Use of Symbolism in Death of a Salesman :: Death of a Salesman Essays

   Arthur Miller is recognized as an important and influential playwright, not to mention essayist and novelist. Although he has had plenty of luck in his writing career, his fame is the product of his ingenious ability to control what he wants his readers to picture or feel. As one of his critics states, "Miller writes ingeniously, conveying the message that 'if the proper study of mankind is man, man's inescapable problem is himself (Broussard, 306).'" Miller accurately puts into words what every person thinks, feels, or worries about, but often has trouble expressing. By the use of symbolism, Arthur Miller portrays Willy's (along with the other Lowmans') problems with family life, the society, and himself in Death of a Salesman. Arthur Miller is an interesting author in the sense that many of his plays reflect or are a product of events in his life. He was born in 1915 in New York City and was the son of a successful businessman, up until the Great Depression when his father lost most of his wealth. This greatly impacts Miller's life, and influences the themes for many of his future writings. To make ends meet at home, Miller worked as a truck driver, a warehouse clerk, and a cargo-mover; consequently, these odd jobs bring him close to the working-class type people that will later be the basis of many characters in his plays. It is while he is involving himself in these jobs that Miller forms his love for literature; he is greatly impressed by Fyodor Dostoevski's The Brothers Karamazov because it questions the unspoken rules of society, a concept he often wondered about, especially after the Great Depression. He believes that American society needed to be made over; for this reason, many of his earlier plays show sympathetic portrayals and compassionate characterizations of his characters. In 1956, Miller marries the eminent Marilyn Monroe. This event significantly affects his writing in that he focuses on female characters more than he had formerly. He also looked back at his prefigured themes in past stories and expanded or reconsidered them (Martin, 1336-7). Clearly, the roots of his works are the result of important events from his past experiences. Death of a Salesman is a play relating to the events leading to the downfall of Willy Loman, an aging salesman who is at one time prosperous, but is now approaching the end of his usefulness (Atkinson, 305).

Classic 45c Notes

* Female by nature, not by law†¦are supposed to be obedient†¦ruled by men†¦there’s something unnatural about what Antigone is doing†¦. * This play is about gender also * Ismene =ideal woman * Women should be silent and Ismene voices that * Women should be sensible, should be ruled by men * Greek audience at the time is supposed to hate Antigone * Creon he wants to see himself as voicing the opinions of the gods†¦ Antigone also says that she’s working for the divine†¦and that complicates things * Creon stands for the city He aligns his authority with the authority of the gods * He doesn’t think of himself of going against the gods * He has taken over and summoned the people and asked them how he rules†¦.. how does he rule? Notice how he likes public speaking! When the city is suffering†¦. when the city is in trouble, you shouldn’t be silent * The city is at this point in a kind of danger that Creon does not see yet. H e will see it later on†¦. if the city is suffering he wants the people to speak up and take action†¦. he’s not talking about Antigone of course†¦. but she’s doing just that†¦. Loyalty is to the state! Not to another human being! * And yet at the end of the play, to whom does he show loyalty HIS SON * These are his values and he does not abide by his values†¦ * It is not in a way family vs. state†¦. it is family vs. Creon state†¦. this is the state that Creon is organizing†¦.. why does this state have to fall? Not state in general†¦. keep that in mind†¦ * He wants us to see the proclamation coming up is in harmony†¦.. he’s inviting us to see the proclamation: Eteocles will be buried in his grave while Polyneices will not be buried†¦. he is not to be mourned†¦.. Creon uses the future ( Eteocles SHALL BE BURIED†¦Ã¢â‚¬ ¦) * Antigone uses the past * Another thing we noticed is the cruelty of the ki ng ( you shall watch him chewed up )†¦something that we see rot, devoured, we see the body, he doesn’t belong with the living †¦. or the dead†¦what happens when the body becomes food for the animals * The idea that we’re supposed to watch someone rot, take delight in it†¦. * Someone is going to violate the proclamation, we don’t know who is the criminal†¦we are looking for the identity of the person who has violated the law†¦. what is the crime It looks almost miraculous, someone sprinkled dust over the body and buried it without leaving any marks†¦.. or traces†¦as if the body was visited from above * Chorus wonders if it’s the god’s doings†¦Ã¢â‚¬ ¦and Creon loses it when the Chorus says that! * Here’s Creon is arrogant, how can a man know what the gods want? * Both characters act in a way that they think the gods want them to do†¦. * Creon thinks he’s doing all this to please the gods Creon cannot believe that Antigone did the burial†¦. She is his niece and a woman! :O Notice that he’s interrogating and asking for the truth just like Oedipus * Nature is assisting Antigone†¦. ature participates in the events†¦mimicking what Antigone was gonna do with her own hands.. * The dust rising†¦Ã¢â‚¬ ¦she was about to finish the ritual but then someone removed the dust off the body the second time she visited the body * Why does Antigone abide by the laws of the gods? They are there forever†¦. * Human laws like everything human, are subject to change * Antigone is basically saying Creon’s worthless cause once someone comes after you to rule, things will change * Antigone’s demise and Creon’s demise * Both will have terrible ends Creon thinks that he has supreme power over her, and that power is to kill her†¦. according to the proclamation, whoever †¦they will be stoned to death in public,†¦fate given to he r by man†¦. gender roles is very important * Antigone tries to weaken his powers by put down his laws†¦. saying that his laws are not strong as the gods cause they were there forever†¦whereas his laws are only in effect in his reign†¦. that is one way * Second way is saying that I know I will die†¦. even if you are not the one putting me to death, I will die anyways†¦.. by saying that, she is robbing away of his power†¦. ssentially Creon is only a guy killing her†¦but her death is just gonna come to us†¦. death is part of the universe†¦what makes a difference is that we die naturally or someone is killing us†¦. * And creon’s reaction to antigone’s words is that he’s being lectured by a woman†¦ * Creon’s the man, so therefore he needs to teach this subordinate woman how to behave†¦. * He seems to think that whatever he believes is what the gods and how their people want†¦. identifies the ir wishes with what they think others wishes also * Ismene comes out, shy, obedient, at the end of theplay changes her mind and wants to die with Antigone†¦.. he had a real change of mind namely she saw that what she wanted in the beginning of the play when she was called cowardly†¦. her decision is as cowardly now namely that now she wants to be accused of the burial †¦is that she doesn’t want to be left alone†¦ * LONLINESS†¦. that’s another theme of the play * Antigone enjoys the support of the citizens but dies alone in a tomb * Creon is loathed by his citizens and is also alone when his family is no longer alive†¦he is ruling a kingdom and no one respects him†¦thought to be a corrupt king * Ismene doesn’t want to be alone†¦.. Creon changed his mind so that DEATH is killing her†¦and not him†¦so DEATH will kill Antigone and not Creon himself and that is an act of cowardice†¦. some of the characteristics tr ansfer to other characters * Haemon and exchange between father and son * Antigone is very much the daughter of Oedipus†¦.. Antigone and Haemon never talks†¦or interacts†¦. they never will come together†¦so son goes to talk to his father * What seems to matter to Creon more than anything else is obedience†¦power relationships†¦someone is obeying someone else†¦. e demands obedience from his sons and his subjects†¦ruling both state and family in the same way†¦. he does not differentiate the family and the state†¦.. in EVERYTHING†¦. small and just things and unjust things.. bigs.. that is the problem†¦. it is NOT family vs. state! It’s actually family vs. tyranny / Creon’s state†¦. * Is Creon disobedient? Does he violate his own principle? Yes he is disobedient to himself to his own proclamation†¦. this is to be contrasted to Oedipus†¦Ã¢â‚¬ ¦what Creon does when Tiresias comes forth†¦.. he cha nges his mind and does something different†¦. he actually tries to save Antigone to which he has condemned her†¦.. Creon thinks that both his family and city as his possession * He does rule the land at someone else’s judgement in the end†¦. by Tiresias †¦.. CONTRADICTIONS AND INCONSISTANCIES†¦. * He is not changing his principles†¦. but the change in action was for personal gain! Had he saved in Antigone, it’s doubtful for him to change his ruling if she even lived†¦. * Unmarried women are put to death in marriage gown†¦.. marrying dead kind of a ritual and so Antigone’s addressing the tomb as the bridal chamber†¦.. she’s having sex with Death, that’s her husband from now on.The idea is that DUE BRIDAL CHAMBER†¦already an emphasis on DEATH, not Haemon†¦ * To die if she so wishes or live†¦. how can she live?! SHE CANNOT LIVE†¦. she does NOT wish to die!!†¦. Creon wants a clean co nscience†¦. he makes it sound like whether Antigone dies or lives, it is up to her or the gods, he has nothing to do with it†¦.. * Antigone put in the tomb, locked inside, left there to die†¦. Polynices and he is not in his tomb†¦notice the unnatural of things†¦a living person taken into tomb†¦. not dead yet†¦a corpse is left outside left to rot†¦Ã¢â‚¬ ¦ * Rituals are important the gods will not listen to the chorus cause of Creon’s past * protecting, shielding himself!†¦ he wants to keep Haemon so he can stay in his throne†¦. not for the sake of his son, it’s for himself†¦ * they might belong to different realms cause Creon does not see what’s going on inside the cave/tomb * Haemon is embracing Antigone, and Creon is asking him to join his father†¦. he would be saying bye to Antigone and joining the father, and also joining the political succession of his father and no love†¦. so what does he doâ € ¦he attempts to kill the father with his swords but fails†¦and cannot touch the father†¦. o far away and even the attempt fails,†¦so the father is still the king and Haemon †¦.. he no longer belongs to anyone†¦. disowns his father†¦. he does not belong with death yet†¦. he leans on the sword (phallic symbol) and kills himself†¦. FULFILLMENT of marriage †¦.. sexual union with Antigone†¦. sword is the phallic that enters him†¦blood is of the woman†¦.. once blood starts coming out, blood drops fall on her white cheeks, break of hymen†¦Ã¢â‚¬ ¦. Antigone has never been touched by anybody†¦. Haemon’s body receives the wound * Eurydices kills herself with a knife and Creon is alone Political situation in france in the play * Think about nazi, jews, money, greed, later on before she dies (ring) * Who is the hero? Who is the villain? This makes it harder for us to pinpoint who is who†¦. * Antigone’s stubborn = French resistance * A lot of emphasis on childhood, beauty, purity * Many people who read anouilh’s play doesn’t like her * she goes back and forth a lot * METATHEATER : beyond the theater, outside the theater, something that goes beyond it * watching a play; any kind of comment about the play, about what’s going on†¦second look at what’s going on†¦. Prologue is a character that tells us what is going to happen * Chorus tends to delay, more of a commentary on the action itself†¦ similar function to the prologue in this play * Prologue is commenting on the roles of the characters, basically introducing us to the main actors, he is talking about the situation†¦.. * Page 4: Prologue gives us that insight into Creon’s soul: sensitive man, someone who doubts his political authority, something very important and different from the Sophocles one * Characters are full of self doubt, is a second level situation†¦looking a t what I’m doing and figuring out what I’m doing†¦.. Function of metatheater? The effect? * Conveys a sense of inevitability as if the characters cannot be anything other than what they are†¦they have been given roles†¦.. assigning the roles and they are going to enact the roles and there’s no escaping that†¦ * The idea that theater and maybe life in a totalitarian regime is more like a play†¦if you live in a state where you can die anytime, your life won’t matter much, might as well go out and have fun†¦.. et’s just do what we have to do and get it done †¦get the job done ( what Creon says a lot) and move on†¦truth of life lies elsewhere†¦.. characters talk about the truth a lot here†¦.. Antigone is kind of like that, but the truth she longs for is an illusion and doesn’t exist and all that she has in her life is what exists, nothing beyond that†¦ Prologue†¦. is just like the Greek gods, a kind of fate†¦. Scene between antigone and nurse Nurse doesn’t exist in the original†¦. have Tiresias but not here†¦ it’s the nurse..We are given a first insight of Antigone†¦. she’s rebellious, not sleeping, she’s out†¦god knows where she is Nurse thinks she’s having a boyfriend†¦yet she’s about to be betrothed to Haemon†¦aristocratic women should not behave this way†¦. there’s all this back and forth between them†¦ The Nurse is perhaps.. IS the example of pure love and care in the play, there’s nothing selfish, impure about her†¦. she’s all about selfless giving to Antigone, cares about her, loves her†¦political outsider, has no role, she’s a servant†¦. nothing to gain from the system†¦.. o you might say that’s what is achieved, introducing kindness and goodness into a world where motives are very much fluid, neither Creon or Antigo ne are good or bad, they are deluded†¦. Nurse is not full of Illusion†¦she loves Antigone Antigone Her famous word is saying NO†¦.. no is a word of a rebel†¦. She says yes to the Nurse†¦affirming a bunch of things to the Nurse even though it’s false†¦. we have a bunch of yeses right after the other. Affirming things to the Nurse, denying things to everyone else†¦WHY? Nurse is someone she trusts, not a political authority†¦.. rusts her and not an opposition to her as she is to everyone else, even her sister One of the things we noticed is that the relationship of Ismene and Antigone and how they are different in here than in Sophocles Ismene still the same in which she is opposite of Antigone, follows rules, obedient She understands where Creon’s coming from, but there’s some other stuff too One of them is the BEAUTY contest†¦. Antigone is physically unattractive and Ismene is physically attractive, and there’s a jealousy thing between the two sisters†¦. Haemon is in between†¦.Antigone steps in and uses Ismene’s stuff to attract Haemon STRESSES Nazi’s term of BEAUTY blonde, blue eyes, and not any way dark skin and stuff Ismene is the resemblance of beauty= German Nazis Antigone= French resistance STRENGTH & WEAKNESS Antigone .. not as beautiful as Ismene apparently Antigone’s love for dirt and mud†¦. has a lot to do with her upbringing, was told to do things in a certain order, she was told to be clean, not dirty†¦. keeping surface clean of mud, cover up the imperfections, not let physical ugliness show†¦. Same applies to strength†¦ Person who says no? erson who says yes? Antigone in this play is IN LOVE WITH LIFE†¦she loved life when she was little, but as she grew up, she realized that the world is really corrupt so now she doesn’t really care about dying and she doesn’t others to touch her†¦does that mean Antigon e is in love with death? NO, not exactly, she is tired of living†¦.. a very young innocent Antigone and now that she is an adult, she doesn’t want the world that she sees in her†¦she js doesn’t want to live IN THIS WAY†¦rejecting REGIME†¦German occupation of France, resisting THAT kind of life†¦ Childhood= paradise†¦. or example Antigone just like in Sophocles play buries her brother twice 1st time she buries her brother= just the sprinkling of the earth†¦.. †are you sure it wasn’t an animal that did it? † animal metaphors †¦. THE SPADE†¦little childhood spade†¦rusty also.. we know that this spade belongs to Polynices children are associated with purity, innocence, all these ideas that the Nurse resembles spade= rusting†¦.. playfulness, innocence, lack of care is gone .. it doesn’t exist. uses this to bury the brother second time, Antigone did it with her bare handsAntigone is very much be having like an animal when she is arrested Creon thinks it might have been an animal the first time She behaves like an animal Why would a girl be like an animal? What’s the association with the animal that ends up being a woman Why bring up animals here? Antigone is very much an adolescent, someone who hasn’t grown up†¦.. her using the spade is a sign of someone clinging to childhood, innocence†¦. the animal means she doesn’t want to enter â€Å"society† Nurse gives her little pet names†¦all of them have to do with birds†¦. alls her dove/sparrow/turtle dove†¦.. so that’s another case in the play where Antigone is thought of as a bird, as a non human, term of endearment used by the bird†¦Ã¢â‚¬ ¦all of them comparing Antigone to a non-human and then we have Creon continuing that later on†¦.. all of these things resemble Antigone as not belonging to society †¦. that and she doesn’t put make up†¦noth ing artificial on†¦sign of clinging to childhood†¦. rejection of artificiality, she’s clean pure, naked†¦.. clings to childhood cause everyone else is an adult * Both Jonas and Antigone are under Creon’s rule Jonas is a guy that says YES†¦doesn’t rebel in any way†¦.. Antigone is the rebel * How does the guards behave†¦. his desire to be on the ruler’s good side†¦promotes himself a lot†¦saying he does his job well†¦. Creon and Jonas are fixated on doing well & being efficient * Creon is very in favor of taking orders and executing†¦Jonas is his subject * Efficiency†¦. every failure was followed by with justifications just in case the king wants to kill you†¦his greed to get more money†¦ * Self promotion, beautifulness, efficiency, desire to be on the ruler’s good side†¦.. nd those are the values that Creon likes and that’s what Jonas displays * We know who did it and now we go to the confrontation between Antigone and Creon * Creon’s obsession with duty†¦. he sees his job as a duty that needs to be executed almost mechanically†¦. Creon has been given the role so he needs to play that role as best as he can†¦it’s all over the play†¦. so a few examples * Creon says that Thebes needs a king with no fuss†¦Ismene’s a sensible person, Antigone’s a irrational person * Creon is the guy that says yes * Antigone’s a person that says no Creon is caring about just DOING THE JOB, doesn’t matter about how it’s done†¦not that kinda guy†¦just DO THE JOB * By doing that, Jonas and Creon is alike * Creon is the lover of CLEANLINESS†¦Antigone is the one that likes to get her hands dirty†¦mud†¦. Ismene is the clean make up etc†¦. make up†¦. Antigone is the natural, and Ismene is not†¦.. * Creon is a practical guy†¦hygiene * **The world is empty of meanin g†¦.. Haemon and Creon are talking†¦Haemon wants someone to look up to, to have values†¦. Creon says that we are alone and the world is empty and you’ve looked up to your father too long * values are what make the world work†¦. ut in the play, if you’re given an order, just go execute it†¦if you want to live and value life, given a task execute that task†¦ * next: keeping quiet†¦is what Ismene shows in both plays†¦. * Creon here does not believe in the gods in this play†¦. he thinks the gods are him in this play†¦absence of the divine completely†¦. gods are actually being ridiculed * Creon: be practical†¦don’t waste time†¦. get married have kids live a happy life and then die * One of the THEMEs: NEGATIVITY†¦fact that she says no all the time†¦. * Antigone thinks she’s the best thing in a corrupt world†¦she will only love a Haemon that is like her†¦

Newborn Fatality And Midwifery - Free Essay Example

Sample details Pages: 18 Words: 5388 Downloads: 8 Date added: 2017/06/26 Category Health Essay Type Analytical essay Did you like this example? CHAPTER-I INTRODUCTION à ¢Ã¢â€š ¬Ã…“Every child born into the world is a new thought of god an ever fresh and radiant possibilityà ¢Ã¢â€š ¬? -Kate dauglas Wiggin Health is the most important, sought-after thing in the world by all, no matter who we are, when well- cared for their earliest years, children are more likely to survive grow up the first month is crucial importance, in terms of health care. The health of women and children is the basis of a healthy family and a healthy nation. This is particularly true of children whose healthy future depends on proper care during the first year life (UNICEF, 2002).Newborns are the blessings for today and tomorrow. Don’t waste time! Our writers will create an original "Newborn Fatality And Midwifery" essay for you Create order The newbornà ¢Ã¢â€š ¬Ã¢â€ž ¢s body is most supersensitive, delicate, immature and susceptible from which can easily harmed if not taken care of newborn. The birth of a baby is an event a moment which creates a great joy and wonder of godà ¢Ã¢â€š ¬Ã¢â€ž ¢s gift, a gift of god in the life of parents. From the moment of birth, many parents are loved to involve in the care of the newborn. The first care given to a neonate include placing him/her in a warm environment , suctioning the oropharynx and nose , cleaning the eyes , clamping and cutting the cord ,checking the weight , tying the identification tag and mummifying the baby. First time the mother smiles when the newborn is cry and she forgets the pain. The newborn, once separated from the mother in the process of delivery, undergoes certain fundamental changes in which he/ she leaves the sterile environment of the uterus and moves into the outside environment .This separation occurs through the severing of the umbilical cord. Afte r birth, the cord is no longer needed, and is cut, leaving a short stump Behind on-pathogenic bacteria such as coagulate à ¢Ã¢â€š ¬Ã¢â‚¬Å"negative staphylococci, e-coli, and streptococci, clostrium tetani may also be present on the skin and can track up the umbilical stump causing infection (ZUPAN et a l à ¢Ã¢â€š ¬Ã‚ ¦, 2005). The UNICEF report released at the National conference on child survival and development in New Delhi, claims that out of nearly 26 million children born in India each year, 1.2 million die during the first 4 weeks .This is the 30% of the 3.9 million global neonatal deaths. According to current report (neonatal mortality) of 44/1000 live birth accounts for nearly 2/3rd of all infant deaths (death before the age of one) and nearly half of under à ¢Ã¢â€š ¬Ã¢â‚¬Å" five children deaths in India. Indiaà ¢Ã¢â€š ¬Ã¢â€ž ¢s NMR significantly from 69/1000 live births in 1980-50/1000 à ¢Ã¢â€š ¬Ã¢â‚¬Å"live births in 1990 .In recent years NMR has remained static onl y dropping four points from 48-44/1000 live birth in 1995 and 2000. The main causes of neonatal deaths are low birth weight and infections (Indian express, 2004). One million newborn infants die every day by multiple of organisms which often enter in to the body via the umbilicus. The other contributing causes of umbilical cord infection includes maternal factors like maternal infections e.g. amionitis, repeated vaginal examinations during labour, duration of rupture of membrane, unhygienic practice of delivery, delivery conducted by untrained dais, environment factors like cleanliness of the ward and caregiver with severe infection, upper respiratory infection and neonatal factors like small for gestational age, preterm newborns ,birth condition during labor like me conium stained liquor, umbilical cord infection had caused many neonatal death before aseptic technique were used .In developing countries umbilical cord infections constitute a major cause of Neonatal morbidity and pose significant risk for mortality, in the environment as the umbilical outbreaks of cord infection continue to occur even in developed nurseries (Zupan et al 2000). The hospitalized neonates may get infection from various sources like tube feeding, unhygienic cloth, avoidance of baby bath, using many cosmetics, etc. Environment as the umbilical cord is a means of entry for systemic infective agents that colonize the skin of the newborn. Umbilical cord is the only route of entry for microbes, because it has opening in the umbilicus, even though the cord clamp was there in the cord It is therefore essential to keep the cord clean to prevent infection and promote a normal healing until the stump dries up and falls off by giving umbilical cord care during the transition period. SIGNIFICANCE OF AND NEED FOR THE STUDY In midwifery practices, the newborn care is an important aspect and the kind of care and attention given immediately after birth and later is greatly valued. Umbilical cord care is very important since infections of the cord can be so fatal that it may even lead to the death of the neonate. Despite the importance of umbilical cord care, both traditionally and medically, there have been few randomized trials investigating the impact of different cord care regimen on rates of local or systemic infections, particularly in developing countries (Mullany et al 2003) Also, nursing studies and literature pertaining to the care of umbilical care relatively limited and the procedures adopted for umbilical cord care is varied. The present study intends to investigate the effectiveness of lukewarm water application on the umbilical cord of newborns in terms of occurrence of umbilical cord infection. Bain (1994) undertook a study to find the effect of four different cord care regimens in pre term babies. The evidence of the trail suggested that cleaning the cord with alcohol, wiping and dusting with sterzac powder resulted in less cord related infection and a shorter time for cord separation compared to any other cord care regimen. All these conclusive evidences prove that the policy of leaving umbilical cords untreated is not a safe practice. In many studies reported clean the umbilical cord with warm water compare than antiseptic solution. Antiseptic solution may cause delay in healing and form the pus (NNT 2010). Zupan and Garner (1998) carried out a study on the effectiveness of topical agents for umbilical cord care to prevent cord care infection, illness and death in newborn infants in developed countries. They have included newborns of any gestation, using any of the following interventions à ¢Ã¢â€š ¬Ã¢â‚¬Å" topical antiseptic applications. Clean with warm water, Including the newborns who were born outsides well as inside the hospital, the incidence of umbil ical sepsis was2001-10 cases,2002-24case,2003- 19 cases.,2004( Jan out) -15 cases. Early onset of neonatal sepsis is clinically apparent within 72 hours of life , with an overall mortality rate of 15-50% .Late onset neonatal sepsis is usually present after 72hours of life and includes nosocomially acquired infections .The overall mortality rate of late onset sepsis is 10-20% Bobak et al (1995).The UNICEF report released at the National conference on child survival and development in New Delhi, claims that out of nearly 26 million children born in India each ye1.2 million die during the first 4 weeks .This is the 30% of the 3.9 million global neonatal deaths. According to the current report (neonatal mortality) of 44/1000 live birth accounts for nearly 2/3rd of all infant deaths (death before the age of one) and nearly half of under à ¢Ã¢â€š ¬Ã¢â‚¬Å" five children deaths in India. Indiaà ¢Ã¢â€š ¬Ã¢â€ž ¢s NMR significantly from 69/1000 live births in 1980-50/1000 à ¢Ã¢â€š ¬Ã¢â‚¬ Å"live births in 1990 .In recent years NMR has remained static only dropping four points from 48-44/1000 live birth in 1995 and 2000.India contributes to 20% global birth and highest number of neonatal death within a country, each year, 26 million infants are born in India of these 1.2 million die during the neonatal death period before completing the first four weeks of life. Two newborns deaths occur every minute in this vast country. The current neonatal mortality rate (NMR) is around 40/1000 live birth of less than five mortality rate. Between 1995and 2000, there was only a legible decrease 4 points in NMR à ¢Ã¢â€š ¬Ã¢â‚¬Å" from 48-44/ 1000 live birth. The tapering off the rate decline is a cause of concern requiring serious planning and newer strategies. The main causes of neonatal deaths are low birth weight and neonatal infections; maternal infections (Indian express, 2004). One million newborn infants die every day by bacterial infection which often enters the body vi a the umbilicus. The other contributing causes of umbilical cord infection includes maternal factors like maternal infections e.g. amionitis , repeated vaginal examinations during labour, duration of rupture of membrane, place of delivery, environment factors like cleanliness of the ward and caretaker with URI , technical factors like method of cord care , hand washing technique, and transfer of infant and neonatal factors like gestational age, birth condition during labor , umbilical cord infection had caused many neonatal death before aseptic technique were used. In developing countries umbilical cord infections constitute a major cause of Neonatal morbidity and pose significant risk for mortality, in the environment as the umbilical outbreaks of cord infections continue to occur even in developed nurseries (Zupan et al 2000). The traditional practices of cord care in this area include application of hot fermentation (31.5%), use of rag and latern(19.5%), use of Vaseline (9,5%) , ash/charcoal(9.3%), groundnut/palm oil (8.3%), use of powder (6.5%),and red sand (3.5%), These practices are harmful because these substances are often contaminated with bacteria and spores, thus increasing the risk of infection.(Konduga local government area of born state-2005) Traditional nursing procedures are being gradually substituted by more modern Practices. As technologic advance, Nursing practices also change. As many routine procedures like predelivery perineal shave, predelivery enema are questioned, the efficacy of the antiseptic solution usage for umbilical cord care has also become a question and a study is necessitated through comparing the existing practices with the key outcomes .Therefore, the investigator strongly felt need to do study, comparing the use of antiseptic solution with lukewarm water for umbilical cord care in order to find out the effectiveness of lukewarm water. STATEMENT OF PROBLEM An experimental study to evaluate the effectiveness of umbilical cord care using lukewarm water among newborns in selected hospital at Madurai district. OBJECTIVES To assess the umbilical cord after cord care experimental group and control group. To compare the effectiveness of cord care experimental group and control group. To find the association between experimental group with selected demographic variables To find the association between control group with selected demographic variables. HYPOTHESIS There will be significant difference between experimental group and control group after cord care. There will be significant association between experimental group with selected demographic variables. There will be significant association between control group with selected demographic variables OPERATIONAL DEFINITION Effectiveness In this study it refers to the outcome of an experimental study indentified with help of significant difference between tests among newborns. Newborn In this study it refers to the period from birth to28 days of life is called period and the infant in this period is termed as neonate or newborn baby. Umbilical cord care with lukewarm water In this study it refers to warm water with a degree of 70-97à ¢Ã¢â‚¬â€Ã‚ ¦f or 26-36à ¢Ã¢â‚¬â€Ã‚ ¦c to clean the umbilical cord and the cord is left dry and open. ASSUMPTION Application of lukewarm water will prevent infection of the umbilical cord. Application of lukewarm water it promotes early healing of umbilical cord. DELIMITATIONS `The study is limited to the newborn of the mothers who had LSCS. The study is confined to selected hospitals. PROJECTED OUTCOME The result of the study would help the investigator to identify the effectiveness of cord care using lukewarm water among newborns. The study will help to promote a early healing of the umbilical cord and to reduce the infections. The findings on demographic variables would help to identify the factors which affect the newborns with infection CHAPTER-II REVIEW OF LITERATURE Review of literature is an important, essential aspect of scientific treatment .It involves the systematic identification, location scrutiny and summarization of the written material that contains information on a research problem. It broadens the understanding and provides the insight necessary for the development of a broad conceptual context into which the problem fits (polit hungler, 1995). A review of related research and non- research literature was undertaken and an attempt was made to organize the materials. This includes Umbilical cord care Review on studies related to umbilical cord care using lukewarm water Review on studies related to cord care. UMBILICAL CORD CARE Umbilical cord Inspect the Umbilical cord area for the correct amount of blood vessels, two arteries and one vein. The umbilical vein is larger than the umbilical arteries. A yellow à ¢Ã¢â€š ¬Ã¢â‚¬Å" brown or green tinge to the cord indicates the me conium was released. The umbilical cord should be checked for bleeding or oozing during the early hours after birth. The clamp must be securely fastened with no skin caught and tissue injury. Pathophysiological background The umbilical cord is a tissue, which of consisting of two arteries and one vein covered by a mucoid connective tissue called Whartons jelly and a thin mucous membrane. During pregnancy, the placenta supplies all nutrients for fetal growth and development and removes waste products. Blood flowing through the cord brings nutrients and oxygen to the fetus and carries away carbon dioxide and metabolic wastes. After birth, until the placenta separates and while the cord is still pulsating, a small volume of blood may be transfused from the placenta to the newborn. The amount transfused depends on when the cord is cut and the level at which the baby is held in relation to the mother at the time of cord clamping Umbilical cord healing process The cord darkens and shrivels as it dries and falls off within 7-14 days. The cord should be dry and not have any drainage. After the cord falls, a small pink, granulating area about a quarter of an inch in diameter may remain. This should also be left clean and dry until it has healed (about 24- 48 more hours). umbcord Umbilical cord infection In umbilical cord if the ulcerous area has remained as long as one week it indicates of sign of infection. Source of infection Unhygienic environment of delivery Contaminated cord cutting instrument Infected hands of care giver or infected clothing Causative organisms Staphylococcus E-coli Clostridium tetani Signs and symptoms Swollen and moist per umbilical tissue with redness Foul smelling Serous or purulent discharge Delayed falling of umbilical cord Fever Management Umbilical cord should leave uncovered rather than application of dressing. Systemic antibiotic is given in complicated cases. Complication Jaundice Hepatitis Peritonitis Umbilical granuloma Prevention Aseptic technique and clean practices at birth. Administration of tetanus toxoid to antenatal mothers. Prognosis Prognosis depends upon the nature of infection, intiation of management and nursing care. Prevention of umbilical cord infection is more easy and important in neonates. Cord care DOà ¢Ã¢â€š ¬Ã¢â€ž ¢s and DONTà ¢Ã¢â€š ¬Ã¢â€ž ¢S Doà ¢Ã¢â€š ¬Ã¢â€ž ¢s Cut the cord with a clean instrument. Tie the cord tightly with clean or sterile thread or clamp. Tie napkin or diaper below the umbilical cord. Donà ¢Ã¢â€š ¬Ã¢â€ž ¢ts Bandages are unnecessary and may delay in cord healing and introduce infection to the newborn. Alcohol cleaning may delay in healing and cause pus. Apply traditional remedies to the cord may cause infection World Health Organization,  (1999) Current standards of cord care is based on the principles of aseptic techniques. The aim of WHO to prevent the cord infections. However, the introduction of infection in neonatal care unit and well baby clinic for newborns in hospitals in the 1940s increased the risk of staphylococcal skin and cord infections by facilitating the spread of bacteria among infants in hospital. Clean the cord at birth and in the days following birth is effective in preventing cord infections and tetanus neonatrum. Clean cord care practices at birth include washing hands w ith clean water and soap before delivery and again before cutting and tying the cord, laying the newborn on a clean surface and cutting the cord with a sterile instrument and sterile clamp. Clean cord care in the postnatal period includes washing hands with clean water and soap before and after care and keeping the cord stump dry and exposed to air or loosely covered with clean clothes. If soiled, the cord should be washed with clean warm water (cleaning with alcohol seems to delay healing). The napkin should be folded below the umbilicus. REVIEW RELATED TO CORD CARE USING LUKEWARM WATER Kimberly Dow,(2010 ) reported news about the umbilical cord, After the umbilical cord is cut at birth, a stump of tissue remains attached to the umbilical cord. The cord will dry and shrinks. It is important to keep the umbilical cord stump and surrounding skin clean and dry. This cord care helps to prevent infection. It may also help the umbilical cord stump to fall off and the cord to heal 90% more quickly; gently clean the umbilical cord once a day. Soak a cotton swab in warm water. Squeeze out the excess water. Gently wipe around the sides of the cord and around it. Wipe away any wet, sticky, or dirty substances. Gently pat dry the area with a soft cloth. The stump usually falls off in a week or two but sometimes it takes longer. Continue to clean around the umbilical cord at least once a day until the cord has completely healed. Keeping the area Wyeth (2010) reported news about the umbilical cord. Keep the stump of the umbilical cord clean and dry until it falls off, which usually happens within a few weeks Clean the cord at each napkin change to help to dry out and to prevent entry of infection Wipe gently around the cord with a damp cotton swab .Keep the napkin folded below the navel area to keep the cord from being soaked with urine. Evidence-based clinical practice guidelines(2010) was reported about umbilical cord Sometime between five and 15 days after birth, the cord will dry up, turn black and drop off, leaving a small wound that may take a few days to heal. It must be kept clean and dry to prevent infection. Harmful bacteria that live naturally on the skin can enter in to the cord causing infection. Avoid the traditional practice of taping a coin to retract the belly button as it may encourage infection and delay the healing process. Avoid the cord stump getting urine by folding the napkin down away from it, leaving the cord exposed to the air. If the cord gets urine, wash it off using clean warm water or just water alone. When the stump f alls off, it may shows of signs of little blood on the umbilical cord which is normal. In the past, cord stumps have been cleaned with antiseptic tissues or sprinkled with an antiseptic powder. Studies of the healing process have found no advantage to using antiseptics over simply keeping the cord clean, unless the baby is premature or in intensive care. Antiseptics also cause the cord to take longer to fall off, which causes anxiety to parents and increases the number of postnatal consultations with doctors. Satish Chandra. V.Naik etal (2009) in pune, study was to conduct impact of training of traditional birth attendants on the newborn care. The setting of the study was PHC, 45 TBAs attended 2 days training programme. Different AV- aids were used to interact the sessions by LCD, flipcharts, videoclipings. Pretest evaluation showed that there was a difference in the depth of knowledge regarding newborn care between previously trained tai and untrained tai .this difference was st atistically difference p(0.05). Umbilical cords assessed by 2 methods clean with warm water and application of herbal preparation. The results in pretest for trained TBA for warm water 17(85%) post test 19(67.8%) and application of herbal preparation for untrained TBAs pretest 26(86.6%) post test 19(67.8%). In this study the practice of keeping the umbilical cord stump clean and dry, progressively improved from 15% and 53.3%and0-52% among warm water and application herbal preparation. It reported a 25% in reduction of NMR (NNT)* Luke C Mullany.g.etal (2009) reported a study was to conduct cluster-randomized, community-based trial to assess the impact of three cord care regimens either A large community-based trial in rural southern Nepal conducted between 2002 and 2006 randomized babies within clusters to receive one of three cord care regimens: (1) 4.0% chlorhexidine cleansing for 7 of the first 10 days after birth or (2) soap and warm water cleansing for 7 of the first 10 days after birth, or (3) dry cord care. Overall, mortality among enrolled infants was 24% lower in the chlorhexidine group compared to dry cord care. Clinical evidence of a protective of warm water cleansing among this newborns subset was increased. Warm water cleansing reduced severe infection by 87% and mortality by 34% among those enrolled within 24 hours. Alam .M. Ali .etal (2008) in Bangladesh, the study conducted by cluster- randomized. Unstructured interview (n-60), structured interview (n=20), rating and ranking exercises (n=40),83% of umbilical cord care revolved around the bathing. Over all 40% of newborns are clean with warm water during newborn age of period only 9% of reported of infections and other application of cord care (83%) of reported of infections. Jane heiza in health and safety (2008) reported news about the umbilical cord is cut at birth, a stump of tissue remains attached umbilical cord. The stump gradually dries and shrivels until it falls off, usually between 1 and 2 weeks after birth. Gently clean umbilical the cord stump and the surrounding skin at least once a day and as needed during diaper changes or baths. Soak a cotton swab in warm water. Squeeze out the excess water. Gently wipe around the sides of the stump and the skin around it. Wipe away any wet, sticky, or dirty substances. Gently pat dry the area with a soft cloth. The stump usually falls off in a week or two but sometimes it takes longer. Continue to clean around the cord at least once a day until the cord has completely healed Medves JM, OBrien BA.etal (2008) reported study was to identify differences in time to cord separation and bacterial colonization when using alcohol or warm water to clean the cord area in healthy newborn infants. Randomized controlled trial designed was selected. 148 newborn infants who were enrolled within 3 hours of birth. Gestational age was 36.7 weeks and all infants had an Apgar score of à ¢Ã¢â‚¬ °Ã‚ ¥7 at 5 minutes. Follow up was 92%. Parents were shown a video on cord care that was developed for the study. Parents applied warm water. Cleaning with 95% alcohol did not reduce umbilical cord separation time. 95% of warm water groups had reduces the infection and early healing of cord. Khatry .C.Mullany .etal (2005) in Nepal, conducted a study on the impact of umbilical cord care. The selected sample is 15123 infants were assigned randomly selected within communities, the following 3- cord regimens: cleansing with 4.0%, cleansing with warm water. The mean separation time wa s shorter in warm water (4.25days) and in chlorhexidine (5.23days). Janssen PA, Dobson. R.etal (2003) reported study was to compare cord bacterial colonization and morbidity among newborns whose cords were treated with triple dye and alcohol versus warm water. The investigator was randomly allocated 766 newborns to either 2 applications of triple dye to the umbilical cord stump on the day of birth with alcohol swabbing twice daily until the cord fell off (n = 384) or warm water cord care (n = 382). hemolytic streptococcus and coagulase-negative staphylococcus. Infants in the dry care group were significantly more likely to be colonized with Escherichia coli (34.2% vs. 22.1%), coagulase-negative staphylococci (69.5% vs. 50.5%), Staphylococcus aurous (31.3% vs. 2.8%), and group B streptococci (11.7% vs. 6.0%). Community health nurses were significantly more likely to observe exudates (7.4% vs. 0.3%) and foul odor (2.9% vs. 0.7%) among infants allocated to the dry care group during the home visit. Patricia A. Barbara L .etal (2003) reported study was to compare cord bacterial colonization and morbidity among newborns whose cords were treated with triple dye and alcohol versus warm water cord care. The sample was randomly selected 766 newborns to either 2 applications of triple dye to the umbilical cord stump on the day of birth with alcohol swabbing twice daily until the cord fell off (n = 384) or dry care (n = 382). The umbilical stump was colonized with {alpha}-hemolytic streptococcus and coagulase-negative staphylococcus. Infants in the warm water group were significantly more likely to be colonized with Escherichia coli (34.2% vs. 22.1%), coagulase-negative staphylococci (69.5% vs. 50.5%), Staphylococcus aurous (31.3% vs. 2.8%), and group B streptococci (11.7% vs. 6.0%). Community health nurses were significantly more likely to observe exudates (7.4% vs. 0.3%) and foul odor (2.9% vs. 0.7%). M. Bello .j.p Ambe etal (2005) in Kondugal, the study was conducted, the survey which was cross-sectional was conducted over eighth period. Systemic random sampling method was used to select the newborns. 400 samples was selected, majority of the mothers 74.3% delivered at home have same results for other groups. Warm water 2.0% results of infection. This will go reduce in mortality and morbidity in the newborns. Andrea guala (2003) study was reported about the time of cord separation, a controlled clinical trial was carried out of healthy full- term neonates. The study was to evaluate the cord separation. According to the hospital protocol, umbilical cord cleaned with cotton soaked warm water. This was statistically difference (p0.05) 10% of each infant groups discharge the mean time of cord separation is shorter than warm water. Luke C Mullany.g.etal (2002 ) study was conducted to assess cord care the Within a community-based, cluster-randomized study of the effects of 4.0% chlorhexidine on omphalitis and mortality risk, we aimed to describe the distribution of times to separation and the impact of topical chlorhexidine treatment on cord-separation times infants were assigned randomly within communities in southern Nepal to receive 1 of the following 3 cord-care regimens: cleansing with 4.0% chlorhexidine, cleansing warm water, or dry cord care. In intervention clusters, field workers cleansed the cord in the home on days 1, 2, 3, 4, 6, 8, and 10 after birth. The mean separation time was shorter in dry cord care (4.24 days) and warm water (4.25 days) clusters than in chlorhexidine clusters (5.32 days; mean difference: 1.08 days). Cords of infants who received chlorhexidine were 3.6 times more likely to separate after 7 days. Facility-based birth and birth attendant hand-washing were associated with cord separation after 7 days of age. REVIEW RELATED TO CORD CARE. Mullany .Katz. etal (2007) reported study was to assess to umbilical cord care trial in Nepal during (2002-2005). Newborns were evaluated in the home for signs of cord infection (pus, redness, and swelling) omphalitis was identified in 954 of 17.198 newborns (5.5%) infection risk was 29%- 62% higher in infants receiving topical application , skin-skin contact (relative risk (RR) = 0.64, 95% confidence interval (CI) =o.43,0.95) and hand washing (RR=0.73, 95% CI 0.64, 0.84). In this community, unhygienic newborn à ¢Ã¢â€š ¬Ã¢â‚¬Å" care practices lead to continued high risk for omphalitis. Ahmadpour à ¢Ã¢â€š ¬Ã¢â‚¬Å"kacho.z.etal (2006) reported study was to compare the effect topical application of human milk, ethyl alcohol 96% and silver sulfadiazine on umbilical cord separation time in infants. This study was undertaken place at a primary- level newborn nursery at a university teaching hospital and a private hospital. Samples are randomly selected. Motherà ¢Ã¢â€š ¬Ã¢â€ž ¢s milk , ethyl alcohol, silver sulfadiazine ointment for group 3 were applied to the days after umbilical cord separation. It was observed a significant difference in the mean cord separation time along the four groups. No significant complications were observed in any group. Breast milk could be substituted for topical agents for umbilical cord care. Gilson .k .etal (2006) reported large urban university hospital in Turkey and participant homes after discharge Umbilical cord care consisted of one of three methods: topical application of povidine-iodine twice daily, topical application of mothers milk twice daily, or dry care (keeping the cord dry and clean).Outcome was measured in terms of the presence or absence of omphalitis and the number of days elapsed before cord separation. An ongoing questionnaire was administered by telephone every other day after the participants left the hospital. There were no significant differences between the three groups in terms of omphalitis occurrenc e. The cultural practice of applying human milk to the umbilical cord stump appears to have no adverse effects and is associated with shorter cord separation times than are seen with the use of antiseptics. Kelley  Evens  .j.etal (2006)reported study was to compare alcohol versus natural drying for umbilical cord care in preterm infants and to examine its effects on bacterial colonization and cord detachment randomized to receive either umbilical cleansing with 70% isopropyl alcohol at each diaper change or natural drying. Umbilical stump cultures were performed at 12 to 24 hours, 72 hours, 7 days, and 14 days of age. A total of 109 infants were enrolled; 102 completed the study. There was significantly shorter in the natural drying group compared to the alcohol group (13.0 versus 16.0 days;  p=0.003). There were no cases of local umbilical infection in either group. It appears that natural drying is a safe and effective means of umbilical cord care in p reterm infants. Chamnanvanaki.S.etal (2005) conducted a randomized controlled trial was to compare time of cord separation, among 3 regimens of cord care at home1) triple dye, 2) alcohol, 3) no antiseptic solution.185 infants were recruited. Time to cord separation in infants of group1 was significantly longer than in group 2(p=0.036) and group 3 (p=0.003).The satisfaction score of group1 were significantly lower than group 2 and group 3.Triple dye delayed time to cord separation and was less satisfactory. The authors conclude that using alcohol or dry clean could be alternative ways of cord care at home Sezer.G (2005) conducted a quasi-experimental study to comparing topical human milk, Povidine iodine, and dry care.150 sample was selected, convenience sampling used, results there was no significant difference between the three groups in terms of omphalitis occurrence in the Povidine-iodine group, cord separation occurred of 9.9days. in the dry care and topical human milk groups, cord separation occurred at a mean of 7.7 days, respectively.Therewas a statistical relationship between the groups in terms of cord separation time (f=13.24, p0.05). Shoaeib Barrawy .J.etal (2005) conducted a quasi-experimental study that aimed to compare the use of alcohol and traditional methods of cord care with no à ¢Ã¢â€š ¬Ã¢â‚¬Å"treatment approach, natural drying. A convenient sampling was selected; specially designed interview schedule was developed and utilized to collect data. Bathing baby while cord was attached carried out by all women of alcohol and natural drying groups, compared to only 28.6% of traditional methods of group. Breast feeding was significantly related to less incidence of cord infection (p=0.008) and shorter time of cord separation (p=0.002) incidence of cord infection was significantly related to using cloth diaper (p=0.005).It was significantly longer with bathing the baby while cord was attached. Ustav.matku.p.etal (2004) th e objective of the study was to evaluate the umbilical stump care in perinatological center in the Czech. An epidemiological approach was designed.The telephonic questionnaire evaluated the following methods: the treatment method used in the first after birth; the time of surgical removal, leaving the umbilical stump, after removal antibiotics are applied locally in 2 centres and antiseptics applied in 10 centres. The period after which neonates were released was or= 72 hours in 8 centers and or =96 hours in 4 centres. The current trend is to prefer a non- surgical method with spontaneous mummification and detachments of umbilical cord Zupan G.etal (2004) reported study was to assess the effects of topical cord care in preventing infection. Randomized and quasi randomized. Trials of topical cord care compared with no topical cord care, and comparisons between two different forms of care. No difference was demonstrated between cords treated with antiseptics compared with dry cord care or placebo. There was trend to reduced colonization with antibiotics compared to topical antibiotics and no treatment. Antiseptics prolonged the time to cord separation; use of antiseptics was reduced in maternal concern. The research has not shown any advantage of antibiotics or antiseptics over simply keeping the cord clean Zupan .G omari etal (2000) reported study was to assess the effects of topical cord care in preventing cord infection. Randomized and quasi- randomized trials of topical compared with no topical care, and comparison between different forms of care. No difference was demonstrated between cords treated antiseptics compared with dry cord care or placebo. There was a trend to reduced antiseptics prolonged the time to cord separation. Use of antiseptics was associated with a reduction in maternal concern about the cord. There is limited research which has not shown an advantage of antibiotics over simply keeping the cord clean. Ford L (1999) conducted a descriptive study about newborn umbilical cord treatment and healing conveniently selected 30 women who had delivered healthy newborn between39 and 42 weeks gestation .The hospital à ¢Ã¢â€š ¬Ã‹Å"s protocol for umbilical cord care triple dye applied once daily in the hospital and alcohol applied with every diaper change at home. The home visit, they had concerns about the infantà ¢Ã¢â€š ¬Ã¢â€ž ¢s cord. Lacour boutte.c.etal (1999) reported study was to determine whether umbilical cord of the neonate is in accordance with the guidelines of antiseptic treatment at this age of life. Six differences groups of antiseptic products were used, corresponding to 17 distinct commercial preparations. This survey shows that a variety of umbilical cord modalities is used in this region, and that the recommendations for antiseptic treatment in young babies, are not always respected.