edema among Primigravid

mothers during third trimester in Elariyampannai, Primary Health Center,

Virudhunagar district Tamilnadu. The study comprised of 60 samples selected by

purposive sampling method. Demographic data was collected through interview

method, and pre-test was assessed using Erin edema Scale. Foot massage was given

over 20 min for each leg. The mean value of post test level of physiological lower leg

edema after receiving foot massage was 2.38 and it was more than the pretest mean

value 0.58. The calculated t test value showed that there was a significant difference

supporting the effectiveness of foot massage at p<0.05 level.

77

Section III : Effectiveness of lower limb massage on Comfort among gravid mothers

during third trimester

Percentage distribution of pre and post intervention comfort scores among gravid

mothers during third trimester

In pre test more than half (56.6%) of them had serious discomfort, 30% of them had

extreme discomfort, and 13.4% of them had moderate discomfort. In post test after the

intervention of lower limb massage 63.4 % of them were less comfortable, 26.6% of

them had discomfort and 10% of them felt very comfortable.

These findings were supported by a study was conducted in Japan on “comfort over pain

in pregnancy”. The sample comprised of 114 primipara and 102 multipara mothers.

Holistic/ alternative techniques (positioning and massage) individualized over three

sessions were administered to the participants. Levels of pain and comfort were measured

before and after the treatment, using the validated general comfort questionnaire and

pain outcomes profile. Result of the study showed that pain scores decreased from an

average of 5.8/10 to 5/10 (p=.00). Comfort scores increased from an average of 17.5 to

30 (p=.00).

Comparison of mean pre and post intervention comfort scores among gravid

mothers during third trimester.

The mean pre-test comfort score is 8 with a standard deviation of 1.26 and the post test

score is 4.1 with a standard deviation of 1.6. The calculated paired‘t’ value is 8.9 which is

greater than the table value (2.05). Hence H2 is accepted stating that there is a

78

statistically significant difference in the comfort scores before and after lower limb

massage among gravid mothers during third trimester as measured using comfort scale.

Section IV: Association between pre interventional scores and selected sample

characteristics

a) Association between sample characteristics and pretest edema scores among

gravid mothers with physiological lower leg/s edema during third trimester.

The computed chi-square values between the pre intervention oedema

scores and the sample characteristics like age, religion, occupation, type of family,

educational status, weeks of gestation, , maternal weight gain during pregnancy, family

income/ month, number of previous deliveries and previous information obtained about

lower limb massage were less than the corresponding table values at p> 0.05 level. Hence

the research hypothesis H3 is rejected stating that there is no significant association found

between pre interventional edema scores and selected sample characteristics.

b) Association between sample characteristics and pretest Comfort scores among

gravid mothers with physiological lower leg edema during third trimester.

The computed chi-square values between the pre intervention comfort scores and

the sample characteristics like age, religion, occupation, type of family, educational

status, weeks of gestation, maternal weight gain during pregnancy, family income/

month, number of previous deliveries and previous information obtained about lower

limb massage were less than the corresponding table values at p> 0.05 level. Hence the

research hypothesis H4 is rejected stating that there is no association found between the

79

pre- interventional comfort scores among gravid mothers during third trimester and

selected sample characteristics.

80

CHAPTER VII

CONCLUSION

This chapter deals with conclusion, implication, limitation, suggestions and

recommendation. The purpose of the study was to evaluate the effectiveness of lower

limb massage on physiological lower leg edema among gravid mothers during third

trimester in a selected community Koramangala.

The conceptual frame work of the study was based on Kolcaba’s Comfort theory. The

sample size selected was 30. The study design used was one group pretest posttest design.

The conclusions drawn from the study are:

Lower limb massage is effective in reduction of physiological lower leg/s edema during

third trimester of pregnancy

There is no significant association found between the pre interventional edema scores and

comfort scores with sample characteristics.

NURSING IMPLICATIONS

The present study was conducted to assess the effectiveness of lower limb massage on

physiological lower leg/s edema and comfort during third trimester among gravid

mothers. The study findings have several implications on Nursing education, Nursing

practice, Nursing administration, Nursing research and community.

81

NURSING PRACTICE

• To provide a comprehensive maternity care, even the mild discomfort caused by

physiological edema should not be neglected.

• Nurses can use suitable assessment tools to identify edema and take appropriate

measures to ease the discomfort caused.

• Nurses in practice can make time to teach the pregnant women about minor

ailments in pregnancy with simple remedial measures.

• Massage involving therapeutic touch can improve interpersonal relationship and

promote comfort.

NURSING EDUCATION

• Lower limb massage as a complementary therapy is easy to learn as it is neither

machine oriented nor technology dependent.

• The staff nurses and student nurses, may be oriented to the use of objective tools

to assess various minor ailments and provide appropriate nursing intervention.

• The student nurses should be taught and encouraged to practice simple cost

effective therapeutic procedures to relieve discomfort during pregnancy.

NURSING RESEARCH

• Evidence based research is needed to improve quality of health services and to

improve client satisfaction towards nursing care.

82

• The study findings serve as an evidence to practice lower limb massage in

reducing physiological lower leg edema and discomfort during pregnancy.

• The study findings can be disseminated through mass media, journal clubs,

presentations and conferences.

• The nurse researchers can work to develop suitable interventions for physiological

lower leg edema during third trimester, test them through research and implement

them effectively to reduce the edema related discomfort.

NURSING ADMINISTRATION

• The nurse administrators can encourage the nursing staff to utilize effective

interventions tested through research which can increase the client satisfaction.

• Information regarding minor ailments and discomfort during pregnancy with

appropriate intervention such as lower limb massage in reducing edema and

discomfort, can be made known to the general public through pamphlets, running

screens at the waiting areas and out patient departments.

LIMITATIONS

The limitations of the study are

The findings of the study cannot be generalized as the sample size is 30

The study was limited only to antenatal mothers in Koramangala community

RECOMMENDATIONS

83

Based on the findings of the present study, recommendations offered for future research

are

A similar study can be replicated on large samples and for a long duration for the

generalization.

A comparative study can be conducted to assess the effect of lower limb massage

with other interventions like salt water soaking, position during sleep, life style

modification, and elevation of leg during resting period.

A true experimental study can be done with randomization and control for

generalization.

A comparative study can be conducted on the same between primiparous and

multiparous mothers in different settings.

84

CHAPTER VIII

SUMMARY

Physiological lower leg edema is one of the cutaneous manifestations of pregnancy. The

weight gain during pregnancy and gravity slow the circulation of blood and body fluids

particularly in lower limbs.1 The swelling or edema is a common discomfort of

pregnancy. It is estimated that about 75% of women experience this excessive

accumulation of fluid around the leg and ankles during pregnancy.2 Physiological edema

results from hormones induced sodium retention. Leg edema in lower extremities

unilateral or bilateral.4 Edema may also be present when the enlarged uterus

intermittently compresses the inferior vena during recumbency, obstructing outflow from

both femoral veins.10 Dorsum of the foot, medial malleolus, and anterior 2/3rd of tibia are

the common sites of physiological edema.2

STATEMENT OF THE PROBLEM

A study to assess the effectiveness of lower limb massage on physiological lower leg/s

oedema and comfort during third trimester among gravid mothers in a selected

Community, Bengaluru.

85

OBJECTIVES

To assess the level of physiological lower leg/s oedema and comfort during third

trimester among gravid mothers.

To evaluate the effectiveness of lower limb massage on physiological lower leg/s

edema and comfort during third trimester among gravid mothers.

To find out the association between the pre interventional physiological lower

leg/s oedema scores and selected sample characteristics.

To find out the association between the pre interventional comfort scores and

selected sample characteristics

ASSUMPTIONS:

Gravid mothers may experience physiological leg/s edema during third trimester.

Edema may cause discomfort to gravid mothers during third trimester.

Foot massage may have an effect on physiological leg edema.

HYPOTHESES

At 0.05 level of significance:

H1: There will be a statistically significant difference in the physiological lower leg/s

oedema scores before and after the lower limb massage among gravid mothers during

third trimester as measured by using Erin Edema scale

86

H2: There will be a statistically significant difference in the comfort scores before and

after lower limb massage among gravid mothers during third trimester as measured

by using comfort scale

H3: There will be a statistically significant association between pre interventional

physiological lower leg/s edema scores among gravid mothers during third trimester

and selected sample characteristics

H4: There will be a statistically significant association between pre interventional

comfort scores among gravid mothers during third trimester and selected sample

characteristics

CONCEPTUAL FRAMEWORK

The conceptual frame work used for the study was Katharine Kolcaba’s Theory of

Comfort.

RESEARCH METHODOLOGY

The final tool consisted of three sections including the Sample Characteristics, Erin

edema scale, and Comfort scale.

SECTION A: Sample characteristics

SECTION B: Erin edema scale

SECTION C: Comfort scale

87

Content validity of the tool was established by 14 experts. The tool was found feasible for

the study. The reliability of the tool was established through Karl Pearson’s Correlation

Coefficient prior to the study (r=0.96). The research approach used was quantitative

approach. The research design was pre experimental one group pretest post test design.

The study sample comprised of 30 gravid mothers. Data were collected from subjects

through an interview method using Erin edema scale and comfort scale. The data was

further analyzed by descriptive and inferential statistics.

MAJOR FINDING OF THE STUDY

Section:I – Description of percentage distribution of sample

characteristics.

Among the antenatal mothers, half (50%) of them belonged to the age group of 23-27

years, 50% were Christians, 46.7% of them completed their PUC, 53.3% were home

makers,70% of them belonged to nuclear family, 43.3% of them were in their 28-32

weeks of gestation, 66.6 % of them gained 7-9kg weight during their pregnancy,56.6% of

them had an family income of Rs 10001-15000/ month,53.4% of them were nulliparas

and 73.3% of them had obtained previous information about lower limb massage .

88

Section II Effectiveness of lower limb massage on physiological lower

leg edema among gravid mothers during third trimester

a) Percentage distribution of pre and post intervention lower leg edema scores

among gravid mothers during third trimester.

In pretest most (76.6%) of them had severe edema, 20% of them had moderate edema,

3.4% of them had mild edema. In post test after the intervention of lower limb massage

majority (90%) of them had mild edema and 10% of them had trace edema.

a) Comparison of mean pre and post intervention lower leg edema scores among

gravid mothers during third trimester.

The mean pre-test edema score is 10.8 with a standard deviation of 0.96 and the post test

edema score is 4.23 with a standard deviation of 0.67.The calculated paired ‘t’ value is

32.49 which is greater than the table value (2.05). Hence H1 is accepted stating that there

is a statistically significant difference in the physiological lower leg/s oedema scores

before and after the lower limb massage among gravid mothers during third trimester as

measured using Erin Edema scale

89

Section III : Effectiveness of lower limb massage on Comfort scores

among gravid mothers during third trimester.

a) Percentage distribution of pre and post intervention comfort scores among

gravid mothers during third trimester

In pre test more than half (56.6%) of them had serious discomfort, 30% of them had

extreme discomfort, and 13.4% of them had moderate discomfort. In post test after the

intervention of lower limb massage 63.4 % of them were less comfortable, 26.6% of

them had discomfort and 10% of them felt very comfortable.

b) Comparison of pre and post intervention comfort scores among gravid mothers

during third trimester.

The mean pre-test comfort score is 8 with a standard deviation of 1.26 and the post test

score is 4.1 with a standard deviation of 1.6. The calculated paired‘t’ value is 8.9 which is

greater than the table value (2.05). Hence H2 is accepted stating that there is a

statistically significant difference in the comfort scores before and after lower limb

massage among gravid mothers during third trimester as measured using comfort scale.

Section IV: Association between sample characteristics and pretest Erin edema

scores and comfort scores among gravid mothers with physiological lower leg edema

during third trimester.

90

a ) Association between sample characteristics and pretest Erin edema scores among

gravid mothers with physiological lower leg edema during third trimester.

The computed chi-square values between the pre intervention oedema scores and the

sample characteristics like age, religion, occupation, type of family, educational status,

weeks of gestation, maternal weight gain during pregnancy, family income/ month,

number of previous deliveries, previous information obtained about lower limb massage,

source of information were less than the corresponding table values at p< 0.05 level of

significance.. Hence the research hypothesis H3 is rejected stating that their no significant

association found pre interventional edema scores and selected sample characteristics.

b) Association between sample characteristics and pretest Comfort scores among

gravid mothers with physiological lower leg edema during third trimester.

The computed chi-square values between the pre intervention comfort scores and the

sample characteristics like age, religion, occupation, type of family, educational status,

weeks of gestation, maternal weight gain, family income/ month, number of previous

deliveries and previous information obtained about lower limb massage were less than

the corresponding table values at p< 0.05 level. Hence the research hypothesis H4 is

rejected stating that there is no association found between the pre interventional comfort

scores among gravid mothers during third trimester and selected sample characteristics.

91

SUMMARY

On the whole, carrying out the present study was really an enriching experience of the

researcher. It helped the researcher to improve the skill of lower limb massage. Lower

limb massage helped in the reduction of physiological lower leg/s edema and discomfort

during third trimester in gravid mothers. Timely guidance and assistance from the experts

helped the researcher to complete the study successfully.

92

CHAPTER IX

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100

FORMAT OF CONSENT FORM

Letter to the subject requesting to participate in this study

Dear participant,

I am a post graduate student of St.Philomena’s College of Nursing. I am conducting a research

on the following topic

“A study to assess the effectiveness of lower limb massage on physiological lower leg/s oedema

and comfort during third trimester among gravid mothers in a selected community, Bengaluru.”

As a part of the study, I will be giving foot massage for 5 days. On the beginning and end of the

foot massage I will be assessing lower limb edema by using Erin edema scale and comfort

assessed by Comfort scale. Please read the instructions care fully and place a tick mark[√against

the answer of your choice. Any information obtained in connection with the study remain

confidential. Please be free to clarify the same at any point of time.

The decision to participate in the study is entirely voluntary. Further after having given the

consent, you will have the right to withdraw the same at any time during the study.

Thanking you. Yours faithfully,

Ms. Elizabeth Joseph

101

DECLARATION OF CONSENT

I Ms/Mrs …………………………………….. have understood the need for participation

in the study and willingly giving the consent for the same

Name of the participants Signature of the participant/ care giver

Signature of the investigator

Date:

Place : Bengaluru

102

CONSENT FORM-KANNADA

103

104

ETHICAL COMMITTEE CLEARANCE CERTIFICATE

105

PROFORMA PROTOTYPE

LETTER SEEKING EXPERTS OPINION AND SUGGESTIONS FOR CONSENT

VALIDITY OF THE TOOLS

From,

Ms. Elizabeth Joseph

2nd year M.Sc. Nursing

St.Philomena’s College of Nursing

Bengaluru-47

To,

Forwarded Through,

Rev. Sr. Martha Thirumal Reddy

Principal

St. Philomena’s College of Nursing

Bengaluru- 47

Subject: Seeking expert opinion and suggestions on content validity of the tool

Respected Madam/ Sir,

106

I am a post graduate student of St. Philomena’s College of Nursing. I have selected the

topic mentioned below for the research project to be submitted to Rajiv Gandhi University of

Health Sciences, as a partial fulfillment of Masters Nursing Degree.

Title of the study

“A study to assess the effectiveness of lower limb massage on physiological lower

leg/s oedema and comfort during third trimester among gravid mothers in a selected

community, Bengaluru.”

OBJECTIVES OF THE STUDY ARE

To assess the level of physiological lower leg/s oedema and comfort during third

trimester among gravid mothers.

To evaluate the effectiveness of lower limb massage on physiological lower leg/s edema

and comfort during third trimester among gravid mothers.

To find out the association between the pre interventional physiological lower leg/s

oedema scores and selected sample characteristics.

To find out the association between the pre interventional comfort scores and selected

sample characteristics

ENCLOSURES

SECTION A: Sample characteristics

SECTION B: Erin edema scale

107

SECTION C: Comfort scale

I would be highly obliged and remain thankful for your great help if you could validate and give

it as early as possible. I also request you to kindly sign the certificate that tool and video has been

validated. Your kind co-operation and expert judgment will be highly appreciated.

Thanking you,

Place: Bengaluru

Date: Yours Sincerely,

Elizabeth Joseph

II Year M.Sc Nursing,

St Philomena’s college of nursing

Bangalore- 47

Ph no: 9496399278

108

ACCEPTANCE FORM FOR TOOL VALIDATION

Name: -------------------------------------------------------------------------------------------

Designation: ------------------------------------------------------------------------------------

Name of the college/Hospital: ------------------------------------------------------------------

Statement of acceptance/non acceptance

I give my acceptance/ non acceptance to validate the tool,

TOPIC:

“A study to assess the effectiveness of lower limb massage on physiological lower leg/s

oedema and comfort during third trimester among gravid mothers in a selected community,

Bengaluru.”

Place:

Date: Signature of Expert:

109

CONTENT VALIDITY CERTIFICATE

I hereby certify that I have validated the tool of Ms. Elizabeth Joseph, IInd Year Msc Nursing

student of St.Philomena’s College of Nursing, who is undertaking following study.

“A study to assess the effectiveness of lower limb massage on physiological lower leg/s

oedema and comfort during third trimester among gravid mothers in a selected

community, Bengaluru.”

Place: Signature of expert

Date: Name and Designation

110

TOOL FOR THE STUDY

SECTION A:

SOCIO DEMOGRAPHIC DATA PROFILE

Sample No: Date of data collection:

Instructions: Dear respondent, you are requested to answer the following which are appropriate

to you. Information given by you will be kept confidential.

1) Age ( in years)--------------------------------------

2) Religion

a. Hindu

b. Christian

c. Muslim

d. Others

3) Educational status

a. No formal education

b. Primary school education

c. High school education

d. Pre-university

e. Diploma/ Graduate and above

4) Occupation

a. Self employee

b. Private employee

c. Government employee

d. Homemaker

5) Type of family

a. Nuclear

111

b. Joint

6) Weeks of gestation-------------------------------------

7) The maternal weight during first antenatal visit: …………………………………

8) Maternal weight at present: …………………………………………………………

9) Family income / month: …………………………………………………………..

10) Number of previous deliveries

a. 0

b. 1

c. 2

d. 3 or above

11) Have you obtained any information regarding lower limb massage

a. Yes

b. No

112

SECTION: B ERIN EDEMA SCALE

Instructions

Dear participant,

Kindly cooperate with the researcher as she examines you. The data collected will be kept

confidential.

SCORE

NATURE OF EDEMA

OEDEMA

ASSESSMENT

0

NONE

NO- OEDEMA

+1

TRACE

RAPID RETURN TO NORMAL

+2

MILD

REBOUND IN FEW SECOND

+3

MODERATE

10-20 SECONDS TO RETURN TO NORMAL

+4

SEVERE

>30 SECOND TO RETURN TO NORMAL

Site wise edema assessment:

Site of assessment Right leg Left leg

Lower 2/3rd of tibia

Medial malleolus

Dorsum of the foot

113

INTERPRETATION OF SCORES

1 to 3 = Trace

4 to 6 =Mild

7 to 9 = Moderate

10 to 12= Severe

SECTION C: COMFORT SCALE

114

TOOL FOR THE STUDY-KANNADA

Sample Characteristics

115

116

Erin Edema Scale

117

Comfort Scale

118

119

120

ANNEXURE 1

PERMISSION LETTER FOR RESEARCH PILOT STUDY

121

ANNEXURE 2

PERMISSION LETTER FOR RESEARCH ( MAIN ) STUDY

122

ANNEXURE 3

CERTIFICATE OF FOOT MASSAGE

123

ANNEXURE 4

4 (a) Manuscript of Lower limb massage-English

Lower limb massage is a simple, cheap and effective method to relax the body and mind. It is

based on the tenets. This technique has been practiced for many centuries for its various benefits.

Our feet contain greater than 7,000 nerves. By stimulating them gently you can get pleasurable

and relaxing sensations.

Peaceful, Easy Feeling: lower limb massage can help to relieve anxiety and induce deep

relaxation. This is because stress is normally stored in a point called the solar plexus reflex in the

feet. By pressing and massaging this point, you can release stress and induce relaxation.

Improves Cleansing and Circulation: Stress inhibits proper blood flow which is important for

transporting nutrition and oxygen to body cells. Blood circulation also removes toxins and

wastes out of the body. Lower limb massage reduces stress and facilitates unimpeded blood flow

throughout the body.

Facilitates Homeostasis: It occurs when our body systems work harmoniously to produce

balance and good health. A relaxing lower limb massage can facilitate homeostasis and optimum

functioning of the body systems.

Lower limb massage removes blockages: to enable proper energy flow throughout the body.

This can give you more energy and vitality to perform daily tasks.

124

Enhances Immunity: Another ill-effect of stress is that it reduces immunity by taking a heavy

toll on body and mind. Lower limb massage heals and relaxes our body and mind, and protects

against stress-related ailments.

Feel Sensual Bliss: A sensual lower limb massage can be the soothing. Rubbing feet in a,

relaxing and sensual manner will improve comfort.

Lower limb Massage is used in sports to break down adhesions (deep friction) reduces swelling

and oedema in muscles. Massage will aid relaxation and reduce swelling and oedema. Lower

limb massage helps to induce deep relaxation, avoid foot pain and reduces physiological leg

edema.

When is lower limb massage done?

It can be done at any time of the day

It is more effective when it is done in the evening or at night before retiring to bed.

Massage technique

Joints of hands and legs: Rotation movement

Hands and legs: From up, downward, with the flow of muscles.

Use long strokes on the limbs (arms and legs) and circular strokes on the joints

Finger walking: dorsum of the foot.

Thumb walking sole of the foot

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Instructions:

Dear participants

You are requested to clean the legs with soap and water and dry it with clean towel and

be in a comfortable position either in sitting or lying down.

Take two comfortable deep breaths.

Take light food half an hour before the foot massage.

Researcher will massage your foot for 30 minutes.

Researcher uses soft, gentle strokes while giving foot massage.

Avoid emotions like frustration, anger, and irritation during the foot massage and keep

yourself calm and free from mental stress.

If you feel any discomfort during the massage you are free to communicate with the

researcher about it.

Do not bath immediately following the foot massage.

After completion of foot massage rest for at least 15 mintues.

Step 1:

The researcher starts by massaging the pressure points on the soles of the foot. Then applies

pressure lightly on the middle of the sole for 2 mintues to relax the whole body.

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Step 2: Lower 2/3rd of the tibia

Massage from the lower 2/3rd of the tibia to dorsum of the foot and toes for five times and stretch

and pull the great toe gently and rub each side of the nail.

Step 3: Medial malleolus

The researcher applies gentle pressure on both sides of the heel below the ankle joint, followed

by circling around the ankle joint with both tip of thumb in a clockwise and anti clockwise

direction. This improves circulation and the energy level of the body.

Step 4: Dorsum of the foot

The researcher uses fingers walking forward in a crawling movement similar to a worm

from the dorsum of the foot till the ankle for five times and then the thumb running

backward movement starts from the ankle towards the toes for five times. This

promotes circulation and improves venous return.

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Step 5 : Lower 2/3rd of the tibia and dorsum of the foot

The researcher uses small circular motion to massage the lower the 2/3 rd of the tibia till

the dorsum of the foot for five times.

Total duration of lower limb massage is 15 minutes in each leg for 30 minutes. The researcher

administer this foot massage twice (morning and evening) a day for the five consecutive days.

Conclusion

Lower limb massage is an alternative therapy. Slow and light massage should be preferable for

pregnant mothers. Man is considered as an inverted tree. Foot massage help in the locomotion or

easy movement, feasibility of body, reduce stress and depression, helpful in the activation of

immunity, promotes sleep and prevents insomnia, and reducing edema.

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4(b) Manuscript in Kannada

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ANNEXURE 5

5(A) Certificate Of English Editing

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5(B) Certificate Of Kannada Editing

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ANNEXURE 6

LIST OF EXPERTS WHO VALIDATED THE TOOL

1) Dr.Swetha Reddy

Obstetric and Gynaecological Department(MBBS, MD,DNB)

St.Philomena’s Hospital, Bengaluru

2) Dr.Anitha David

Obstetric and Gynaecological Department(MBBS, MD,DNB)

St.Philomena’s Hospital, Bengaluru

3) Dr. Shylaja

Obstetric and Gynaecological Department(MBBS, MD,DNB)

St.Philomena’s Hospital, Bengaluru

4) Mrs. Gayathri

Assistant professor

St. John’s college of Nursing

5) Mrs. Mary Ann Washington

Nurse Researcher

St. John’s Researcher Institute, Bengaluru

6) Mrs. Sonam Maclay

Nurse Researcher

St. John’s Researcher Institute, Bengaluru

7) Mrs.Vrigin Mary

Nurse Researcher

St. John’s Researcher Institute, Bengaluru

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8) Mrs. Kamala

Assistant professor

KIMS

9) Mrs.Alma Juliet

Assistant Professor

St. Martha College of Nursing

10) Mrs. Balakshimi

Professor

Oxford college of nursing

11) Mrs. Sangeetha

HOD of Obg

Ramiaya College of Nursing

12) Mrs.Teena

Assistant professor

Ramiah College of Nursing

13) Mrs. Swathy

Assistant professor

T. John College of nursing

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ANNEXURE 7

FORMULAE FOR STATISTICAL ANALYSIS

1 . Mean : ∑ X

N

2) Standard Deviation : SD

S= ∑ (x – x)2

n-1

3. Karl Person’s correlation co-efficient Formula:

4. Paired t-test :t = ∑d

n(∑d 2) - (∑d)2

n-1

5. Degree of freedom df = ( n -1)

2r

1+r

r 1 =

∑ ( x - x ) ( y - y )

r =

∑ (x - x )2 ∑ (y – y )2

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6 . Chi square test :

ꭓ2 = ∑ ( O- E )2

E

ꭓ2 = ∑ ( | O- E| -0.5)2

E

Where , O = Observed frequency, E = Expected frequency