A COMPARATIVE STUDY TO ASSESS THE EFFECTIVENESS OF MEDICATED AND NON MEDICATED SITZ BATH IN EPISIOTOMY HEALING ON POSTNATAL MOTHERS ADMITTED IN SELECTED GOVERNMENT HOSPITAL- BANGALORE. M.Sc. Nursing Dissertation Protocol submitted to

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

By

Ms. GLADIS . P. GEORGE

M.Sc NURSING 1ST YEAR

2011-2013

Under the Guidance of

Mrs. Jancy Rani

Associate Professor, Department of Obstetrics and Gynaecology Nursing

National College of Nursing

Yeshwanthapura Hobli,

Hegganahalli cross,

Sunkadakatte road,

Vishwaneedam, post

Bangalore-560091

1

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,KARNATAKA, BANGALORE

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE

AND ADDRESS

Ms. GLADIS .P. GEORGE

1st YEAR M.Sc NURSING

NATIONAL COLLEGE OF NURSING,

BANGALORE

2 NAME OF THE INSTITUTION NATIONALCOLLEGE OF NURING,YESHWANTHAPURA HOBLI, HEGGANAHALLI CROSS, SUNKADAKATTE ROAD, VISHWANEEDAM POSTBANGALORE-560091

3 COURSE OF THE STUDY AND

SUBJECT

M.Sc. NURSING, OBSTETRICS AND

GYNAECOLOGY NURSING.

4 DATE OF ADMISSION TO

COURSE

20-06-2011

5 TITLE OF THE STUDY

“A COMPARATIVE STUDY TO ASSESS THE EFFECTIVENESS

OF MEDICATED AND NON MEDICATED SITZ BATH IN

EPISIOTOMY HEALING ON POSTNATAL MOTHERS

ADMITTED IN SELECTED GOVERNMENT HOSPITAL-

BANGALORE” .

2

6 BRIEF RESUME OF THE INTENDED WORK:

INTRODUCTION

It is the most wondrous time in people's lives, when they bring a

new family member in to the home to settle their family's hearts and household.

The moment of birth is both joyous and beautiful. Birth is a unique dynamic

process, fetal and maternal physiologies interact symbiotically (RCM, 1997). The

physiological transition from pregnancy to motherhood heralds an enormous

change in each woman physically and psychologically. (Bennett R 1993)

Perineal trauma is a common occurrence in childbirth, with up to 50-60% of

women needing stitches called episiotomy after a vaginal delivery. Episiotomy is

performed on millions of women every year. The latest statistics show that an

episiotomy was performed for 14.9% of vaginal births, with the highest rate being

recorded in Victoria (20.5%). A combined laceration and episiotomy occurred in

1.6% of women who had a vaginal birth, giving a total of 16.6%. (Australia’s

Mothers and Babies 2006 Report). Sir Fielding Ould, in 1742, recommended the

procedure called episiotomy, for those cases in which the external vaginal opening

is so tight that labor is dangerously prolonged. However, it did not become

common until the early 1900,s when the shift from home to hospital delivery. The

use of episiotomy was expanded in 1921. The popularity of episiotomy among

obstetricians continued to grow with the introduction of anesthetic and suture

material and as a result of advocacy for its performance by two obstetricians, Delec

and Pomerocy (Maior, 1997).

Carroli, Belizen and Stamp, (1999) stated the rationale for episiotomy that,

it depends largely on the need to minimize the risk of severe spontaneous, maternal

trauma and to speed up delivery, and to minimize fetal distress.

3

Tryrac, Panel el al., (2007) stated that, the routine use of episiotomy

decreases the risk of moderate anterior perineal laceration, and reduces the chance

of perineal tears. The incidence of episiotomy is increased in the following

circumstances like primiparity, Asian women, forceps and vacuum deliveries

(Murphy, Maureen (2007). The outcome of episiotomy is found that delayed

wound healing due to wound separation or clinical infection (Mary McGuiness and

Kathleen 2005)

Kathleen, and Karla,(2005) stated that the routine use of episiotomy

harmful to the pelvic floor , that creates greater extent of surgical incision and

delayed perineal wound healing, compared with no episiotomy group. Continuous

improvement in quality of care after episiotomy could helps to controls the

infection and improves episiotomy wound healing (Faruel F.H, Ventlttelli.F 2007).

The care of episiotomy is an important aspect of postnatal care. The

application of water externally to the body for therapeutic effect is a practice called

Hydrotherapy or Water therapy.” One of the most popular methods of using

hydrotherapy is the sitz bath Originating in Germany, a sitz bath is natural method

of soaking in very warm water. Doing this repeatedly is said to stimulate the

lymphatic system, increase circulation and remove toxins. (Mc Guinas, 2004)

Sitz bath is the form of water bath, which is coming back into popularity as

a low risk. Sitz bath-term comes from the German verbs “sitzen” meaning to sit.

The sitz bath is a European tradition in which only the pelvis and abdominal area

are placed in the water .It helps for women after child birth whether or not had an

episiotomy.

NEED FOR STUDY

4

6.1A wound affects the first line, of our body’s defense system, the skin. When such

takes place, a plethora of symptoms may appear like, bleeding, swelling, redness, pain and

tenderness, fever with infection, heat, stiffness, discoloration, scabbing, itching and scar

formation. Wounds on skin and other soft tissues, trigger a self-healing process of our

body which is summarizes to the scientific term “inflammation”. This process increases

collagen production below the skin (dermis). Then, follows the regeneration of the outer

skin layer.5

“Episiotomy is just one of the practices that contribute to the supposed

“harm of vaginal birth” as more women in developing countries deliver their babies

in hospitals. They can be routinely subjected to episiotomies; even, the unnecessary

routine episiotomy has no demonstrable benefit for the infant or mother, but causes

delayed wound healing leading to puerperal infection, unnecessary pain and

adverse psychological effects. (Faruel Fossie 2007).

The world health organization has taken a clear stand against routine

episiotomy. The episiotomy infections are preventable and can be reduced by

practicing clean delivery and effective postnatal care. Midwives have an important

role in the care of episiotomy wound after child births (WHO statistics, 2007).

Sitz bath is the form of hydrotherapy to relieve discomfort and promote

physical well being.Aua, Saxton, and Sue Markwell, (1998) experimentally proved

that sitz bath plays an important role in providing the thermal and mechanical

effects and administering the curative treatment. The powerful thermal impressions

transmitted inward and by the profound vascular impression made through the

5

dilatation of the surface vessels, heat production, the oxidation of nitrogen, and

metabolisms are quickened under the influence of the elevated temperature of the

water. The effect is to enhance the pelvic circulation, reduce swelling tissues,

reduce itch, soothe sore vaginal tissues and helps in episiotomy healing. Medicated

herbs and antiseptic solutions can also added in the sitz bath to reduce the growth

of bacteria and enhance healing.

Sitz bath is a simple and cost effective and easy method of treating

episiotomy wound in the hospital as well as in home settings. As its takes less time,

sitz bath is not a routine practice in our O G ward settings in spite of it being cost

effective and less time consuming. During this procedure care giver can talk and

communicate with the mothers which may reduce the fear and may relieve the pain

and increases comfort, during the postnatal days. The postnatal mother can do this

independently in the home settings when they get discharged from the hospitals

following the delivery.

6.2 REVIEW OF LITERATURE

INTRODUCTION

6

Review of literature is a key step in the research process. The typical

purpose of analyzing a review of existing literature is to generate questions and to

identify what is known and what is unknown about the topic. The major goals of

review of literature are to develop a strong knowledge base to carry out research

and non research scholalarly activity.

The review has been divided under the following headings:

Section – A: Importance of episiotomy in obstetrics and issues related to

episiotomy

Section – B: Traditional post partum practices and different types of treatment

Section – C: Practices of hydrotherapy in child birth

Section- D: Evidence of sitz bath in postnatal care

IMPORTANCE OF EPISIOTOMY IN OBSTETRICS AND ISSUES

RELATED TO EPISIOTOMY :

A study was conducted on post pregnancy genital tract wound

infections, stated that the post pregnancy infections remain a significant source of

maternal morbidity and mortality. Obstetric infection accounts for more than 12%

of maternal death. Infection occur most frequently in women who have cesarean

birth and following spontaneous or elective termination while 0.3% of the women

who gave birth vaginally [n=2301] developed episiotomy infections and

recommended frequent sitz bath and meticulous attention to perineal hygiene (Nell

Tharpe 2008).

A study was conducted on “Does episiotomy prevent perineal

trauma’ the objective of the study to assess the efficacy of episiotomy to prevent

perineal tear, urinary incontinence, faecal incontinence and genital prolapse. Result

7

shows that the routine use of episiotomy did not prevent severe perineal tears. It

decreased the risk of moderate anterior perineal lacerations. The risk of severe

perineal tears during episiotomy increased in the following circumstances prim

parity, Asian women, instrumental deliveries (Tayac et al., 2007).

A study was reported, “The value of episiotomy in regard to the prevention

of descends of the vagina, and uterus examined in a statistically reliable number of

patients (64 cases). Women who were delivered without episiotomy provided the

control group (70 cases). In both groups factors promoting pelvic relaxation were

taken into consideration. According to the results of this examination, the

importance of episiotomy as prophylaxis of pelvic relaxation does not justify any

obligatory use.

A study was conducted that “effectiveness of teaching on episiotomy and

perineal care among primipara women of selected hospital in Karnataka. The

knowledge deficit about perineal care was found. The mean percentage knowledge

score was 22.50% and recommended midwives have major role in peuperial

infection and also recommended essential conduction of research to prevent

infection and improve healing (Noronha and Angelia, 2004).

TRADITIONAL POSTPARTUM PRACTICES AND DIFFERENT TYPES

EPISIOTOMY TREATMENT:

A study was conducted by Faruel fosse (2007) on post delivery local

care after episiotomy. The aim of the study was define the most appropriate care

after an episiotomy. The result shows that personal hygiene is the best possible

way to heal the episiotomy.

Clinical trail of aromatherapy in post partum mothers perineal healing

reported by Hur and Han (2004). The purpose of the study to verify the effects of

aromatherapy on a post partum mothers perineal healing. Research suggested that

the REEDA scale was significantly low in the experimental group. This study 8

finding indicates postpartum aroma sitz bath for perineal care could be effective in

healing.

A study was conducted to assess the effectiveness of moist and dry

heat application on healing of episiotomy wound on 30 postnatal mothers by using

REEDA scale. The subjects were randomly allocated to experimental and control

group. The study concluded that rate of wound healing with of moist heat and dry

heat application was similar.(Anupama. 2004).

A study to verify the evaluation of lavender cream effect on perineal

pain and episiotomy wound healing in 100 primiparous women with term

pregnancies requiring surgical repair of episiotomy fiiowing a normal and

spontaneous delivery at Moderre’s hospital in Kashmar. The effectiveness was

assessed for perineal pain by VAS and wound healing by REEDA scale at first

24hrs,3rd , 5th and 7th day postpartum. The data was analyzed with chi- square,

mann-withny u and t-test and analysis in spss software.There was no significant

differences in perineal pain at first 24hrs postpartum between two group(P=0.78),

but perineal pain at :3rd(P=0.035), 5th (p=0.0)and 10th ( P=0.04) days postpartum

was less in experimental group.In wound healing there was no significant

difference between two groups at 3rd day postpartum (P=0.170) but at 5th day

(0.002), and 10th day (P=0.0) there was significant difference between two

group.The study concluded that the topical application of lavender creem was

effective in reliving perineal pain and episiotomy wound healing (Molkizadeh et al)

PRACTICE OF HYDROTHERAPY IN CHILD BIRTH :

Stanley J, Swierzewski (2001) Reported that warm sitz bath is one of the

easiest and most effective ways to ease the discomfort associated with uterine

discomfort and painful conditions in the pelvic area. In hot sitz bath the

temperature is 105 to 110 degree F, the patient should sitz in the hot water 15 to 20

minutes and this procedure should repeated three to five times a day.

Aua, Saxton and Sue Markwell (1998) stated that sitz bath is a

9

medicine free solution providing relief to the discomfort of hemorrhoids, fistulas,

anal fissures, episiotomies and other infections. A sitz bath (also called a hip bath)

is hydrotherapy that increases the blood flow to the pelvic and abdominal

areas. Sitz baths have become extremely popular in hospitals and are especially

given to women after childbirth.

Researchers at the department of obstetrics and gynecology, university

of Liverpool have confirmed that hydrotherapy is extremely beneficial for

pregnant mothers as well as postpartum period in the form of sitz bath (Aird and

Luckas, 1997).

EVIDENCE OF SITZ BATH IN POSTNATAL CARE:

A study “the sitz bath post birth healing and comfort for new

moms” reported that soaking in the hot sitz bath soothes soft tissue, keep the

perineal area clean, prevent infection and help in circulation and cool sitz bath treat

the perineal swelling.(Moon Darkan, 2007).

Ladewig, London, and Davidson (2006) reported that the warmth of

the water in the sitz bath provides comfort, decreases pain and promotes

circulations to the tissues, which promotes healing and reduces the incidence of

infection.

“Sitz bath where is the evidence? Scientific basis of a

common practice”, the study was designed to determine the evidence existing to

justify and support the sitz bath. The results reported that 36 articles were found

which high lightened the physiology, benefits, risks, complications and techniques

of sitz bath. Most of the studies were published in gynecologic or nursing journals.

Two articles speculated that sitz bath induces relaxation of the internal sphincter

muscles. In cold sitz bath, perineal edema is more than warm sitz bath. This study

was recommended future studies (Tejirian et al., 2005).

Romberger, (2005) Reported that portable bath or sitz bath are often 10

prescribed by doctors as this type of therapy gives much relief from the discomfort

and promotes a more rapid healing of the vaginal and rectal areas following

incisions at the time of childbirth or rectal surgery.

The study was reported that effects of heat and cold on the perineum

after episiotomy / laceration (Hill 2004). Tool was used to evaluate the effects of

heat and cold on the perineum during the first 24 hours after delivery. Ninety

patients were randomly assigned to one of three treatment groups. Treatment

consisted of 30 subjects applying a warm perineal pack, 30 applying a cold

perineal pack and 30 taking a warm sitz bath. Analysis of variance indicated no

differences in the REEDA scale of these treatments.

A study to justify and support the recommendation of sitz bath in the

management of ano-rectal disorders. Thirty six articles were found which

highlighted the physiology, benefits, risks, complications and techniques of sitz

bath. This study concluded that sitz bath induces relaxation of the internal

sphincter muscle and cold sitz bath was reported to decrease perineal edema. This

study also recommended additional studies are needed to investigate the benefits

of sitz bath.9 (Tejirian et al. 2003)

Lafoy and Geden (2003) evaluated the effectiveness of warm versus

cold sitz bath to relieve edema and hematoma, as well as reduce the sensation and

distress of pain in 20 postnatal patients. Sensation and distress were measured on

visual analogue scale. Preineal edema and hematoma formation were graded on a 3

point scale ranging from 0 being none to 3 being extensive edema and hematoma

formation. Both warm and cold baths were found comparable in relieving

hematoma and edema. The women’s preference should be major determinant of

water temperature; some woman found cold sitz baths uncomfortable.

A Study was reported about the “comparison of hygienic sitz bath and

personal hygiene’’ Different perineal cleaning techniques were used following 11

bowel movements by a female test subject .This "post hygiene" wash liquid was

allowed to fall into a sterilized basin and was subsequently transferred to a sterile

Erlenmeyer flask, removed to a laboratory, and evaluated for the presence of

micro-organisms. Although these results only come from a single test subject, they

show conclusively that some personal hygiene techniques are significantly more

effective than others. The results show particularly that the sitz bath more

effective than personal hygiene wipe to removing microorganisms from the

perineal area. A reduction in bacteria from this area reduces the probability of

cross-infection to the vaginal area with enteric pathogens.

6.3

6.4

STATEMENT OF PROBLEM : A COMPARATIVE STUDY TO ASSESS THE EFFECTIVENESS OF

MEDICATED AND NON MEDICATED SITZ BATH IN EPISIOTOMY

HEALING ON POSTNATAL MOTHERS ADMITTED IN SELECTED

GOVERNMENT HOSPITAL. BANGALORE

OBJECTIVES OF THE STUDY

12

6.5

6.6

6.6.1

6.6.2

6.6.3

6.6.4

The objectives of the study are:

1. To assess the episiotomy status before and after the sitz bath

2. To determine the effects of medicated sitz bath in episiotomy healing.

3. To determine the effects of non medicated sitz bath in episiotomy healing

4. To compare the effectiveness of medicated and non medicated sitz bath in

episiotomy healing.

HYPOTHESIS

H01 : There will be a significant difference between medicated and non-medicated

sitz bath in episiotomy healing.

H02 : There will be significant association between the episiotomy wound healing

and selected demographic variable such as age, education, occupation, family

income per month and parity.

OPERATIONAL DEFINITIONS:

EFFECTIVENESS:

Effectiveness refers to the improvement in episiotomy wound status which is

observed in terms of improvement in healing process which is measured by the

score of REEDA Scale.

NON MEDICATED SITZ BATH:

Non Medicated Sitz bath refers to sitting in plain warm water only deep

enough to cover hip and buttocks.

MEDICATED SITZ BATH:

Medicated Sitz bath refers to sitting in Betadine 10% added plain warm

water only deep enough to cover hip and buttocks.

13

6.6.5

6.7

6.8

6.9

7

7.1

7.1.1

EPISIOTOMY

A Surgically planned incision on the perineum and the posterior vaginal wall

during the second stage of labour..

POST-NATAL MOTHERS

It refers to primi and multiparous women with episiotomy during normal

vaginal delivery and instrumental delivery.

ASSUMPTIONS

Medicated sitz bath is more effective in episiotomy wound healing.

DELIMITATIONS:

The study is delimited :

To postnatal mothers who are selected in Government hospital at Bangalore

Who knows Kannada or English

Who are willing to participate in the study.

PROJECTED OUTCOME:

The result of the study helps to treat the episiotomy equally with medicated and non

medicated sitz bath to enhance the episiotomy healing on postnatal mothers.

MATERIALS AND METHODS

SOURCE OF DATA

The data will be collected from the postnatal mothers in selected

government hospital, Bangalore.

RESEARCH DESIGN

14

7.1.2

7.1.3

7.1.4

7.2

7.2.1

7.2.2

7.2.3

Quasi experimental research design.

RESEARCH APPROACH

An evaluative descriptive approach.

SETTING:

The study will be conducted at selected Government hospital at Bangalore.

POPULATION

The populations in this study will comprise all post natal mothers with

episiotomy with normal vaginal delivery and instrumental delivery in

selected government hospital at Bangalore.

SAMPLING PROCEDURE

The Sample will be selected through convenient sampling technique.

SAMPLE SIZE

The sample size is 50.

INCLUSION CRITERIA

The criteria for sample selection are,

Primi and multi parous mothers with episiotomy

EXCLUSION CRITERIA

15

7.3

7.3.1

Who are not willing to participate in the study

Those who don’t know kannada or English.

Heavy vaginal bleeding with episiotomy

Post natal mothers with perineal tear

Mothers with cardiac diseases, gestational diabetes and hypertensive

disorders etc.

INSTRUMENT INTENDED TO BE USED

SELECTION OF TOOL

Tool consists of two parts. First part consist of assessment, second part

consist of protocol for medicated and non medicated sitz bath.

Part 1: section A: Through interview will be used regarding Age,Education

Occupation, , Family income per month , parity ,Gravida. From the record types of

delivery and weight of the baby will be recorded .By examination, types of

episiotomy and length of episiotomy will be assessed.

Section B: Episiotomy wound will be assessed through REEDA scale. The REEDA

scale consist of 5 main area of assessment such as redness, edema of the perineal

area, ecchymosis of the perineal area, discharge from wound and approximation of

the edges.

Part II: Protocol will be prepared for administration of medicated and non

medicated sitz bath.

SCORING PROCEDURE

The REEDA scale consist 5 major assessments area. Each assessment area will be

given a minimum score of 0 and maximum score of 3. The total REEDA score

ranged from 0 to 15. As the score increases, it will indicate higher rate of infection.

16

7.4

7.5

7.6

7.7

If the score decreases, it shows the evidence of healing process.

DATA COLLECTION METHOD

Prior permission will be obtained from the government hospital before

conducting the study. Thorough interview will be conducted about the demographic data

and medical record will be refer for the information regarding type of delivery and birth of

baby , REEDA scale will be used to assess the episiotomy wound.

PILOT STUDY

10 samples will be selected and a study will be conducted to find out the feasibility.

DATA ANALYSIS PLAN

To assess the demographic variable the investigator will be used

descriptive statistics. To meet the objectives and to compare the data between two

groups the investigator will be used descriptive and inferential statistics such as

mean, standard deviation, paired “t” test and z test.

DOES THE STUDY REQUIRE ANY INVESTIGATION OR

INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER

HUMANS OR ANIMALS?

Yes, the medicated and non medicated sitz bath will be provided for the

17

7.7.1

8.

post natal mothers with episiotomy at selected government hospital, Bangalore.

HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION?

YES, Ethical clearance will be been obtained from the research

committee of National college of nursing.

Consent will be taken from the selected hospital authority and permission

will be taken from the study subjects before the collection of data.

LIST OF REFERENCES

1. Aiien,R.E.Hoster,G.L.Smith,A.R.Warrell.Pelvic floor damage and childbirth.British

journal of obstetrics and gynaecology.1990;97, pp770-9.

2. Carroli, Blizan.Episiotomy for vaginal birth. Journal of cocharne review, The

cocharne library. Jan very.2004;3,24-32.

3. Hur.M.H,Han S.H. Clinical trial of aromatherapy on postpartum mothers perineal

18

healing. Tachan Kanho Hakhow chi.June 2004.

4. Anupama Dutta.Evaluate the effectiveness of moist and dry heat application on healing

of episiotomy wound. Dissertation.RGUHS.2004.

5. Cheryl .U.Sussman.G.Ramastadium.B. Wilson b (2006) Best practical Technical,

Techniques and pressure in wound healing , international Journal of Evidence based

health care, The Journal of brigger institute publication, volume 10, issue (2) 45-78

6. Gentz, Brend, A (2001) Alternative thearapy for the management for Pain in labour

and delivery, Jouranal of clinical obstetrics and gynecology, Volume 44 (4) 704 – 732.

7. Molkizadeh.M, Khadivzadeh.T, Rakshandeh.H, Khajedaleui.M. Evaluation of

lavender cream effect on perineal pain and episiotomy wound healing.

8. Cats P.M ,Chan K.C,Williams, M.beard, R,J (1999), A Comparison Beiweenmidline

and Mediolateral episiotomies. British Journal of obstetrics and Gynecology, Volume

87, 408-412.

9. Gentz, Brend, A (2001) Alternative thearapy for the management for Pain in labour

and delivery, Journal of clinical obstetrics and gynecology, Volume 44 (4) 704 – 732

10. Low Angeles (2005) Sitz Bath is form of water therapy, medical journal of malsia.

Volume 30(20) 135-138.

11. D.C.Dutta.Text book of obstetrics”, 6th edition, published by new central book of

agency, 2004,p.

12. Albance P.M, Chambglwn,S,R,Jament,J. etal (2006)Lippincott manual of nursing

practice, 8 th edition, Lippincott Williams publications.

13. Ava, S.R, Saxton, B.J. Sue markwell(1998), Womens Health Text Book for

Physiotherapist, I edition, W.B Saunders Philadelphia.

14. Buchman, D.D Jonson,Kate.K. (2004), Complete Book of Water healing, I edition,

Thomson Publication, Philadelphia.

19

15. Adrle Pilitter (2007). Materanal and Childbirth Nursing, care of the child bearing

and child bearing family, 5 th edition, Lippincott Williams publications, Philadelphia

16. Kozer B, Glenora (2007) , Fundametals of Nursing, Concepts, procedure, Practice,

4th edition, Darking publication.

17. F. Ganez.S.R. Griffiths R. (2007) Water Bath for Health AND Beauty, 2 edition,

element Publications.

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19. www.science directive.com

20. www.pubmed .com

21. www.medline.com

9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE

11. NAME AND DESIGNATION OF

11.1 GUIDE

20

11.2 SIGNATURE

11.3 CO-GUIDE

11.4 SIGNATURE

11.5 HEAD OF DEPARTMENT

11.6 SIGNATURE

12 12.1 REMARKS OF THE PRINCIPAL

12.2 SIGNATURE

21