INTRODUCTION:

Perineal trauma can cause considerable distress and discomfort to many women following childbirth. Perineal trauma affects the mental, social and physical wellbeing of the woman. Some have postpartum pain and discomfort, which may persist beyond the puerperium as chronic pain and dyspareunia. In addition, infection, wound breakdown, urinary and faecal incontinence and other spectrum of adverse effect of treatment of perineal trauma can make the postpartum period very unpleasant. While factors like suture techniques, operator skills and suture materials may affect perineal pain and wound healing, different strategies have been used in order to promote episiotomy healing. Severity of perineal discomfort was frequently under estimated and many women suffered without cause, very frequently in silence.

Episiotomy refers to a surgical incision into the perineal body to enlarge the vaginal opening to facilitate birth or to prevent perineal tears. Episiotomy is one of the most common procedures performed during delivery, yet, there is extensive disagreement about necessity and benefits of this procedure¹. It is also defined as the surgical enlargement of the vaginal orifice by an incision of the perineum during the last part of the second stage of labor².

Even though episiotomies have been performed for several hundred years, the routine practice of episiotomy was not adopted until the 1920s. For decades, episiotomies have been performed on a routine basis to help speed delivery during the second stage of labor; as well as to prevent tears to the mother's vagina, especially serious tears that may stretch to the urethra or the anus. The procedure was also thought to lessen trauma to the baby and protect the mother's vaginal muscles.

Used widely in the present day, episiotomy is advocated to have several advantages such as prevention of lacerations, better healing, easier to repair than a ragged tear, allows for easier and safer regression of the head thereby preventing possible brain damage reduced incidence of uterine prolapse in subsequent deliveries. If performed before, tissues are overstretched, shortens the second stage of labor and it may prevent painful hemorrhoids. It is also performed for a majority of forceps deliveries, breech and face deliveries.

The rate of episiotomy rates vary widely worldwide depending on its restrictive or routine use. Studies reveal that episiotomy rates vary from 8% in the Netherlands, 13% in England to 25% in the USA. In developing countries, episiotomy rates are still high as restrictive use of episiotomy has not been widely embraced in primigravidas³. Episiotomies in the United States have declined since the late 1970’s from 61% in 1979 to 25% in 2004⁴.

A study determined episiotomy rate in 1345 vaginal births in Nigeria. Findings revealed that the prevalence rate of episiotomy was 46.6% and over 90% of the primigravida had undergone episiotomy.

A study conducted by Sathiyasekaran BWC et al⁶ investigated the episiotomy rate in Chennai’s rural population on a sample of 442 postnatal mothers who had delivered vaginally. Findings revealed an overall episiotomy rate of 67% among these mothers. It was concluded that episiotomy rates were high and even higher when delivery was conducted by a doctor and place of delivery was private medical college hospital.

In this era of advanced modern technology all mothers are looking hopefully at nurses to help in bringing down the maternal morbidity rate and relieve them from suffering, pain and discomfort after child birth. Thus, it becomes the nurse’s responsibility to identify the ways of preventing and reducing maternal morbidity as well as to identifying the cost effective measures in relieving pain⁷.

Postnatal mother might have painful micturation because of local bruises on the vulva, clitoris, vagina and the episiotomy scar. Retention of urine may occur due to painful scar or the operative delivery. Sitz bath provide pain relief, infrared exposure relives perineal pain. Analgesics may require for treating local pain⁷.

Exposure the perineum to dry heat in the form of a perineal hot pack or moist heat by a sitz bath are ways of increasing circulation to the perineum and therapy to reduce pain, edema, promote healing and provide comfort⁸. An experimental study was undertaken to investigate the effect of infra red therapy on episiotomy pain and wound healing in 60 postnatal mothers with episiotomy at selected hospitals at Kovilpatii by randomly assigning 30 postnatal mothers to control group and 30 postnatal mothers to experimental group each. Data was collected using REEDA scale to measure wound healing. The results of the study indicated that the infra red therapy enhanced wound healing in postnatal mothers⁹.

A study was conducted to evaluate the effectiveness of warm versus cold sitz bath to relieve edema and hematoma, as well as to reduce the sensation and distress of pain in 20 postpartum mothers. Findings revealed that, although cold bath was significantly more effective in reducing edema, both cold and warm sitz bath were found comparable in relieving hematoma formation¹⁰.

Postnatal infections are the leading cause of hospital acquired infection and a leading cause of maternal morbidity and mortality. They expose mothers to increased risk of delayed mother-infant bonding, prolonged hospital stay or re-admittance to the hospital, lactation difficulties, increased expense and possibly permanent injury or death¹⁰.

Today, when the cost of medical treatment and care is soaring. Providing economical care to patients with episiotomy is possible provided nurses realize the relevance of their care and potential impact of the advocated procedure in wound healing as nurses play an important role in the care of perineal wounds following childbirth.

Available data demonstrates that high percentages of women are undergoing episiotomy during child birth. However, at the same time episiotomy wound is a neglected aspect in post natal case both by the health personnel and mothers themselves. This in part may be attributed to work load or lack of understanding of importance good episiotomy wound healing in the long term. Mother’s lack of knowledge or health status may also be considered as a contributing factor. Infection of episiotomy wound can lead the puerperal sepsis. Puerperal sepsis is one of the major causes of maternal morbidity and mortality.

From investigators’ personal clinical experience, it has been observed that most of the mothers with episiotomy remained in the bed in lying position as they had difficulty while sitting properly and breastfeeding. Keeping in mind the current trends in health care, postnatal mothers may be discharged from the hospital on 2^nd or 3^rd postnatal days with incomplete wound healing and persisting pain.

So, the investigator felt the need to evaluate the effectiveness of Infrared radiation therapy vs Warm sitz bath on level of pain in episiotomy wound among postnatal mothers.

OBJECTIVES:

1. To compare the effectiveness of infra red light therapy vs. sitz bath on episiotomy in terms of wound healing among postnatal mothers.

2. To determine the association of wound healing scores of post natal mother with selected variables.

MATERIAL AND METHODS:

Approach and design:

The research approach adopted for the study was experimental approach with repeated measures design.

Setting and Subjects:

The present study was conducted in the postnatal ward of Government Multi specialty Hospital, Chandigarh. This 500 bedded hospital has 24 hours round the clock emergency and indoor facilities manned by specialists. Major specialties provided in this hospital were Medicine, Surgery, Orthopedics, Gynecology and Pediatrics. Casualty and Emergency Services are provided 24 hours all days. A sample of 60 postnatal mothers was selected using purposive sampling technique. Thirty postnatal mothers were allotted for the treatment of infra red light therapy and another thirty postnatal mothers were allotted for treatment with sitz bath. The study was carried out in the month of December 2010-January 2011.

Tool:

The tools used for the study were socio demographic tool and REEDA scale. Socio Demographic tool consisted of 11 items seeking information on background data such as age, education, type of family, parity, type of delivery, type of pregnancy, type of antibiotic therapy. REEDA Scale was used to assess healing of the perineum. It comprised of five items related to redness, edema, ecchymosis, discharge and approximation. The maximum score for REEDA was 15 and the minimum score was zero.

Reliability:

Reliability of the REEDA Scale was established by Kappa method of inter rater reliability and was found to be .75 (acceptable range .61-.81 COHEN)

Procedure:

Administrative approval and ethical clearance was obtained from the designated authority and institutional ethical committee respectively. Written consent was obtained from the participants after explaining the nature and purpose of the study. Confidentiality and anonymity was ensured. First thirty postnatal mothers allocated to group I received infra red light to the episiotomy for 15 minutes. Next 30 postnatal mothers allocated to group 2 received sitz bath to the episiotomy for 15-20 minutes. Each therapy was provided twice daily for three consecutive days. Healing of wound was observed after giving the treatment using REEDA Scale. The obtained data was analyzed by using descriptive and inferential statistics.

RESULTS

Findings related to demographic characteristics of postnatal mothers

Nearly three fourth of postnatal mothers (76.7 %) in the group 1 and two third of mother (66.7%) in group 2 were in the age group of 18-25 years. Nearly half of the postnatal mothers (53.5%) in group 1 (infra red light therapy) and 46.7% in group 2 (sitz bath therapy) had primary level of education. Majority of the postnatal mothers (73.3%) in group 1 (infra red light therapy) and 83.3% in group 2 (sitz bath therapy) belonged to nuclear family. Majority of the postnatal mothers (70%) in group 1 and group II were primipara. All samples(100%) in Group I and group II were with singleton pregnancy. All (100%) the postnatal mothers had spontaneous delivery in group 1(infra red light therapy) and 3.3% in group 2 (sitz bath) had aided delivery. Majority of the postnatal mothers (83.3%) in the group 1 (infra red light therapy) received cephalosporins as antibiotics as compared to 6.7% in group 2 (sitz bath therapy). whereas 93.3% postnatal mothers in group 2 (sitz bath therapy) received amino-glycosides as compared to 16.7% in group 1 (infra red light therapy).

Table 1: Comparison of infra red light therapy and sitz bath therapy in terms of wound healing scores among the postnatal mothers on day 3. N=60

Therapy	Mean	M_D	SD_D	SE_MD	‘t’ value
Infra red light (n=30)	1.43	0.30	0.15	0.11	2.72^*
Sitz bath (n=30)	1.13	0.30	0.15	0.11	2.72^*

‘t’(58) = 2.00, p≤0.05 ; *significant at 0.05 level

The data presented in table 1 shows that the mean wound healing score (1.43) of postnatal mothers receiving infra red light therapy was higher than the mean wound healing score (1.13) of postnatal mothers receiving sitz bath therapy with a mean difference of 0.30. This obtained difference was found to be statistically significant as evident from the ‘t’ value of 2.72 for df 58 at 0.05 level of significance. Hence it can be inferred that sitz bath was more effective in promoting wound healing after episiotomy among postnatal mothers.

Table 2: Observation wise mean, mean difference, standard deviation difference, standard errors of mean difference of wound healing scores of postnatal mothers receiving infra red light therapy from day 1 to day 3 N=30

Observations	Mean	MD	SD_D	SE_MD	‘t’ value
Observation 1	1.67	0.04	0.01	0.13	0.25^NS
Observation 2	1.63
Observation 2	1.63	0.20	0.01	0.11	1.80^NS
Observation 3	1.43
Observation 1	1.67	.24	0.02	0.09	2.53*
Observation 3	1.43

Data presented in table 2 shows that the mean wound healing score of postnatal mothers receiving infra red therapy was 1.67 and 1.63 on day one and day two respectively with a mean difference of 0.04. This difference was not found to be statistically significant at 0.05 level of significance as indicated by the computed t value of 0.25 df (29).

The mean wound healing score of postnatal mothers receiving infra red therapy was 1.63 and 1.43 on day two and day three respectively with a mean difference of 0.20. This difference was not found to be statistically significant at 0.05 level of significance as indicated by the computed t value of 1.80 df (29).

The mean wound healing score of postnatal mothers receiving infra red therapy was 1.67 and 1.43 on day one and day three respectively with a mean difference of 0.24. This difference was found to be statistically significant at 0.05 level of significance as indicated by the computed t value of 2.53 df (29).

Thus it can be inferred that infra red light therapy was effective in promoting wound healing after being administered for three consecutive days.

Table 3: Observation wise mean, mean difference, standard deviation difference, standard errors of mean difference of wound healing scores of postnatal mothers receiving sitz bath therapy from day 1 to day 3 N=30

Observations	Mean	Mean Difference	SD_D	SE_MD	‘t’ value
Observation 1	1.77	0.14	0.13	0.14	0.94^NS
Observation 2	1.63
Observation 2	1.63	0.50	0.21	0.14	3.52*
Observation 3	1.13
Observation 1	1.77	0.64	0.08	0.08	7.08*
Observation 3	1.13

Data presented in table 3 shows that the mean wound healing score of postnatal mothers receiving sitz bath therapy was 1.77 and 1.63 on day one and day two respectively with a mean difference of 0.14. This difference was not found to be statistically significant at 0.05 level of significance as indicated by the computed t value of 0.94 df (29).

The mean wound healing score of postnatal mothers receiving sitz bath therapy was 1.63 and 1.13 on day two and day three respectively with a mean difference of 0.50. This difference was found to be statistically significant at 0.05 level of significance as indicated by the computed t value of 3.52 df (29). Thus it can be inferred that sitz bath therapy was effective in promoting wound healing after being administered for three consecutive days.

The mean wound healing score of postnatal mothers receiving sitz bath therapy was 1.67 and 1.43 on day one and day three respectively with a mean difference of 0.24. This difference was found to be statistically significant at 0.05 level of significance as indicated by the computed t value of 2.53 df (29). This, it can be inferred that sitz bath therapy were effective in promoting episiotomy wound healing after from 2^nd observation onwards.

Data presented in table 4 shows that the mean would healing score of postnatal mothers receiving intra red light and sitz bath was 1.67 and 1.77 respectively on day one with a mean difference of 0.10. This difference was not found to be statistically significant at 0.05 level of significance as indicated by the computed t value of 0.85 df (29).

The mean would healing score of postnatal mothers receiving intra red light and sitz bath was 1.63 and 1.63 respectively on day two with a mean difference of 0.00. This difference was not found to be statistically significant at 0.05 level of significance as indicated by the computed t value of 0.00 df (29).

The mean would healing score of postnatal mothers receiving intra red light and sitz bath was 1.43 and 1.13 respectively on day two with a mean difference of 0.30. This difference was found to be statistically significant at 0.05 level of significance as indicated by the computed t value of 2.69 df (29).

Thus it can be inferred that infra red light theray and sitz bath therapy are comparable in promoting wound healing after episiotomy, while sitz bath is more effective.

Findings further revealed there was no significant association of wound healing scores of the postnatal mothers receiving infra red light therapy and sitz bath therapy with the selected sample characteristics viz age, level of education, type of family, parity, mode of delivery, and type of antibiotics prescribed.

DISCUSSION:

The number of women who die during pregnancy or childbirth has reduced by nearly 50% globally since 1990 from 543,000 to 287,000. In the developing regions, the number of maternal deaths per 100,000 live births, the maternal mortality rate has fallen from 440 in 1990 to 240 in 2010. Eastern Asia has the lowest level in the developing regions with the maternal mortality rate of 37. But for every woman who dies, approximately 20 others suffer injuries, infection, and disabilities¹¹. The present study was aimed at comparing the effect of infra red ray therapy versus sitz bath therapy in terms of episiotomy wound healing of postnatal mothers. Findings of the present study revealed that infra red light therapy and sitz bath therapy were effective in promoting episiotomy wound healing. These findings are consistent with the findings reported by Baruahb B et al which reported that infra red light was an effective therapy for episiotomy wound healing¹². Venkadalakshmi1 V et al ⁹ also reported that infra red therapy was effective in enhancing episiotomy wound healing among postnatal mothers.

Finding further showed that sitz bath therapy was effective in promoting episiotomy wound healing among postnatal mothers. These findings are consistent with the findings reported by Michel S, which revealed that sitz bath was effective in promoting episiotomy wound healing among postnatal mothers

No significant association was found between episiotomy wound healing and age, education, type of family, parity. These findings are consistent with the findings reported by. Begum S¹³ also reported no significant association of episiotomy wound healing of postnatal mothers and selected variables age, education, occupation, parity and activity¹³.

Although application of both infrared and sitz bath therapy was effective in enhancing the healing process, however findings revealed that REEDA score was significantly lower among post natal mothers who received sitz bath therapy. These findings are consistent with the findings reported by Dutta A¹⁴ which revealed that sitz bath was effective in episiotomy healing. This could also be attributed to the fact that both wet and dry heats have local effects on wound healing. Moist application warms the skin more quickly and is more penetrating than application of dry heat as water is a better conductor than air¹⁵.

Findings further revealed that there was no significant difference between the wound healing scores of mothers receiving infra red light and sitz bath therapy. However, on day two and three, the REEDA scores of postnatal mothers receiving sitz bath were significantly lower than mothers receiving infra red light. These findings are parallel to the findings reported by Kaur N et al which showed that episiotomy healing of mothers who received sitz bath therapy was comparatively quicker as compared to mothers who received dry heat therapy with a hair dryer¹⁶.

IMPLICATION:

Perineal trauma due to episiotomy causes a number of distressing conditions in postnatal period such as discomfort, pain and disturbed normal activities increased the risk of infection. In addition, these mothers experience a feeling of inadequacy, prolonged postnatal recovery and increased cost of healthcare. The findings of the study imply that there is need for ensuring comfort and promoting episiotomy wound healing of postnatal mothers.

NURSING PRACTICE:

· Although all pregnant mothers may not end up having episiotomy at the time of delivery, however, educating mothers regarding use and advantages of sitz bath in the postnatal period can promote perineum recuperation.

· Nurses working in postnatal wards can consistently practice the use of infrared light and sitz bath to provide comfort to the postnatal mothers and hence promote healing.

NURSING EDUCATION:

· Nurse educators should orient the students towards various forms of interventions for episiotomy pain and wound healing.

· Demonstration to the students and regarding use of infrared rays and sitz bath therapy should be done.

NURSING ADMINISTRATION:

· Dissemination of research information through multiple channels such as publications, conference paper presentation related to strategies to improve perineal healing of postnatal mothers.

· Journal club presentations related to most current evidence based practices for management of episiotomy and latest innovations.

· Provide perineal care guidelines and protocols for nurses providing postpartum care.

· Availability of episiotomy kits for mothers who have episiotomy wound at the time of admission in the postnatal ward.

RECOMMENDATION:

· A study on larger sample for generalization of results

· A study to determine effectiveness in terms of cost and nursing time of different strategies used for providing episiotomy care.

LIMITATION:

Limited sample size, hence generalization is not possible

REFERENCES:

1. Kumar SJ, Singh SG et al. restricted use of episiotomy. Journal of obstetric gynecology India. 60 (5); 2010: 4-8-412 (The American College of Obstetricians and Gynecologists. Practice Bulletin Episiotomy. Number 71, April 2006 (Reaffirmed 2008)

2. Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews. Issue 1; 2009 Art. No.: CD000081. DOI: 10.1002/14651858.CD000081.pub.2

3. Kettle C, Tohill S. Perineal care. Clinical Evidence. 9. 2008;1401-18

4. Frankman EA, Wang L, Bunker CH, Lowder JL. Episiotomy in the United States: Has anything changed? American Journal of Obstetrics and Gynecology. 2009: 573.e1-573.e7. (available from: http://www.ncbi.nlm.nih.gov/pubmed/19243733)

5. Gayathri J. A study to compare the effectiveness of sitz bath versus infra red radiation on episiotomy wound healing among postnatal mothers in a selected hospital, Banglore. MSN thesis available form: http://119.82.96.198:8080/jspui/bitstream/123456789/8387/1/GAYATHRI.J.pdf)

6. Sathiyasekaran BWC, Palani SG et al. Population based study of episiotomy. Sri Ramachandra Journal of Medicine. 2007: 9-14 (available from: http://www.sriramachandra.edu.in/srjm/pdf/nov _2007/book_3.pdf)

7. Padubidri. V, “Textbook of Obstetrics”, 1^st edition, BI Publication (P) Ltd, (2006), New Delhi, Pp.389)

8. Adele Pillitteri (2007) (Pillitteri Adele, Maternal and child health Nursing, 4^th edition, lippincott publishers, Philadelphia, 2003; 512, 612-14)

9. Venkadalakshmi V et al. Effects of infra red therapy on episiotomy pain and wound healing in postnatal mothers. Nursing Journal of India. 32(9); 2010: 212-14

10. Lafoy EA, Geden EA et al. Post episiotomy pain: Warm versus cold sitz bath. Journal of Obstetrics, Gynecology and Neonatal Nursing. 1990;19(1):13

11. WHO 2012. Chronic disease and health promotion; Region and country Specific Information Sheets (Available at http://www.countdown2015mnch.org/documents/2012Report/2012-part-2.pdf)

12. Baruah B, Raddi SA. A study to assess the effect of infrared lamp in episiotomy wound healing. Journal of South Asian Federation of Obstetrics and Gynecology. 2(3); 2010: 236

13. Begam S. An experimental study to assess effectiveness of routine hospital practices versus cold application on healing of episiotomy wound of postnatal mothers. Master of Science dissertation. Rajiv Gandhi University of Health Sciences. Karnataka. Bangalore. 2006 (available form http://119.82.96.198:8080/jspui/bitstream/123456789/1442/1/CDNNOBG00046.pdf)

14. Dutta A. Effectiveness of moist and dry heat application on healing of episiotomy wound in postnatal mother. Rajiv Gandhi University of Health Sciences. 2004. [Cited sep 2011];

15. Rosdahl CB, Kowalski MT. Textbook of basic nursing. 9^th edition. 2008. United States of America. Lippincott Williams and Wilkins.

16. Kaur N, Rana AK, Suri V. Effect of dry heat versus moist heat on episiotomy pain and wound healing. Nursing and Midwifery Research Journal. 2013;9(1):21-33

Received on 26.08.2013 Modified on 25.12.2013

Asian J. Nur. Edu. & Research 4(1): Jan.-March 2014; Page 70-75