Effect of Sitz Bath on Episiotomy Wound Healing and Level of Pain among Post Natal Mothers

 

Pratibha Khosla

Assistant Professor, Faculty of Nursing, Siksha ‘O’ Anusandhan University, Bhubaneswar, Odisha

 

ABSTRACT:

Enhancing healing of episiotomy wound is one of the major concerns after a normal delivery. The study aimed to identify the effectiveness of sitz bath on reducing pain and wound healing. With use of universal pain scale and REEDA scale were measured from sample of 20 from experimental and control group on 1^st, 3^rd and 5^th postnatal day. The experimental group had a significant improvement in wound healing and level of pain.

 

 

 

INTRODUCTION:

To facilitate the birthing process and prevent perineal tear, episiotomy is routinely done, but there are many complications associated with episiotomy wound. With proper episiotomy care, infection can be prevented and healing takes place faster.¹

Health care is dynamic field, ever spiraling to words greater improvement and innovative technologies and intervention. Perineal wounds are either a tear or an episiotomy.² Perineal pain is most commonly associated with vaginal delivery with episiotomy. The care of episiotomy is an important aspect of postnatal care and sitz bath is one of the most popular methods of relieving episiotomy discomfort and pain.³ Approximately 33% of women with vaginal deliveries received an episiotomy in 2000. However; the prevalence of episiotomy can vary between countries.

 

Studies have reported that 10% of women experienced pain for more than two months following spontaneous vaginal delivery with the rate rising to 30% for those who had an assistant vaginal birth. One recent study revealed that episiotomies were performed in 97.3% of 510 Primiparous women undergoing vaginal deliveries. At present, regular antiseptic sitz baths are one of the methods for treating episiotomy wounds. The concern of health personnel during this period should be to provide comfort to her, help her in relieving pain and to prevent infection. Enhancing healing of episiotomy wound is one of the major concerns after a normal delivery. The episiotomy wound should be assessed for oedema, swelling, tenderness, and discharge and also for localized pain. Puerperal infections are costly in terms of delayed mother infant interaction, lactation difficulties, prolonged hospital stay or readmission in hospital and increased expenses. Heat increases circulation to the perineal area and relaxes the tissue. Either moist or dry heat can be applied after the first 24 hours^4.

 

Approximately 70% of women who have a vaginal birth will experience some degree of damage to the perineum, due to a tear or cut (episiotomy), and will need stitches. Asian race are presumed to have smaller and tighter perineum, so the routine episiotomy may reduce the risk of perineal tearing during delivery⁵ 

 

It may causes mental disorders in mother during postpartum and change her attitude and activities towards her neonate⁶. The application of water externally to the body for therapeutic effect is a practice called Hydrotherapy or Water therapy.” One of the most popular methods of using hydrotherapy is the sitz bath Originating in Germany, a sitz bath is natural method of soaking in very warm water. Doing this repeatedly is said to stimulate the lymphatic system, increase circulation and remove toxins. (Mc Guinas, 2004) Sitz bath is the form of water bath, which is coming back into popularity as a low risk. Sitz bath-term comes from the German verbs “sitzen” meaning to sit. The sitz bath is a European tradition in which only the pelvis and abdominal area are placed in the water .It helps for women after child birth whether or not had an episiotomy. If the perineum has been sutured it should be kept clean and dry. The perineum should be attended in the morning, in the evening, and after each urination or defecation. Sitz bath is used to reduce discomfort and perineal pain. Sitz bath or hipbath is used to soak a client’s pelvic area. The client sits in a special tub or chair and usually immersed from the mid thighs to the iliac crest or umbilicus. The desired temperature of the water should be from 40- 43 degree centigrade. A sitz bath depends on whether the purpose is to promote relaxation or to clean a wound. It may be necessary to add warm water during procedure which normally last twenty minutes, to maintain a constant temperature. Heat in the form of lamps, warm sitz bath and moist pack is thought to produce vasodilatation, increase circulation, thereby alleviating pain, and promote healing. Local anesthesia in the form of sprays, creams and ointments penetrate into the sensory nerve endings and reduce the response to sensory stimuli by producing a depressant effect on the peripheral nerves. Ice packs are used to reduce swelling. 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 pain.⁷

 

A descriptive scale known as the REEDA scale (Davidson, 1974) measuring five components associated with the healing process. The acronym REEDA is derived from five components that have been identified to be associated with the healing process. These are: redness, edema, ecchymosis, discharge and approximation of skin edges. Each category is assessed and a number assigned for a total REEDA score ranging from 0–15. The higher scores indicate increased tissue trauma. This tool appears to be the first systematic attempt to evaluate postpartum healing, which acknowledges the need for a standardized assessment tool independent of the severity of the perineal injury Brooke Anspach, 1915, an associate in Gynecology at the University of Pennsylvania in annual meeting of the AGS declared that episiotomy wound reduce the physical incapacity following labour and by facilitating delivery would reduce infant mortality and maternal morbidity, some studies have linked episiotomy with increased perineal damage, postpartum pain, blood loss and infection. Any procedure which tends to lesser irksomeness and bounder will find a ready ear in the profession. The mother is vulnerable to get infection in the postnatal period. Perineal management is increasingly becoming part of midwifes role. Not only to prevent puerperal sepsis but also intervention towards the goal of relieving mother pain, discomfort, to promote healing and prevent complication of episiotomy.⁸

Pain and discomfort from episiotomies therapeutic cleaning soak, such as warm water sitz bath to promote blood flow to the episiotomy for rapid healing⁶ Episiotomy rates vary wildly worldwide, depending on whether the procedure is used restrictively-routinely. The world wide episiotomy rate was 27%, 54%, are nuiliparous and 6% are multiparous women (WHO 2003). Rates vary from 8% in the Netherland, 13% in England to 25% in USA. Among English speaking Countries, US had the highest episiotomy rate varying greatly from region. One in 3 mothers who delivered vaginally in the US from 1995 to 2003 had episiotomies. In India the birth rate is very high 56% of women had an episiotomy Compared to the 46% of white women. The difference between these % age (10%) is measure of the excess frequency of episiotomy in Indian women. According to the American collage of obstructive and gynecology approximately 1 in 3 women having a vaginally delivery also has an episiotomy².

 

MATERIAL AND METHODS:

This study was done in two groups with  pre-test post-test quasi experimental design one receiving the intervention and other taken as control group with a sample of 20 in each group and non probability type of convenient sampling techniques was used. The intervention sitz  bath was done two times daily once in the morning and once in evening for 20 minutes with the cooperation of the mother after 12 hours of delivery for five consecutive days and assessment was done in the 1^st,3^rd and 5^th day. The socio demographic data like age, education, religion, occupation, type of family, socioeconomic status, area of residence was collected and the level of pain was assessed with the help of universal pain scale, absence of pain, mild pain, moderate pain and severe pain where the lowest score is 0 and highest being 10 and assessment of episiotomy wound healing by standardized REEDA scale was used where healed, mildly healed, moderately healed and not healed.The reliability of the tool confirmed at 0.87 through chronbach co-efficient estimation. The data was analyzed by using SPSS version 21. The baseline characteristics were analyzed by percentage, mean and SD. The independent‘t’ test showed the difference in mean score among the groups.

 

RESULTS:

Majority of mothers 46.25% belong to the age group 25-30 years, 50% had secondary level education 81.25% women were house wife, 77.5% women belongs to middle class, Day one in pre- test 86.25% had severe pain and in post test 57.5% had severe pain, post-test in 3^rd day 57.5% had severe pain and on post-test in 5^th day only 5% had severe pain in both groups. Infection rate in pre-test 83.75% had moderate infection. In post-test 3^rd and 5^th day mild infection was 57.5% and 45% respectively. The mean percentage of pain score in sitz bath is 2.5, and in control group it is 2.95. This is strongly supports that the effect of sitz bath on pain and REEDA scale assessment is more than control group.

Table 1. Comparing mean level of pain among both the groups

*significant

 

Table 2. Comparing mean on REEDA scale among both the groups

*significant

 

DISCUSSION:

The main aim of the study was to explore the effectiveness of sitz bath on episiotomy wound healing and level of pain. Most of the study samples in both the groups are above 25 years of age. This study reveals that in experimental group (sitz bath) mean was 2.5 in 1^st day,3^rd day it was 2.05 and in 5^th day it was 1.7. The rate of wound healing mean in moist heat was on 1^st day 6.95, 3^rd day it was 5.6 and in 5^th day it was 2.5.Whereas in control group on 1^st day the mean of the pain was 2.95, 3^rd day it was 2.5 and in 5^th day it was 2.05.The mean of the wound healing on 1^st day was 11.3, 3^rd it was 7.5.5^th day was 2.95.The findings shows that the sitz bath has effect on Episiotomy wound healing and reduction of pain than without any intervention.

 

The findings of this study are supported by another study which states that both the experimental and control group were statistically homogenous (p>0.05). Application of sitz bath therapy had significant reduction in episiotomy pain as mean score of episiotomy pain got decreased from 5.205.20±2.17 to 0.73±0.78 in experimental group and 4.90±2.33 to 2.73± 1.50 in control group (p=0.05).Application of sitz bath therapy had significant improvement in episiotomy wound healing as mean score of episiotomy wound healing got decreased from 8.26±2.03 to 2.70±0.65 in experimental group and 7.73±1.61 to 3.233±1.47 in control group (p=0.001) Experimental group had greater change in mean score of episiotomy pain and wound healing on 1st, 2^nd and day 3rd day of post-intervention which was statistically significant (p=0.001) as compared to control group.⁶

 

LIMITATION:

The study result is limited for generalization due to few samples in a restricted set up.

 

Ethical approval:

The study proposal was duly approved by the Hospital Ethical Research committee before commencement of the main study. The permission was accorded priorly from the medical superintendent of the hospital. The mothers were explained about the purpose of the study and mothers those were not willing to participate were excluded.

 

ACKNOWLEDGEMENT:

I really appreciate the contribution of ward sisters in assisting in completion of study and the Doctor in Charge, in guiding for correct assessment.

 

REFERENCES:

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2.        Al-Ghammari K, Al-Riyami Z, Al-Moqbali M, Al-Marjabi F, Al-Mahrouqi B, Al-Khatri A, et al. Predictors of routine episiotomy in primigravida women in Oman. Appl Nurs Res. 29; 2016:131–5.

3.        Behmanesh F, Aghamohammadi A. Effects of olive oil sitz bath on improvement of perineal injury after delivery. Koomesh. 14(3); 2013:309-315.

4.        Kaur N, Rana AK, Suri V. Effect of dry heat versus moist heat on Episiotomy pain and wound healing. 9(1);  2013: 21–33.

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6.        Sagar N, Kaur J, Jindal P. Research article effect of sitz bath in reduction of episiotomy pain and wound healing among postnatal mothers. International Journal of Current Research. 7(2); 2015: 12461-12463

7.        Sheikhan F, Jahdi F, Khoei EM, Shamsalizadeh N, Sheikhan M, Haghani H. Episiotomy pain relief: Use of Lavender oil essence in primiparous Iranian women. Complement Ther Clin Pract. 18(1): 2012:66–70.

8.        Das S. Evaluative study to assess the effectiveness of infrared therapy on episiotomy wound. Siksha O’ Anusandhan University; 2012.

 

 

 

 

 

Received on 28.02.2017          Modified on 28.03.2017

Accepted on 01.05.2017          © A&V Publications all right reserved