RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.
.
AN EXPERIMENTAL STUDY TO EVALUATE THE EFFECTIVENESS OF INFRARED LAMP THERAPY ON HEALING OF EPISIOTOMY
WOUND IN POST NATAL MOTHERS IN A SELECTED
HOSPITALS, AT KOLAR DISTRICT,
KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION.
Ms. VALARMATHI EASAKKIAMMAL.R
A.E & C.SPAVANCOLLEGE OF NURSING
KOLAR
RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECTFOR DISSERTATION
1 / NAME OF THE CANDIDATE &ADDRESS / MS. VALARMATHI EASAKKIAMMAL. R
IST YEAR M.SC., NURSING STUDENT
A.E & C.S. PAVAN COLLEGE OF NURSING,
BANGALORE-CHENNAI BYEPASS
ROAD, KOLAR – 563 101.
2 / NAME OF THE INSTITUTION / A.E & C.SPAVANCOLLEGE OF NURSING
KOLAR-563101
3 / COURSE OF THE STUDY AND SUBJECT / MSc NURSING
OBSTETRICS AND GYNECOLOGY IN NURSING
4 / DATE OF ADMISSION / 30-05-2007
5 / TITLE OF THE TOPIC / AN EXPERIMENTAL STUDY TO EVALUATE THE
EFFECTIVENESS OF INFRA RED LAMP THERAPY
ON HEALING OF EPISIOTOMY WOUND IN POST
NATAL MOTHERS IN A SELECTED HOSPITALS, AT
KOLAR DISTRCT, KARNATAKA
- BRIEF RESUME OF INTENDE
- BRIEF RESUME OF INTENDED WORK
INTRODUCTION
“A nice clean cut is better than a jagged tear”
Episiotomy is a surgical procedure that involves cutting the perineum (skin between the vagina and the anus) during labour to enlarge the vaginal opening. The procedure is intended to prevent vaginal tears during delivery1
Episiotomy is a common surgical procedure performed during the second stage of labour. The first performance of episiotomy was done in 1742, when perineal incisions were used to facilitate deliveries2
In the 1970s and early 1980s the episiotomy rate rose to approximately 50 % of all births and as high as 90% in some maternity units. Women having their first baby needed to have episiotomies. During mid to late 1980s many studies were carried out to examine the “routine” use of episiotomy. Researchers determined that an episiotomy does not result in less childbirth trauma, improved healing or fewer maternal problems than a tear.
In India the birth rate becoming very high. (72.3 per thousand births). The incidence of episiotomy was high3.
More moderate forms of genital cutting which account for an estimated 80% of the practice worldwide4.
Episiotomies were once routinely performed in an attempt to prevent tearing during labour, particularly to avoid tears that reach to the anus. The number of episiotomies performed remains high in the U.S, but there is now a great deal of controversy over whether they should be routine.
The rate of episiotomy has wide geographic variations from 8% in the Nether lands, 20% in England,. 50% in the USA and 99% in some Eastern European countries. It is also high in many developing countries. Defining a “good” episiotomy rate is therefore difficult.
Many physicians use episiotomy because they believe that it will lessen perineal trauma, minimize postpartum pelvic floor dysfunction by reducing anal sphincter muscle damage, reduce the loss of blood at delivery, and protect against neonatal trauma .
Most recently, Williams obstetrics Cunningham, Mac- Donald and Gant 1989, states “The reasons for (episiotomy’s) popularity among obstetricians are clear. It substitutes a straight neat surgical incision for the ragged laceration that otherwise frequently results. It is easier to repair and heals better than a tear”5
Pritchard, Mac Donald, and Gant 1985, described that episiotomy reduces the incidence of cystocele, rectocele and stress incontinence.
In cases where an episiotomy is indicated, a medio lateral incision may be preferable to a median (midline) incision as the latter is associated with a higher risk of injury to the anal sphincter and the rectum.6
The tool used for post partum assessment of episiotomy healing was developed by Davidson. This tool appraises the perineum or incision for signs of redness, edema, ecchymosis, discharge and approximation . Thus the tool came to be known as the REEDA scale7.
Infrared lamp is very safe and provides pain relief within 10-15 minutes without medications and do not have to be concerned about side effect. Infra red lamps are intended to use to emit energy in the infrared spectrum to provide topical heating for the purpose of temporarily elevating local tissue temperature. This light therapy is intended to use for the temporary relief of minor muscle strain spasm, temporary increase in local circulation where applied, and the relaxation of muscle.
The infra red lamp requires the voltage of 220V/250V, and should be kept 50cms away from the affected area. It can be applied for 3-7 days, 5 times per day. The suggested time of heating is 15 – 30 minutes. It has no harmful side effects but in case of over heat application leads to burns, over dilatation of blood vessels and increased in pain8
Doctors recommend infra red lamp as a simple and effective treatment for pains9
The infrared lamp has a round plate consists of 33 earth elements essential to the human body, when activated the plate emits a special band of infrared waves ranging from 2 to 25 microns in wavelength. This coincides with the infra red waves generated by our own bodies, and are absorbed by our tissues10
The heat from this infra red lamp penetrates upto 3 inches into the body, increasing circulation and loosening tight muscles. This warming not only feels good and helps in relaxation, it also aids in healing damaged tissue. The infra red lamp therapy is a highly effective pain relief device, with no harmful side effects.
6.1 NEED FOR THE STUDY
Episiotomy is one of the most widely performed surgical procedures. The rate of episiotomy ranges from 50- 90 % in developing countries. In various countries, routine episiotomy has been accepted medical practice for many years.
Having an episiotomy may increase perineal pain in the post partum period, resulting in trouble while defecating, it may complicate sexual intercourse by making it painful and replacing erective tissues in the vulva with fibrotic tissue11.
Perineal trauma, whether a cut or a tear, is very painful. This may interfere with bonding with the baby and the establishment of breast feeding12
Most women have an episiotomy results in lot of problems with pain, incontinence and poor healing. Most women say that they didn’t feel anything when their episiotomy was performed. The tissues around the vagina are tightly stretched when they are giving birth, and a cut can be made very easily. However recovering from an episiotomy can be quite painful13.
The potential side effects of an episiotomy are infection, bruising, swelling. bleeding, extended healing time, painful scar which may require a period of abstinence from sexual intercourse, future problems with incontinence.
Macarthur AJ, MacArthur C, (2004), conducted a study to determine the frequency of perineal pain in the 6 weeks after vaginal delivery and to assess the association between perineal trauma and perineal pain. Results showed that perineal trauma was more common among primiparous women, those with operative vaginal deliveries and epidural analgesia during the second stage of labour. Acute post partum perineal pain is common among all women. However perineal pain was more frequent and severe for women with increased perineal trauma14
Larsson P.G, Platz- Christensen JJ, Bergman B, Wallstersson. G (1991):- Conducted a study about episiotomy and perineal problems after episiotomy. Results showed that a significantly higher infection rate (P<0.001) and a longer healing period in the episiotomy group. Many women suffered after an episiotomy. The patients subjective problems are significantly increased15
Following delivery, patients who had an episiotomy complain of perineal pain more than those with an intact perineum or first or second degree tears. Episiotomy appears to be the cause of more perineal pain and dyspareunia during the early post partum weeks
The rate of episiotomy increased with the duration of second stage of labour. The rates of episiotomy in women from the Indian sub continent were very high compared with those for white women17.
Episiotomy are performed on over 90% of first time mothers delivering in major U.S hospitals, in Netherlands only 8% of births18.
Heat are applied to the body for local and systemic effects. The physiologic effect of heat are vasodilation, increases capillary permeability, increases cellular metabolism, sedative effect, increases blood flow to the affected area, bringing oxygen, nutrients, antibodies and leukocytes. Application of heat promotes soft tissue healing.19
Studies done around the world showed that this infra red lamp technology is effective for more than 100 ailments, it helps and promotes healing of various soft tissue injuries, chronic & surgical wounds.
In many hospitals episiotomy become a normal procedure on every women delivering her first child to avoid perineal laceration and damage to pelvic floor and to reduce birth trauma.
In SNR hospital - Kolar district , Karnataka, where 1523 vaginal deliveries were recorded in the year, 2006, there was a 100% incidence of episiotomy among primigravid woman and 50% incidence of episiotomy among multi gravida women during the second stage of labour.
Midwives have an important role to play in the care of perineal wounds following childbirth. A wide variety of practices are carried out in this area. However, midwives must realize the relevance of their care and potential impact, both positive and negative of advocated treatment in wound healing. The maintenance of effective pain relief must be balanced with the need to promote wound healing.
Based on the review of literature and the personal experience of the investigator during her clinical field posting, found that in many hospitals episiotomy care involves several practices such as perineal wash, sitz bath, applications of infrared light, antibiotics etc to relieve excruciating pain, add comfort and promote faster wound healing. Hence the investigator is interested to find out the effectiveness of infrared lamp therapy on episiotomy wound healing.
6.2.REVIEW OF LITERATURE
Review of literature is a key step in research process. It refers to an extensive exhaustive and systematic examinations of publications relevant to the research project. The researcher analysis existing knowledge before delving into a new area of study while conducting a study,when interpreting results of the study and when making judgements about applications of new knowledge in nursing practice.
The review of literature is defined as a broad, comprehensive in depth, systematic and critical review of scholarly publications, unpublished scholarly print materials, audiovisual materials and personal communications20
This chapter is divided into 3 sections
Section I : Studies related to episiotomy
Section II : Studies related to various methods used for episiotomy care.
Section III : Studies related to effect of infrared therapy on wound healing.
Section I : Studies related to episiotomy
RONNIE FALCAO. LM MS CALIFORNIA (2004): Conducted a study to assess the extent of post partum pain nay linger for several weeks after delivery. 445 women who delivered babies vaginally were selected from the hospital in Toronto, Canada. Results showed that the percentage of women who reported perineal pain up to one week after child birth varied among the women depending on the degree of perineal trauma. for eg, 75% of women with an intact perineum reported pain one day after child birth, and 38% a week later. 95% of women with 1st and 2nd degree tears in the perineum, involving skin and muscle of the vagina, reported pain one day after delivery & 60% one week later. 97% of women who had an episiotomy reported perineal pain 1 day after child birth. 71% 7 days later 100% of women who had 3rd or 4th degree tears, an extension of the episiotomy to or through the rectum, reported pain 1 day following vaginal delivery and 91% 7 days later.
The study suggested that the mothers need to have awareness regarding perineal pain need to use pain relievers to ease their pain21.
BODNER ADLER B, BODNER K, KIMBERGER O, WAGENBICHLER P, MAYERHOFER K, 2003 were conducted a retrospective study to examine the association of episiotomy with the frequency and severity of perineal trauma in women undergoing forceps delivery in semmelweis women’s hospital, Austria between February 1999 and July 1999. Episiotomy was not performed routinely and was either midline or mediolateral. Results showed that the frequency and severity of perineal tears were significantly lower in forceps deliveries when an episiotomy was performed.Mediolateral episiotomy is the more protective against perineal trauma in women undergoing forceps delivery22
ENYINDAH CE, FIEBAI PO, ANYA SE, OKPANI AO, (2000) were Conducted a retrospective study to determine the rate and risk factors for episiotomies and perineal trauma at the university of post Harcourt teaching hospital, in Nigeria, between 1st January 1996 and 31st December 2000. Result showed that the episiotomy rate in 4720 vaginal deliveries during the period of study was 39.1%in all parturients, while in primigravida, it was 77.1%. Rates for first and second degree perineal tears in all women were 10.6 and 25% respectively. The incidence of episiotomy decreased with increasing parity, but the incidence of perineal tears slightly increased with parity. Nulli parity, vaginal breech deliveries and instrumental vaginal deliveries were identified as risk factors for episiotomy.The study concluded that episiotomy rate was high but the procedures appears to have prevented the occurrence of third degree and complete perineal tears23.
PEON AC, FELT –BERSMA RJ, DEKKER GA, DEVILLE W, CUESTA MA, MEUWISSEN SG, ( 1997) Were conducted a retrospective case control study to determine risk factor for third degree obstetric perineal tears and to give recommendations for prevention in a teaching hospital, Netherlands. 120 cases of vaginal delivery. Complicated by third degree perineal tear and 702 uncomplicated vaginal deliveries were compared with respect to possible risk factors. Results showed that high birth weight, forceps delivery , induced labour, parity were risk factors for anal sphincter tear. Nulliparous women are at higher risk than multiparous women. Mediolateral episiotomy may be sphincter saving especially in nulliparous women and it prevent the chronic faecal incontinence24.
Section II : Studies related to various methods used for episiotomy care.
FARRUEL – FOSSE.H. (2006): Conducted a study to define the most appropriate post delivery care after episiotomy, the best suited treatment of the pain of episiotomy and examine the course of repair stitches in paris. A survey of the literature done between 1990 and 2005 in medline and Cochrane library. Results showed that personal hygiene is a key to healing but no specific treatment has been accepted. The treatment of pain by non medical as well as topically is not very efficient. Non steroidal anti inflammatory drugs were the most studied among medical treatments and have shown an effect on pain, some of them can be used during maternal breast feeding. Acetaminophen has not been sufficiently studied to assess its effectiveness.The study suggested that the medical staff must emphasize the importance of self care and personal hygiene. The pain of episiotomy is a crucial element to treat, and it is most effectively done medically. The treatment must be adapted to each patient depending on her tolerance25.
FYNEFACE – OGAN S, MATO CN, ENYINDAH CE, 2006 were conducted a comparative study to assess the effect of two local anesthetic agent on post partum perineal pain in university of port Harcourt teaching hospital, Nigena. By using a random sampling technique, the study was conducted in primi parous women who had spontaneous vaginal delivery, comparing with 1% plain lidocaine and 0.25 % plain bupivacaine infliltration for the repair of selective episiotomy.Results showed that within 2 to 4 hours, women who had perineorraphy under lidocaine had significantly higher pain scores on the visual Analogue scale (VAS) than those who had the repair under bupivacaine. The P value was P< 0.0000 ( students ‘t’ test ) and statistically significant. The study suggested that bupivacaine had a prolonged analgesia and need a fewer doses of oral analgesics in the immediate postpartum perineal repair period26
JUDITH ANGELITA NORONHA,(2004), Conducted a study to assess the effectiveness of teaching on episiotomy and perineal care among primipara women of selected hospitals in Karnataka.By using convenience sampling technique, the study was conducted in 2 phases. The phase I of the study, the data were collected from 30 primipara women to identify learning needs of primipara mothers in terms of knowledge and ability to perform self perineal care. The phase 2 of the study consisted of 25 subjects in the experimental group, 30 subject in control group. The date was collected by using an interview method, observation checklist, and episiotomy wound assessment scale to measure episiotomy healing. The planned teaching programme on episiotomy and self perineal care was given to experimental group,The results showed that planned teaching programme was effective in increasing the knowledge (t=23) and ability (t=24.34) of the experimental group.The study suggested that nurse and midwives have a major role in identifying and providing necessary supportive- educative care to clients who have undergone episiotomy27.
HUR MH, HAN SH (2004), were conducted a study on clinical trial of aromatherapy on post partum mothers perineal healing in Korea. By using a clinical trial method the aromatherapy were applied with sitz bath or soap application using essential oils with lavender, rose, grapefruit, orange. The experiment was applied to post partum mother who delivered vaginally with an episiotomy. The study was conducted in 3 groups. 1 group for Aroma – sitz bath, 2 group for aroma - soap application, 3 group was control group. To evaluate the effect of aroma therapy the perineal healing status was measured by using REEDA scale and smears of episiotomy wound were obtained. Results showed that the post partum aromatherapy for perineal care could be effective in healing the perineum28
HILL PD, (1989), conducted an experimental study on effect of heat and cold applications on the perineum after episiotomy during the first 24 hours after delivery in college of nursing, Chicago. By using a random sampling technique 90 patients were selected to one of the three treatment groups. 30 patients were treated with warm perineal pack and another 30 patients were treated with cold perineal pack and remaining 30 patients were treated with warm sitz bath. The Redness Edema Ecchymosis Discharge Approximation ( REEDA) tool was used to evaluate the episiotomy wound healing. Results showed that no difference in the REEDA score before or 2 hours after treatment 29