Effectiveness of Cold Application on Episiotomy Pain among Postnatal Mothers in selected Hospitals at Kanyakumari District

 

Mrs. Bini¹, Mrs. Reeta Jebakumari Solomon², Mrs. V. Ahitha³

¹2^nd Year MSc Nursing, Department of Obstetrics and Gynecology Nursing, Thasiah College of Nursing, Vellivilagam, Marthandam, India.

²Principal and Professor, Thasiah College of Nursing, Vellivilagam, Marthandam, India.

³Vice Principal and Professor, Thasiah College of Nursing, Vellivilagam, Marthandam, India.

 

ABSTRACT:

Back ground of the study: Pregnancy and child birth are the special events in women’s life. The mother does suffer with much distress after child birth due to painful perineum resulting from an episiotomy. Cold application is an inexpensive, safe and easy to use method. The aim of the study is to evaluate the effectiveness of cold application on episiotomy pain among postnatal mothers in selected hospitals at Kanyakumari district. Material and Methods: The design adopted was quasi experimental pre-test and post-test control group design. The purposive sampling technique was used to select the samples. The conceptual framework selected for this study is Modified Kenny’s open system model. The tool used for data collection procedures was Wong Baker faces pain rating scale. Cold application was administered for15 to 20 minutes twice a day for two days. Results: On day I, in pre-test majority of postnatal mothers 53.33% in the experimental group had very severe episiotomy pain and 46.67% of them had worse episiotomy pain. After cold application, 73.34% of them had severe pain and 13.33% of them had moderate and very severe episiotomy pain in experimental group. On day II, in pre-test most of postnatal mothers 53.33% in the experimental had moderate pain and 46.67% of them had severe pain. In control group, 66.67% of them had very severe pain and 33.33% of them had severe pain. After cold application, it was surprising that 66.67% of them had mild pain and 33.33% of them had no episiotomy pain in experimental group. There was a significant reduction in mean post-test episiotomy pain (in day I, MD=1.97, t=9.85, p<0.001, in day II – MD=3.57, t=31.72, p<0.001) of the experimental group. In day I the mean post-test score of episiotomy pain in the experimental group was 5.56, which was lesser than that of the control group 7.53 (MD=1.97, t=9.85, p<0.001). In day II, the mean post-test score of episiotomy pain in the experimental group was 0.73, which was lesser than that of the control group 5.63 (MD=4.90, t=24.74, p<0.001). Conclusion: It was concluded that, cold application is an effective non- pharmacological intervention for reducing episiotomy pain among postnatal mothers.

 

 

 

INTRODUCTION:

Pregnancy and child birth are the special events in women’s life. The every process of giving birth is the most beautiful one on earth and the mother attains unique capacities and true nobility through child birth. The onset of motherhood present a unique set of physical, emotional and psychological challenges Lawson., (2015).

 

The mother does suffer with much distress after child birth due to painful perineum resulting from an episiotomy. Episiotomy pain affects physical, psychological and social wellbeing of the mother in the postpartum period. It can also disrupt breastfeeding, family life and infant care. Shankar., (2014).

 

Cold application to the perineum decreases the temperature of the skin and underlying tissue, causes alpha receptors in the blood to become stimulated by the sympathetic nervous system and decreases blood circulation to the region because of vasoconstriction, all of which reduce pain.Sonia., (2011)

 

Nurses have important responsibilities for performing cold application under desirable conditions. Cold application helps to reduce episiotomy pain and possibly increasing mother’s comfort in the early postpartum period after vaginal delivery and improving independent nursing practices. Furthermore, the results obtained in the study would contribute to the current literature on effects of cold application on postpartum episiotomy pain.

 

Need for study:

A cross sectional study conducted on “population based study of episiotomy” in Chennai, India among the sample of 442 women who had vaginal delivery. The result revealed that the rate of overall episiotomy was 67%. For women whose delivery conducted by doctor’s the episiotomy rate was 77.4% and conducted by nurses it was 53.1%, episiotomy rate was 91.8% when delivery was conducted in private medical colleges. Shanti Edward., (2007)

 

Caroline., (2015) conducted a study to evaluate the length of episiotomy pain relief after cold application at Brazil. A quasi experimental study, using a pre and posttest design was undertaken with a sample size of 50 women. The intervention involved a single application of cold for 20 minutes. Immediately, after applying cold to the episiotomy area, there was a significant reduction in the severity of episiotomy pain reported (5.4 vs p<0.005). The researcher concluded that, cold application for 20 minutes is effective for alleviating postpartum episiotomy pain and continues to be effective between 1 hour 35 minutes for up to 2 hour.

 

The investigator found that many postnatal mothers have suffered a lot due to severe episiotomy pain. This also have negative effect on breastfeeding and mother’s baby bonding. The investigator had empathy upon the sufferers and planned to do research on non- pharmacological methods to alleviate episiotomy pain. Since many studies have proved the effectiveness of cold application on episiotomy pain reduction, that motivated the researcher to conduct the study on this topic.

 

Statement of the problem:

A study to evaluate the effectiveness of cold application on episiotomy pain among postnatal mothers in selected hospitals at Kanyakumari district.

 

OBJECTIVES OF THE STUDY:

The objectives are,

1.     To assess the level of episiotomy pain among postnatal mothers in experimental and control group.

2.     To find out the effectiveness of cold application on episiotomy pain among postnatal mothers.

3.     To determine the association between pretest level of episiotomy pain and selected demographic variables such as age, religion, occupation, education, family income, type of family etc.

4.     To determine the association between level of episiotomy pain and selected clinical variables such as parity, BMI(Body Mass Index), gestational weeks, type of episiotomy, length of episiotomy etc.

 

Hypotheses:

H₁: The mean posttest score of episiotomy pain will be significantly lower than the mean pretest score of episiotomy pain in experimental group who had cold application

H₂: The mean posttest score of episiotomy pain among postnatal mothers in experimental group will be lower than the mean posttest score of episiotomy pain in control group

H₃: There will be significant association between pretest score of episiotomy pain among postnatal mothers and selected demographic variables such as age, religion, occupation, education and type of family in experimental group.

H₄: There will be significant association between pretest score of episiotomy pain among postnatal mothers and selected clinical variables such as parity, body mass index, gestational weeks, type of episiotomy and length of episiotomy.

 

Conceptual frame work:

The conceptual frame work selected for this study is Modified Kenny’s open system model.

 

METHODS AND MATERIALS:

The study was conducted in selected hospitals at Kanyakumari district. The population of this study were postnatal mothers with episiotomy and who met the inclusive criteria. Purposive sampling technique was used to select the samples for the study. The total number of samples were 60 (i.e.) 30 in each group. The data collection tool used in this study consisted of two sections. Section one was demographic and clinical variables, section two was Wong Baker Faces pain rating scale to assess the episiotomy pain among postnatal mothers. Validity of the tool was obtained from 5 experts. Reliability was tested using inter rater method. 

 

Pilot study was conducted on 6 samples to find out the feasibility of conducting the study. The main study was conducted at Rathna hospital, Swamiyarmadam. The level of episiotomy pain was assessed by Wong Baker Faces pain rating scale for both groups. After pretest, cold application given for experimental group. Post test assessment of episiotomy pain for both groups.

 

As the variations in the level of episiotomy pain could not be completely assessed by a single observation. Therefore two observations were recorded. The data were analyzed by using descriptive and inferential statistics and tested the hypotheses at p<0.001 level.

 

RESULTS AND DISCUSSION:

The data was analyzed and presented under the following sections:

 

Section I: Frequency and percentage distribution of postnatal mothers according to their selected demographic variables

 

Section II: Distribution of the pretest and posttest level of episiotomy pain among postnatal mothers

 

Section III: Comparison of pretest and post-test level of episiotomy pain among postnatal mothers in experimental group.

 

Section IV: Association between the pretest level of episiotomy pain among postnatal mothers with their selected demographic and clinical variables

 

Section I:

Distribution of postnatal mothers after normal vaginal delivery with regards to demographic variables.:

According to age in experimental group most of postnatal mothers 11(36.67%) were between the age group of 20-25 years and 26-30 years each. In the control group majority of postnatal mothers were 12(40%) belongs to 26-30 years.

 

Religion of postnatal mothers depicted that, in experimental group half of them were 15(50%) Christians and in control group also most of them were 12(40%) in Christians. With regards to occupation the dispersion of postnatal mothers in experimental group ¾^th (76.67%) of them were homemakers and only 5(16.67%) of them were professionals. In control group also most of them 22(63.33%) were homemakers and 7(23.33%) of them were professionals.

 

Educational level of postnatal mothers depicted that, nearly ¾^th (73.33%) of them in experimental group, 21(70%) in control group were graduates. Considering the family income of postnatal mothers nearly half of them 15(50%) in experimental group, 14(46.67%) in control group were having the monthly income of 20,001 to 30,000 rupees. 

 

Dispersion of postnatal mothers according to type of family in experimental group, more than half 17(56.67%) of them in experimental group, 18(60%) in control group were from extended family   

 

Considering the age at marriage of postnatal mothers in experimental group, more than half 17(56.67%) of them were married between the age of 23-26 years. In control group, most of them 14(46.67%) were married between the age of 18-22 years and 23-26 years each.

 

Distribution of postnatal mothers after normal vaginal delivery with regards to clinical variables:

The frequency and percentage distribution of postnatal mothers according to their selected clinical variables. With regards to parity majority of them 20(66.67%) were primi mothers and 10(33.33%) were multi mothers in experimental group. In control group, 19(63.33%) were primi mothers and 11(36.67%) were multi mothers.

 

Considering the maternal height, most 20(66.67%) of them were 161-165cm tall. In control group, more than half 18(60%) of them were in between the height of 161-165cm tall. Regards to body mass index, interestingly all postnatal mothers 60(100%) were between 18.5-29.9 in the both groups.

 

According to the weeks of gestation, in experimental group most of them 22(73.33%) were in 39⁺¹ to 40 weeks. In control group, more than half 19(63.33%) of them were in 39⁺¹ to 40 weeks and 11(36.67%) of them in 38⁺¹ to 39 weeks Considering the birth weight of baby in experimental group, majority 19(63.34%) of the babies were born with the birth weight of 3.1 to 3.5kg. In control group, most of them 18(60%) were had birth weight of 3.1 to 3.5kg. According to the type of episiotomy all postnatal mothers 60(100%) received right medio-lateral episiotomy in both groups.

 

Dispersion of postnatal mothers according to the length of episiotomy in experimental group, majority 18(60%) of postnatal mothers had the episiotomy between the length of 4-5cm. In control group, more than half 17(56.67%) of them had episiotomy between the length of 4-5cm long.

Section II:

Table 1: Distribution of pretest and posttest level of episiotomy pain among postnatal mothers in the experimental group. (n = 30)

Level of episiotomy pain reduction	Day I				Day II
	Pretest		Post test		Pretest		Post test
	f	%	f	%	f	%	f	%
No Pain	0	00.00	0	00.00	0	00.00	10	33.33
Mild Pain	0	00.00	0	00.00	0	00.00	20	66.67
Moderate Pain	0	00.00	4	13.33	16	53.33	0	00.00
Severe Pain	0	00.00	22	73.34	14	46.67	0	00.00
Very Severe Pain	16	53.33	4	13.33	0	00.00	0	00.00
Worse Pain	14	46.67	0	00.00	0	00.00	0	00.00

 

Day I:

Table 1 predicts that, in pretest majority of postnatal mothers 16(53.33%) had very severe pain, 14(46.67%) of them had worse pain. But after intervention, majority of postnatal mothers 22(73.34%) had severe pain, only 4(13.33%) of them had very severe pain. But none of them had worse pain.

 

Day II:

In pretest more than half 16(53.33%) of them had moderate pain, 14(46.67%) had severe pain. After cold application, most of them 20(66.67%) had mild pain, 10(33.33%) had no pain. And none of them had moderate pain, severe pain, very severe pain and worse pain.

Table 2: Distribution of pretest and posttest level of episiotomy pain among postnatal mothers in the control group. (n= 30)

Level of	Day I				Day II
episiotomy pain	Pretest		Posttest		Pretest		Posttest
perception	f	%	f	%	f	%	f	%
No pain	0	0	0	0	0	0	0	0
Mild pain	0	0	0	0	0	0	0	0
Moderate pain	0	0	0	0	0	0	5	16.67
Severe pain	0	0	2	6.67	10	33.33	20	66.67
Very severe pain	16	53.33	27	90	20	66.67	5	16.67
Worse pain	14	46.67	1	3.33	0	0	0	0

 

Day I

Table 4 predicts that, in pretest more than half 16(53.33%) of them had very severe pain, 14(46.67%) had worse pain. But in posttest majority 27(90%) of them had very severe pain, 2(6.67%) had severe pain, 1(3.33%) had worse pain and none of them had no pain, mild pain and moderate pain.

 

Day II

In pretest most 20(66.67%) of them had very severe pain, 10(33.33%) had severe pain and none of them had no pain, mild pain, moderate pain and worse pain. But in post test majority 20(66.67%) of them had severe pain, 5(16.67%) had very severe pain, 5(16.67%) had moderate pain and none of them had no pain, mild pain and worse pain.

Section III:

Table 3: Comparison of the pretest and posttest level of episiotomy pain among postnatal mothers in experimental group. n = 30

Group	Observation	Test	Mean	SD	Mean Diff	Paired ‘t’ test	‘P’ value
Experimental group	Day I	Pretest	8.40	0.61	2.83	26.21	0.001*
		Posttest	5.56	0.89
	Day II	Pretest	4.30	0.80	3.57	31.72	0.001*
		Posttest	0.73	0.58

*Significant at 0.001 level

 

Table 3 summarizes that, in day I the pretest pain score in the experimental group is 8.40 and post test pain score is 5.56. The obtained ‘t’ value 26.21, which was statistically significant p<0.001 level. This indicates that the mean difference of 2.83 is a true difference and has not occurred by chance. In day II, the pretest mean score in the experimental group is 4.30 and post test mean score is 0.73. The obtained ‘t’ value 31.72, which was statistically significant at p<0.001 level. This indicates that the mean difference of 3.57 is a true difference and has not occurred by chance. This proves that due to the effect of cold application the mean posttest score of episiotomy pain among postnatal mothers in experimental group had marked reduction.

 

Figure 1: Comparison of mean pretest and posttest score of episiotomy pain among postnatal mothers in experimental group.

Table 4: Comparison of the posttest score of episiotomy pain among postnatal mothers in experimental and control group.N =60

Group	Day	Mean	SD	Mean Diff	Paired ‘t’ test	‘P’ value
Experimental group	I	5.56	0.89	1.97	9.85	0.001*
Control group	I	7.53	0.68
Experimental group	II	0.73	0.58	4.90	24.74	0.001*
Control group	II	5.63	0.96

*significant at 0.001 level

 

Table 4 shows that, on day I in experimental group the mean post test score 5.56 was less than the mean post test score of the control group 7.53. the obtained ‘t’ value 9.85 were statistically significant at p<0.001 level. This indicates that the mean difference of 1.97 is a true difference and not occurred by chance. In day II the mean post test score 0.73 was less than the mean post test score of the control group 5.63. The obtained ‘t’ value 24.74 were statistically significant at p<0.001 level. This indicates that the mean difference of 4.90 is a true difference and not occurred by chance. This shows that a marked reduction in the score of episiotomy pain among postnatal mothers in experimental group.

 

N = 60

 

Figure 2: Comparison of the posttest level of episiotomy pain among postnatal mothers in experimental and control group.

 

Section V:

Association between pretest level of episiotomy pain and their selected demographic variables in the experimental and control group:

There is an association between pretest level of episiotomy pain among postnatal mothers with their selected demographic variable such as age (χ²value 6.01, p<0.05) and clinical variables such as parity (χ² value 6.69, p<0.05), birth weight of baby (χ²value 8.31, p<0.05)and length of episiotomy(χ²value 11.8, p<0.05) in experimental group. So the researcher partially rejects the null hypotheses and accepts the research hypotheses for age, parity, birth weight of baby and length of episiotomy.

 

There is an association between pretest score of episiotomy pain among postnatal mothers and their selected demographic variable such as age (χ²value 6.71, p<0.05) and clinical variables such as parity (χ² value 4.73, p<0.05), birth weight of baby (χ²value 6.16, p<0.05)and length of episiotomy(χ²value 9.02, p<0.05) in control group. So the researcher partially rejects the null hypotheses and accepts the research hypotheses for age, parity, birth weight of baby and length of episiotomy.

 

These findings proves that due to the effect of cold application on episiotomy pain among postnatal mothers in experimental group had marked reduction. Cold application is an effective non-pharmacological interventions for reducing episiotomy pain. Nurse should have knowledge regarding the benefits of cold application as a nursing intervention in reducing episiotomy pain.

 

Limitations:

·       The sample size was 60 postnatal mothers hence generalization is not possible for a larger population.

·       The data collection period was only one month.

·       The study was limited to postnatal mothers with episiotomy and between the age of 20 – 40 years at Rethna hospital, Swamiyarmadam.

 

Recommendations:

·       A similar study can be conducted with large sample size to generalize the result.

·       A study can be carried out for a longer period of time.

·       A comparative study on cold application can be conducted with other measures such as hot application, sitz bath etc.

·       A similar study can be conducted in a different setting.

·       The effectiveness of cold application can be can be tested on other variables such as labor pain, episiotomy wound healing etc.

·       A descriptive study can be done to assess the current knowledge on the management of episiotomy pain among postnatal mothers.

 

REFERENCE:

Book reference:

Dutta, D.C.(2007). Text Book of Gynecology (7^th Edition). Calcutta: New Central    Book Agency.

George, J.B.(2011). Nursing Theories. New Delhi: Pearson Publications.

KaminiRao, (2011).Text book of Midwifery and Obstetrics for Nurses. New Delhi:                  Elsevier.

Journals:

Alison J. Macarthur, (2004). Incidence, severity, and determinants of episiotomy pain after vaginal delivery: A prospective cohort study. American Jorunalof Obstetrics & Gynecology, Vol.191, No. (4).

ChaweewanYusamran, (2007). Relief episiotomy Pain After Perineorrhaphy by Cold Gel Pack Pad: A Randomized Controlled Trial. Thai Journal of Nursing Research, Vol.11, No. (2).

Net reference:

Francisco AA, Vasconcellos de Oliveria SMJ, Barbosa da Silva FM, Bick D, Riesco MLG, Women’s experiences of episiotomy pain during the immediate postnatal period: a cross sectional study in Brazil. Midwifery. 2011; 27(6): 254- 9. Retrieved from: https://doi.org/10.1016/j.midw.2010.10.012

Swain J, Dahlen HG. Putting evidence into practice: a quality activity of proactive pain relief for postpartum episiotomy pain. women birth. 2013; 26(1): 65-70. Retrieved from :https://doi.org/10.1016/j.wombi.2012.03.004

 

 

 

Received on 10.12.2018         Modified on 31.12.2018

Accepted on 28.01.2019      ©A&V Publications All right reserved