INTRODUCTION:

Today, almost all women experiences labor as their first experience of hospitalization. And nowhere birth is treated by those involved in it, as merely physiological process. ¹In obstetrics wisdom, the complex act of labour is simplified into three stages. Out of this, second stage of labour is considered to be most crucial phase, when the parturient may experience injuries to birth canal as a result of passage of fetus through it.² These maternal injuries during and following childbirth contribute significantly to maternal morbidity in post partum period. As a preventive measure, Dr Embroise Pare, Founder of Modern Obstetrics suggested prophylactic measure known as episiotomy.

Since the policy of institutional confinement and era of hospital deliveries, the episiotomy has become the most common obstetric operation performed.³ Though episiotomy is to be limited to fetal distress and operative vaginal delivery even in nullipara, it is mainly followed with the objective to enlarge the vaginal introitus, to minimize overstretching and rupture of perineal muscles and fascia, to reduce stress and strain on fetal head.⁴ The advantages of episiotomy are so great that it is practiced as an almost routine procedure . And the routine performance of episiotomy has become known as prophylactic episiotomy. ⁵

Though episiotomy is the most common obstetric operation performed for maternal and fetal benefit, it is an inflicted second degree perineal tear. With any surgical incision tissue injury occurs. As episiotomy is surgical procedure, edema, erythema, ecchymosis and inflammation are particularly true of the area surrounding it. During this inflammatory process, cells that were destroyed by the trauma of incision releases chemical agent, histamine and plasmakinin, which causes pain, increases local blood flow and capillary permeability. Finally local extra cellular edema result which again contributes to the pain. ⁶

Almost all women accept the labor pains as normal and natural as it brings them closer to their child’s birth. Labour pains are often thought as pains which end with a memorable gift. But at the same time episiotomy pain is felt as most intense and an inflicted pain by most of them. During the entire process of childbirth most of them remember only the pain and agony they were called upon to endure at and after the birth of their child. ⁷

Perineal trauma can cause considerable distress and discomfort to many women following childbirth. Its severity is frequently under-estimated and many women suffer unnecessarily, often in silence, Perineal pain in the early postnatal period has been reported to be one of the most common causes of maternal morbidity (Sleep 1990). Kitzinger and Walters (1993) showed that following an episiotomy women experience more perineal pain and are more likely to experience dyspareunia when compared with other degrees of perineal trauma. Support for this claim was highlighted in an extensive literature review of 350 articles and books published during the period of 1860-1980 (Thacker and Banta 1983). This concluded that 'pain following an episiotomy appears to be universal…’ and reported the level of moderate-to-severe pain as high as 60%. A delay in healing may increase the duration of perineal pain, and studies by McGuiness et al. (1991) and Henriksen et al. (1994) noted a significant delay in the healing of episiotomies when compared with other perineal outcomes. An instrumental delivery is commonly aided by an episiotomy and this appears to cause greater levels of perineal pain when compared with a normal delivery (Cater 1984).^8,⁹

Applications of hot/cold compresses have been in use for centuries as a form of localized treatment to relieve the inflammation of acute soft tissue injuries and it would appear that cold therapy is the preferred choice of the two. The use of application of cold compress locally for first 24 to 48 hours in post operative management for episiotomy is also suggested by Dr Parulekar in his textbook. ¹⁰

So the study was undertaken to try out some independent nursing interventions which would help women in recovery from physical stress and strain caused by episiotomy.

MATERIAL AND METHODS:

The study was conducted in one state government hospital for women and children in South Mumbai. The sample consisted of 60 post natal mothers who had undergone full term normal vaginal delivery with episiotomy. The sampling techniques used were non probability convenient sampling. The tools used for data collection were numerical pain rating scale¹¹ and REEDA scale of episiotomy¹².

The techniques used for data collection were self report and structured observation.

After obtaining the written informed consent each sample was assigned to either of the group. The samples of experimental group were further divided into two subgroups A and B. Based on predetermined plan of action the samples of the experimental groups were given ice application at specific time interval. The samples of experimental group A received the ice application for 6 times on first postnatal day, for 4 times on second postnatal day and for 1 time at the end of third day. The samples of experimental B group received the ice application 3 times on first and second postnatal day and one time at the end of post natal day three. The samples of control group were refrained from this intervention. For application of ice on episiotomy an ice pack made of a zipper locked self sealing polythene bag of size 4X 6 cms was used. The sterile techniques were followed during the procedure to prevent cross infection.

The timings for assessment of intensity of pain at episiotomy site were based on timings of ice application. The samples in the experimental group A and B rated their pain scores each time before the ice application and at the end of first, second and third postnatal day. The samples of control group A and B only rated their pain scores at the timings which were as per the timings of the ice application for the samples of experimental group.

The REEDA scale was used to assess the episiotomy wound condition at end of each day for first 3 consecutive postnatal days. The episiotomy wound was assessed for redness, edema, ecchymosis, discharge and approximation.

RESULTS AND DISCUSSION:

In the present study out of total 60 samples, 59 (93%) samples were given left medio-lateral episiotomy and only one (7%) sample was given medial episiotomy.

Table 1- The analysis of data in relation to pain experienced at episiotomy site -

Sr no	Intensity of pain experienced	Post natal day one						Post natal day two				Post natal day three
		Exp A		Con A	Exp B		Con B	Exp A	Con A	Exp B	Con B	Exp A	Con A	Exp B	Con B
		F		F	F		F	F	F	F	F	F	F	F	F
1	No pain	01	00			00	00	00	00	00	00	02	00	00	00
2	Mild Pain	14	00			01	00	12	00	01	00	05	00	02	00
3	Moderate Pain	00	05			09	05	03	09	12	11	08	11	10	08
4	Severe Pain	00	10			05	10	00	06	02	04	00	04	03	07

Table 2- Distribution of samples in relation to episiotomy condition based scores of REEDA scale

Sr no	Condition of Episiotomy	Post natal day one				Post natal day two				Post natal day three
		Exp A	Con A	Exp B	Con B	Exp A	Con A	Exp B	Con B	Exp A	Con A	Exp B	Con B
		F	F	F	F	F	F	F	F	F	F	F	F
1	Excellence	02	00	02	00	01	00	02	00	01	00	02	00
2	Good	13	12	11	12	14	03	12	04	14	03	12	05
3	Satisfactory	00	03	02	03	00	12	01	11	00	12	01	10
4	Poor	00	00	00	00	00	00	00	00	00	00	00	00

Table 3- Comparison of scores REEDA scale between Experimental group A and total Control group [A+B]-

Sr. No	Time phase in relation to episiotomy	Experimental group A Mean [M1]	Control group [A+B] Mean [M2]	SD	Calculated ‘t’ test value (df=43)	Level of significance
1	At Zero hour [baseline]	0.06	0.13	0.29	0.62	NS
2	At 24^th hour	1.06	4.96	01.55	7.95	**
3	At 48^th hour	2.0	6.13	01.36	9.83	**
4	At 72 hour	2.13	6.33	01.76	7.92	**

**- Indicates 0.01 level of significance. NS- indicates not significant.

Table 4- Comparison of scores REEDA scale between Experimental group B and total Control group [A+B]

Sr. No	Time phase in relation to episiotomy	Experimental group A Mean [M1]	Control group [A+B] Mean [M2]	SD	Calculated ‘t’ test value (df=43)	Level of significance
1	At Zero hour [baseline]	0.06	0.13	0.29	0.62	NS
2	At 24^th hour	1.06	4.96	01.55	7.95	**
3	At 48^th hour	2.0	6.13	01.36	9.83	**
4	At 72 hour	2.13	6.33	01.76	7.92	**

**- Indicates 0.01 level of significance. NS- indicates not significant.

It is evident from the data of table no 1 that on post natal day one, majority of samples ( more than fifty percent) of experimental group A and B experienced mild pain at episiotomy. Whereas majority of samples, ten (sixty seven percent) from control group were victims of severe pain at episiotomy. On post natal day two, majority of samples from experimental group (eighty percent) experienced mild to moderate pain, and none of the sample suffered with severe pain. Whereas 10 samples (66 percent) of control group had severe pain at site.

On third post natal day, it was evident that though the number of samples with moderate pain was almost similar in both the groups, total experimental group had 7 samples (47 percent) with mild pain as compared to nil samples of control group.

It is evident from the tabulated data in table 2 that on the post natal day one, all the groups had almost similar number of samples11 to 13 (73 to 87 percent) with good episiotomy condition. On the post natal day two, though the experimental groups continued to have same number of samples with good episiotomy condition, the majority of samples 11to 12 (73 to 80 percent) from control group showed satisfactory episiotomy condition. And on third post natal day, experimental group had 3 ( ten percent) samples with excellent episiotomy and 26( 87percent) with good episiotomy, the majority 22(73 percent) control group samples showed satisfactory episiotomy condition based on REEDA score.

The data from table 3 clearly shows that significant difference was not obtained in mean scores of REEDA score between experimental group A and total control group, at baseline assessment, as the assessment was done immediately after suturing of episiotomy and before the intervention. This also made the groups homogenous in nature. The obtained significant difference in mean scores at end of postnatal day one, two and three indicated that the samples of experimental group had better episiotomy condition as compared to samples of control group.

It is evident from the data of the table no 4 that there was no significant difference in the mean scores of REEDA scores of experimental B and total control group, at initial assessment. At subsequent assessment done at the end of postnatal day one, two and three the significant difference was obtained in mean scores of REEDA indicating better episiotomy condition of experimental group B as compared to total control group.

CONCLUSION:

It can be concluded from the obtained data that the samples of the experimental group A and B who received the nursing intervention of application of ice on episiotomy had better post episiotomy pain relief and better episiotomy wound condition.

The frequency of application of ice on episiotomy also made the significant effect on the selected variables of post episiotomy pain for first two days and episiotomy condition.

Thus, it could be concluded from the study that application of ice on episiotomy plays an important and beneficial role in the management of post episiotomy pain and in the improvement of episiotomy condition. The wider use of this intervention on episiotomy in practical setting can help to widen the independent function of professional nurse, and also to improve patient’s trust in health care system.

REFERENCES:

1. Arunkumaran S and Ratnam,S. The management of Labour. First edition, Madras:Orient longman Ltd. 1996.

2. Dutta D. C. Textbook of Obstetrics. Seventh Edition. Calcutta, New Central Book Agency Pvt Ltd. 2011.

3. Wilson Jenifer. Nursing Research- ten Studies in patient care. Vol 2, John Wiley and Sons Medical Publications. 1986.

4. Throp J., et al. selected use of midline episiotomy, effect on perineal trauma. Journal of Nurse Midwifery 70(2); Nov –Dec 1987:260-262

5. Bobak, Jenson and Lowdermilk Maternity Nursing. Fourth edition Saint Louise C.V. Mosby Company 1996.

6. Gyton A. Textbook of Medical Physiology. Sixth edition.

7. Dale. Dorothy. Speaking the language of Pain. American Journal of Nursing. 101(2); Feb 2001: 41-49

8. Mary Steen., et al. A randomized controlled trial to compare the effectiveness of icepacks and Epifoam with cooling maternity gel pads at alleviating postnatal perineal trauma

9. chesterrep.openrepository.com/.../Steen,cooper,marchant,griffiths-jones,

10. Dr Parulekar S.V. Textbook for Midwives. First edition. Mumbai Vora Book Publication. 1998.

11. Mc Caffery , Margo. Using 0 to 10 Pain Rating Scale. American Journal of Nursing 101(10); Oct 1989: 399-403

12. Davidson, N.S. REEDA: Evaluating Postpartum Healing. Journal of Nurse Midwifery.19(6); July/Aug 1984: 6-8

Received on 07.05.2013 Modified on 25.07.2013

Asian J. Nur. Edu. and Research 3(4): Oct.- Dec., 2013; Page 207-210