RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA
A STUDY TO EVALUATE THE EFFECTIVENESS OF SITZ BATH IN REDUCTION OF EPISIOTOMY PAIN AMONG POSTNATAL MOTHERS IN SELECTED
HOSPITALS, KOLAR DISTRICT,
KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
Ms. SEETHI SUSEELA
A.E & C.S PAVAN COLLEGE OF NURSING
KOLAR
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. / NAME OF THE CANDIDATE & ADDRESS / MS. SEETHI SUSEELA1ST YEAR M.SC(NURSING),
A.E & C.S PAVAN COLLEGE OF NURSING,
BANGALORE-CHENNAI BYEPASS ROAD, KOLAR – 563101.
2. / NAME OF THE INSTITUTION / A.E & C.S PAVAN COLLEGE OF NURSING, KOLAR – 563101
3. / COURSE OF THE STUDY AND SUBJECT / M.Sc (NURSING)
OBSTETRICS AND GYNECOLOGICAL NURSING
4. / DATE OF ADMISSION / 04-06-2008
5. / TITLE OF THE TOPIC / “A STUDY TO EVALUATE THE EFFECTIVENESS OF SITZ BATH IN REDUCTION OF EPISIOTOMY PAIN AMONG POSTNATAL MOTHERS IN SELECTED HOSPITALS, KOLAR DISTRICT, KARNATAKA.”
6. BRIEF RESUME OF INTENDED WORK
INTRODUCTION
“A stitch intime saves nine”
(k.park)
The postpartum period is a crucial stage for both the mother and baby. Generally postpartum women experience relatively little discomfort and are most concerned with rest, relieving perineal discomfort and learning about the new born.1
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 delivery.2
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 deliveries.3
In India, the birth rate becoming very high, 72.3 per thousand birth (WHO 1998).The incidence of episiotomy was high.4
More moderate forms of genital cutting which account for an estimated 80% of the practice worldwide.5
Although the frequency of performing an episiotomy is decreasing, 30% to 50% of women may still receive episiotomy. Sutures for this can be sore and painful. Although relatively small in size, an episiotomy can cause considerable discomfort because the perineum is an extremely tender area. The muscles of the perineum are involved in many activities like (sitting, walking, squatting, bending, urinating, and defecating). Thus, an incision in this area causes a great deal of discomfort.6
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 .7
An article on postpartum care stated that the perineum must stretch far beyond its ordinary limits as the baby was born. In order to prevent tears during stretching an episiotomy was performed. Discomfort from an episiotomy was a problem during postnatal period, sometimes up to months. For relief of discomfort caused by the episiotomy, ice pack or warm water cleaning was found to be effective .8
Many physicians and nurse midwives order a soothing cream or anesthetic spray to be applied to a suture line to reduce discomfort. A cortisone based cream or sitz bath helps to decrease inflammation and, thus tension in the area .6
Each year, more than 200,000 women in the U.K and over 1.5 million in the U.S undergo an episiotomy. In many countries, this operation has been adopted as routine and standard obstetrical pratice.9
Episiotomies have stitches in a very tender area and need some time to heal. Using ice packs on perineal area immediately after the birth to numb the area and to prevent or reduce swelling. Some other techniques that can speed healing and ease soreness includes 24 hours after delivery , start taking warm soaks in the tub or in a sitz bath . A sitz bath is a shallow plastic basin that fills with warm water and position over toilet seat. It makes it convenient to soak bottom several times a day without having to fill a tub full of water and completely undress each time. Most hospitals will provide sitz bath while in hospital .10
6.1 NEED FOR THE STUDY:
Postnatal women are prone for puerperial infection, which can be prevented by proper hygienic measures, especially perineal care. Any trauma such as episiotomy, tear and laceration will increase the tendency for the development of infection in the postnatal period. Proper care of episiotomy incision should be encouraged to ensure that the trauma is healing satisfactorily. Pain and discomfort from episiotomies can be reduced by providing therapeutic cleansing soak, such as warm water sitz bath to promote blood flow to the episiotomy for rapid healing .11
Episiotomy is one of the most widely performed surgical procedure. The rate of episiotomy ranges from 50-90% in developing countries. In various countries routine episiotomy has been accepted medical practice for many years.12
As of 2007, the average birth rate for the whole world is 20.3 per 1000 total population, which for a world population of 6.6 billion comes to 134 million babies per year .13
A study was conducted 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. Perineal pain was more frequent and severe for women with increased perineal trauma.14
In 2000, one study calculated the percentage of episiotomies performed in the United States out of all vaginal deliveries to be 19.4%. This was a dramatic reduction from the 1983 rate of 69.4% Episiotomy rates were higher among white women (32.1%) than African American women (11.2%) . Similar differences have been reported in other obstetric procedures (eg. Caesarean section and epidural use).15
A study was conducted on relaxing in a tub of water, either a shallow sitz bath or a deep regular bath, the results shows relief, and another study to compare cold sitz baths with warm ones found that the women who took the cold ones had less pain afterward. Cold acts as an analgesic. But warm water feels better. Warmth increases circulation on the area and aids healing.16
A study was conducted on role of the midwife in perineal wound care following child birth. 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 treatments in wound healing. The maintenance of effective pain relief must be balanced with the need to promote wound healing.17
In many hospitals, episiotomy becomes 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 S.N.R hospital, Kolar district, Karnataka, in the year 2007 there was 1531 normal vaginal deliveries were conducted, out of this, 100% incidence of episiotomy among primigravida women and 50% incidence of episiotomy among multigravida women during the second stage of labour.
Warm water relaxes and soothes the sore tissues, keeps the area clean and prevents infection and helps with circulation. Sitzing may begin 24 hours after birth, when a mother can be up and about more comfortably sit on the bath for 10-20 minutes,1-3 times a day or as needed, until the soreness is relieved.18
Based on the review of literature and the personal experience of the investigator during her clinical posting found that in many hospitals episiotomy care involves several practices such as perineal wash, sitz bath, application of infra red lamp, antibiotics to relieve pain and discomfort and to promote faster wound healing. Hence the investigator is interested to conduct the study on effectiveness of sitz bath in reduction of episiotomy pain.
6. 2: REVIEW OF LITERATURE:
Review of literature is a key step in research process. It refers to 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 the results of the study, and when making judgments about applications at a 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, audio visual materials and personal communications.19
The related literature is organized and presented under the following headings.
Section I: Studies related to episiotomy
Section II: Studies related to various methods used for episiotomy.
Section III: Studies related to effect of sitz bath in reduction of episiotomy pain.
Section I: Studies related to Episiotomy
A study was conducted on pudendal nerve block for pain relief after episiotomy. Randomized double-blind, controlled trail was used. Forty women who gave birth vaginally with mediolateral episiotomy were randomized to receive pudendal nerve block with 15ml of either ropivacaine 7.5 mg/ml [Pudendal group] or normal saline [Control group] after repair at the episiotomy. Episiotomy pain was assessed with a visual analog scale. Patient in the pudendal group reported significantly lower pain scores at rest than those in the control group.20
A study was conducted on episiotomy and increases the risk of spontaneous obstetric laceration in the subsequent delivery. A total of 6,052 patients were included, of whom 47.8% had episiotomy at first delivery. Spontaneous second degree laceration at the time of second delivery occurred in 51.3% of women with history of episiotomy at first delivery compared with 26.7% without history of episiotomy (p<.001).Severe lacerations occurred in 4.8% of women with history of episiotomy at first delivery compared with 1.7% without history of episiotomy (p<.001).Prior episiotomy remained a significant risk factor for second degree and severe obstetric lacerations in the second vaginal delivery. It was showed that episiotomy at first vaginal delivery increases the risk of spontaneous obstetric laceration in the subsequent delivery.21
A study was conducted to assess the extent of post partum pain, 445 women who delivered babies vaginally were selected from the hospital in Toronto, Canada. Results showed that 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. 97% of women who had an episiotomy reported perineal pain 1 day after child birth, 21%, 7 days later. The study suggested that the mothers need to have awareness regarding perineal pain need to use pain relievers to ease their pain.22
A study was conducted to assess the effectiveness of teaching on episiotomy and perineal care among primipara women of selected hospitals in Karnataka, by using convenient 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 results showed that planned teaching programme was effective in increasing the knowledge (t=23) and ability (t=24.34) of the experimental group.23
A retrospective study was conducted to examine the association of episiotomy with the frequency and severity of perineal trauma in women undergoing forceps delivery in semmelweis women’s hospital.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 delivery.24
Section II: Studies related to various methods used for episiotomy care.
A study was conducted to define post delivery care after episiotomy. 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. NSAIDS were the most studied among medical treatments and have shown an effect on pain, some of them can be used during maternal breast feeding. The study suggested that the medical staff must emphasize the importance of self care and perineal hygiene. The pain of episiotomy is a crucial element to treat, and it is most effectively done medically.25
A study was conducted to investigate the use of pharmacological and non-pharmacological methods of perineal analgesia used by midwives during the second stage of labour and perineal repair in the U.K. Postal survey design was used self-complete questionnaires were sent to Heads of midwifery in all 219 maternity units. Midwives reported using a variety of non-pharmacological analgesic methods to control pain at the end of the second stage of labour. Hot packs were used in 70(33%) maternity units, cold packs in 44(21%) and perineal massage in 109 (52%) midwives in 131 (62%) maternity units used injectable local anesthetics to control perineal pain.26
A study was conducted on clinical trial of aromatherapy on postpartum mothers perineal healing in Korea. By using a clinical trial method the aromatherapy were applied with sitz both or soap application using essential oils with lavender, rose, grape fruit, orange. The experiment was applied to postpartum mothers who delivered vaginally with an episiotomy. The study was conducted in 3 groups, 1st group for Aroma-sitz bath, 2nd group for aroma-soap application, 3rd group was control group, The effect of aroma therapy on perineal healing was measured by using REEDA scale an smears of episiotomy wound were obtained. Results showed that the postpartum aromatherapy for perineal care could be effective in healing the perineum.27
A study was conducted to determine the effect of a simple relaxation technique on postpartum patients episiotomy incisional pain and overall discomfort by post test only experimental design. 40 subjects (20 in experimental group and 20 in the control group) participated in the study only the experimental group was taught the relaxation technique and told to use it whenever they had pain or discomfort in their episiotomy incision. Results showed that for the subjects who used the relaxation technique, there was a general trend for decreased pain and discomfort.28