http://doi.org/10.33698/NRF0150  Navdeep Kaur, Avinash Kaur Rana, Vanita Suri

Abstract: Perineal trauma is a frequent complication to vaginal delivery especially with episiotomy. Pain and discomfort related to episiotomy interfere with women’s daily activities during postpartum period. Keeping this in mind, present comparative study on effect of dry heat versus moist heat was aimed at relieving pain and promoting wound healing at the episiotomy site. Research setting included Maternity ward, Gynae ward, Clean labor room and Gynae OPD at PGIMER, Chandigarh. Eighty-six subjects were enrolled by purposive sampling and later on allocated randomly into two groups (group 1- dry heat, group 2- moist heat). Tool for pain measurement was modified numerical pain rating scale and for wound healing was modified REEDA (Redness, Ecchymosis, Edema, Discharge, Approximation) scale. Findings of study revealed a highly significant difference between the groups in terms of pain scores and wound healing [p<0.001 on day 7 and p<0.01on day 14 for pain scores] and [p<0.001 on day 7 and p<0.05 on day 14 for wound healing scores]. Though both the interventions were effective but dry heat was more effective than moist heat in relieving pain and promoting wound healing at the episiotomy site.

Key Words:

Episiotomy, Dry heat, Moist heat, Pain, Wound healing

Correspondence at:

Dr. Navdeep Kaur

# 1672, Shahid Karnail Singh Nagar, Phase II, Pakhowal Road, Ludhiana

Introduction

Having an episiotomy may increase perineal pain during postpartum recovery, resulting in trouble defecating, particularly in midline episiotomies. In addition it may complicate sexual intercourse by making it painful and replacing erectile tissues in the vulva with fibrotic tissue. In cases where an episiotomy is indicated, a mediolateral 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.1

According to a study by Mary et al, perineal healing was compared between 181 women with episiotomies and 186 women without episiotomies (tears & lacerations) at one to two weeks after delivery.The results suggest that women without episiotomies exhibit better perineal healing than women with episiotomies.2 A study reveals that sutured damage to the perineum occurs in at least 39% of women being delivered and perineal wound breakdown is associated with perineal edema. Recommendations based on the findings include a careful emphasis on perineal hygiene, cryotherapy, elevation of the foot of the bed in the presence of perineal oedema and regularly performed pelvic floor exercises.3

Many studies in the literature are available on heat therapy in the form of dry heat or wet heat. A study by Pamela D. Hill revealed no difference in wound healing scores after comparison of heat and cold on the perineum.4 Though no research evidence is available but some suggest to air-dry the rectal area with a hair dryer for postpartum hemorrhoids. It is suggested that the woman should lie on the bed without panties or the sanitary napkin. Place towels under buttocks to absorb any vaginal discharge. She should lie on her back with the knees bent and feet flat. Let the rectum dry by holding a hair dryer 10 to 12 inches away from opisiotomy. The dry heat from hair dryer which gives a soothing effect on the wound.5 Another study was undertaken to assess the effectiveness of a warm versus cold sitz bath in relieving post episiotomy pain. Sensation, distress, edema, and hematoma ratings were obtained pre- and post treatments. Both therapies were found comparable, with the exception that the cold bath was significantly more effective in reducing edema.6

Another study identified the effect of sitz bath on intensity of pain at episiotomy site among postnatal mothers and results showed significant difference in mean pain score between control and experimental group as p value was <0.001.7 In another study, comparison of an ice bag versus heat lamp was done to assess the peineal discomfort after vaginal delivery. Study revealed that ice bag was significantly more effective in relieving perineal discomfor t than heat lamp. Researcher suggested that nurses should provide women with adequate information about the use of ice bag and encourage to apply ice bag instead of heat lamp after episiotomy in order to promote the relief of perineal discomfort and the healing of perineal wound.8

According to Venkadalakshmi and coworkers, infrared therapy with lamp reduces episiotomy pain and enhances wound healing in postnatal mothers. It is a suitable alternative of intervention for those with episiotomy wound.9 A clinical trial at Iran was done to assess the healing advantages of lavender essential oil during episiotomy on 120 primiparous women who had undergone normal spontaneous vaginal delivery and episiotomy. Results revealed that redness in lavender group was significantly less than controls (p < 0.001). This study suggests application of lavender essential oil instead of Povidone-iodine for episiotomy wound care.10

Another study revealed that placement of bupivacaine-soaked spongostan into the episiotomy bed resulted in decreased postpartum pain and drug requirement. It may be attributed to a higher drug concentration at episiotomy bed and prolonged drug effect.11 Musgrove H did a randomized controlled trial on the effect of hot packs on the perineum in second stage in terms of pain and trauma. 70% of the recipients of hot packs felt the packs relieved pain and 80% said they provided comfort. The midwifery staff involved also supported the women’s view that hot packs were beneficial in reducing pain and perineal damage.12 Another double-blind clinical trial by Tara et al suggests that the turmeric ointment enhances the healing at the episiotomy site and decreases the duration of healing from 14 days to10 days. Therefore, it seems that this ointment can be prescribed for primiparous women with episiotomy incisions.13

According to a clinical trial conducted by Hur and Han, postpartum aromatherapy for perineal care could be effective in healing the perineum. The REEDA (Redness, Edema, Ecchymosis, Discharge, Approximation) scale was significantly low in the experimental group at postpartum 5th and 7th days (P=.009, P=.003) respectively which suggests better wound healing because lower REEDA scores indicate better wound healing. 14

An ice bag applied to the perineum may help reduce edema and discomfort during the first several hours after episiotomy repair. Beginning about 24 hours after delivery, moist heat as provided with warm sitz baths can be used to reduce local discomfort. Tub bathing after uncomplicated delivery is allowed.15 As a result, there has been increasing number of research studies that challenge the traditional pattern of postpartum care and its overall provision and value.16

Although all these measures enlisted above are used to relieve pain and promote wound healing of episiotomy among postnatal mothers, but providing dry heat with a hair dryer seems to be a much less emphasized strategy. Researcher has found an ample interest to determine the effect of this method as compared to the traditional sitz bath in Indian scenario. Hair dryer will not only dry the stitches at episiotomy site but also provide soothing dry heat that will initiate wound healing and pain relief.

Although, dry heat with a hair dryer is being used in some of the patients with perineal wounds in wards at Nehru Hospital, PGIMER, Chandigarh but researcher could not find any research studies related to this intervention. Hence, it is important that healthcare professionals, who attend to new puerperas, know how to assess and treat perineal pain. Considering the high rates of perineal trauma following vaginal deliveries, we need to offer patients treatment alternatives for perineal pain, based on scientific evidence. The present study is an effort in this direction.

Objective

To compare the effect of dry heat versus moist heat on episiotomy pain and wound healing among postnatal mothers.

Null Hypothesis

There is no significant effect of dry heat versus moist heat on episiotomy pain and wound healing at 0.05 level of significance.

Materials and Methods

A Comparative design was adopted to compare the effect of dry heat (Hair Drier) versus moist heat (Sitz Bath) on pain and wound healing at episiotomy site among postnatal mothers admitted in Nehru Hospital, PGIMER, Chandigarh. The Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh was conceived in 1960 to provide high quality clinical care, attain self-sufficiency in postgraduate medical education. Nehru Hospital is attached to Labour room, Maternity Ward and Gynae Ward are situated at 3rd floor (B-Block) of Nehru Hospital. Labour room is an area where all cases get admitted in emergency obstetrical conditions like leaking per vaginum (LPV), bleeding per vaginum (BPV) etc. Postnatal mothers are shifted to the Maternity ward and Gynae ward as per the availability of beds.

Target population for study was postnatal mothers having normal vaginal delivery with episiotomy. Inclusion criteria was all postnatal mothers delivered within 12-24 hrs., having episiotomy, educated up to matric and residing in or near Chandigarh (Mohali, Ambala, Panchkula). Exclusion criteria was subjects with instrumental delivery (forceps/ ventouse), LSCS, severely anemic, on cortico- steroids, diabeteic and perineal tears. Purposive sampling technique was used to enroll eighty-six subjects. Delivery record register of CLR was checked and mothers who satisfied the above inclusion criteria were randomly allocated by slip method into group1 (dry heat) and group 2 (moist heat) and approached for participation in the study.

Protocols and tools were prepared after review of literature and validated by experts in the field of obstetrics, Gynaecology & Nursing. Tools used were socio-demographic profile sheet of mother, obstetric profile and hemoglobin level of mother, birth weight of baby, for pain measurement modified numerical pain rating scale and for wound healing modified REEDA (Redness, Ecchymosis, Edema, Discharge, Approximation) scale. Minimum score in REEDA tool was 5 and maximum was 20. Lower wound healing score indicated better healing at the episiotomy site.

Separate tub was used for all mothers. Relatives were told to bring the medium sized plastic tub. Hair drier was carried with the researcher for the intervention.

Ethical clearance for the study was obtained from institute ethical committee & informed written consent was taken from the subjects. Data was collected in the month of July-August, 2011. A written permission for conducting the study was sought from Head of department of Obstetrics and Gynecology. Nursing sister in charge of concerned areas was informed about study. Socio- demographic sheet, obstetric profile and hemoglobin level of mother along with birth- weight of baby was filled for all the mothers. Intervention in both the groups was given twice a day as per protocol. Pain and wound healing assessment was done at baseline, day 1, day 7 and day 14 by modified numerical pain rating scale and REEDA tool respectively. Pain was also assessed on day 2. After discharge from hospital, subjects came to Gynae OPD for follow-up on day 7 and 14 as dates were given to them (before discharge) on a slip on which OPD timings and block were mentioned. Descriptive and inferential statistics was used for analysis and interpretation of data by applying mean, standard deviation, Chi-square, Mann-whitney and Wilcoxon sign rank test.

Results

In both the groups 86 mothers enrolled i.e. 43 in each group. Average age of group 1 mothers were 27.3 ± 3.7 years as compared to 25 ±3.4 years in group z mothers. Educational status of 74.5% mothers in group 1 was graduated and above as compared 41.8% of mothers were graduate and above in group z. Most of the mothers in both the groups were urban dwellers, the groups were homogenous as per age and locality as for p.75

Table 1: Socio-demographic profile of subjects                           N=86

 

Variables Group 1 (Hair drier) Group 2 (Sitz bath) X2 , df, p-value
  (n1= 43) (n2= 43)  

Age (years)            n                 (%)                        n                 (%)

<28                      30               (69.8)                   33               (76.7)         0.534, 1, 0.465NS

>29                      13               (30.2)                   10               (23.3)

Mean ± SD          27.3±3.7                                 25±3.4

10th 4 (9.3) 14 (32.6)
10+2 7 (16.3) 11 (25.6)          10.577, 3, 0.014
Graduate 21 (48.8) 13 (30.2)
Postgraduate 11 (25.6) 05 (11.6)
Locality        
Rural 07 (16.8) 08 (18.6) 0.081, 1, 0.776NS
Urban 36 (83.7) 35 (81.4)  
NS – not significant          

 

Education

Table 2 depicts the Parity, Gravida, Period of Gestation (POG), Hemoglobin level of mothers and birth weight of baby. Parity and gravida status was similar in both the groups as depicted by table 2 i.e. 83.7% mothers among both groups had parity 0 and 69.8% mothers among both the groups were primigravida.

In both groups, most of mothers had POG within 36-40 weeks i.e. 88.4% in group 1 and 81.4% in group 2. As per Hemoglobin status of the subjects, 37.2% of the mothers in group 1 had hemoglobin level of 10.1-11.0 gm followed by 27.9% (9.1-10.0 gm) and 37.2% mothers in group 2 had hemoglobin level between 9.1-10.0 gm followed by 27.9% (10.1-11.0 gm). Birth weight of newborns was within 2.0-2.9 kg in both groups i.e. 60.5% in group 1 and 62.8% in group 2. 30.2% newborns in group 1 and 25.6% newborns in group 2 had birth weight 3 kg.

No statistically significant difference was seen in terms of obstetric variables related to parity, gravida, period of gestation, Hemoglobin level of mother and birth weight of baby as per chi-square test (p>0.05).

Table 2: Obstetrical Profile & Hemoglobin level of mother and birth weight of baby N=86

 

Variables Group 1 (Hair drier) ` Group 2 (Sitz bath) X2 , df, p-value
  (n1= 43)   (n2= 43)  
Parity n                (%)   n                 (%)  
1 36 (83.7) 36 (83.7) 0.000, 1,
2 07 (16.3) 07 (16.3) 1.000NS
Gravida            
Multigravida 13 (30.2) 13 (30.2) 0.000, 1,
Primigravida 30 (69.8) 30 (69.8) 1.000NS
POG (weeks)            
31-35 05 (11.6) 06 (14.0) 0.104, 1,
*36-40 38 (88.4) 37 (86.0) 0.747NS
Hemoglobin (g/dl)
<9 01 (2.3) 02 (4.7) 2.450, 4,
9.1-10.0 12 (27.9) 16 (37.2) 0.654NS
10.1-11.0 16 (37.2) 12 (27.9)  
11.1-12.0 11 (25.6) 08 (18.6)  
>12 03 (7.0) 05 (11.6)  
Birth weight (Kg)
01-1.9 04 (9.3) 05 (11.6) 0.297, 2,
2.0-2.9 26 (60.5) 27 (62.8) 0.862NS
>3 13 (30.2) 11 (25.6)  

NS – not significant (p>0.05)

Table 3 depicts the comparison of pain scores at the episiotomy site between both the groups. The subjects in group 1 (dry heat) had lesser pain intensity than the others in group 2 (sitz bath) after the intervention. No significant difference of pain scores was observed at the baseline i.e. pre-intervention observation as per Mann-Whitney U test (p>0.05). At day 1, mean pain score SD in both the groups was lesser than baseline (4.02±1.4 in group 1 and 4.65±1.4 in group 2). At day 2, mean pain score ±SD in group 1 (2.91±1.0) was less as compared to group 2 (3.60±1.4). Maximum difference of mean pain scores SD was seen at day 7 (2.26±1.7 in group 1 and 3.70±1.6 in group 2) which shows increased pain intensity in group 2 (Sitz Bath). Finding was similar at day 14 when mean pain score SD was lesser in group 1 (1.10±0.4) compared to group 2 (1.57±0.8). There was significant difference of mean pain scores between the groups on day 1(p<0.05), 2(p<0.01), 7(p<0.001) and14(p<0.01) as revealed by Mann-Whitney U test.

Table 3: Comparison of Episiotomy Pain Scores between the groups                      N=86

 

Day of pain score assessment Group 1 (Hair Drier) Group 2 (Sitz Bath) Mann – whitney U value, p-value
  n1 Median

Pain

Mean

Pain

n2 MedianMean

Pain    Pain

 
    Score Score±SD   Score Score±SD  
Baseline 43 5.00 5.77±1.5 43 6.00 5.98±1.7 844.50, 0.479NS
Day 1 43 4.00 4.02±1.4 43 5.00 4.65±1.4 688.5, 0.037
Day 2 43 3.00 2.91±1.0 43 3.00 3.60±1.4 637.5, 0.008
Day 7 34 2.00 2.26±1.7 33 3.00 3.70±1.6 220.5, 0.0001
Day 14 29 1.00 1.10±0.4 23 1.00 1.57±0.8 214.0, 0.003

 

NS – not significant

Table 4 depicts the comparison of episiotomy pain scores within group 1 and 2 In both the groups, there was reduction of pain from baseline till day 14 as seen by increasing mean pain score difference on day 1,2,7 and 14 compared to the baseline. Results depict that there was increase in pain intensity on 7th day compared to 2nd day among subjects in group 2 (Sitz bath) as revealed by negative value of mean pain scores difference .

In group 1, on comparison of day 2 versus day 7 the pain score showed significant decrease (p<0.05) whereas in group 2, there is no statistically significant difference in pain score as per Wilcoxon sign rank test.

Hence, dry heat with hair drier decreases the intensity of pain as compared to moist heat with sitz bath.

Table 4: Comparison of Episiotomy Pain Scores within Groups              N=86

 

Comparison of pain scores at different of assessment Group 1 (Hair drier) Group 2 (Moist Heat)  

days

Mean difference                 Z, p-value     Mean difference in Z, p-value in pain scores SD                                      pain scores SD

 

Baseline vs.Day1 1.75±0.1 -5.835, 1.33±0.3 -5.257,
    0.0001   0.0001
Baseline vs.Day2 2.86±0.5 -5.710, 2.38±0.3 -5.399,
    0.0001   0.0001
Baseline vs.Day7 3.51±0.2 -4.561, 2.28±0.1 -4.366,
    0.0001   0.0001
Baseline vs.Day14 4.67±1.1 -4.740, 4.41±0.9 -4.214,
    0.0001   0.0001
Day 1 vs. Day 2 1.11±0.4 -4.494, 1.05±0.0 -3.827,
    0.0001   0.0001
Day 1 vs. Day 7 1.76±0.3 -4.285, 0.95±0.2 -2.804,
    0.0001   0.005
Day 1 vs. Day 14 2.92±1.0 -4.747, 3.08±0.6 -4.219,
    0.0001   0.0001
Day 2 vs. Day 7 0.65±0.3 -2.592, -0.10±0.2 -0.012,
    0.010   0.990NS
Day 2 vs. Day 14 1.81±0.6 -4.626, 2.03±0.6 -3.994,
    0.0001   0.0001
Day 7 vs. Day 14 1.16±1.3 -3.776, 2.13±0.8 -4.133,
    0.0001   0.0001

 

Table 5 depicts the comparison of study subjects as per the category of wound healing scores at the episiotomy site. As revealed by the results, there was no significant difference of wound healing scores at baseline and day 1.

But on 7th day, infection rate was much lower in group 1(26.5%) as per REEDA tool compared to 90.9% subjects in group 2 showing highly significant difference of wound healing scores (p< 0.001) as per chi- square test. Range of wound healing scores is also clearly evident on day 7 which is 5-7 in group 1 and 5-9 in group 2.

On 14th day, none of the subjects from group 1 had infection but 13% subjects from group 2 still had mild infection showing statistically significant difference of wound healing scores (p<0.05) as per chi-square test. Findings of the table reveal that dry heat enhances wound healing by decreasing the duration from 14 days to 7 days.

Table 5: Comparison of wound healing scores at the episiotomy site between the groups

N=86

 

Variables

 

Group 1 (Hair dryer)

 

Group 2 (Sitz bath)

 

X2 , df, p-value

Day of assessment Degree of infection n1 (%) Range of wound healing scores n2 (%) Range of wound healing scores  
Baseline No infection 01 (2.3) 5-12 01 (2.3) 5-12 1.050,
  Mild infection 34 (79.1)   30 (69.8)   2,0.592NS
  Moderate 08 (18.6)   12 (27.9)    
  infection              
Day 1 No infection 01 (2.3) 5-12 01 (2.3) 5-12 1.050,
  Mild infection 34 (79.1)   30 (69.8)   2,0.592NS
  Moderate 08 (18.6)   12 (27.9)    
  infection              
Day 7 No infection 25 (73.5) 5-7 03 (9.1) 5-9 28.585,
  Mild infection 09 (26.5)   30 (90.9)   1,0.0
                001
Day 14 No infection 29 (100) 5 20 (87.0) 5-6 4.014,
  Mild infection (—)   03 (13.0)   1, 0.045

 

NS – not significant Table 6 depicts the status of wound healing scores at the episiotomy site within the group 1 and 2. Mean difference of wound healing scores between day 1 and 7 is more in group 1 (3.59±1.2) compared to group 2 (2.42±0.9) which suggests better wound healing in group 1. On comparison of day 7 and 14, mean difference of wound healing scores is lesser in group 1 (0.32±0.6) compared to group 2 (1.57±0.7) which shows that subjects in group 1 had better wound healing at day 7 as dry heat decreased the duration of wound healing from 14 to 7 days. Almost all the observations are showing highly significant difference within the groups (p<0.001) as per wilcoxon sign rank test. However, no difference is seen between baseline and day 1 observation. As per data, majority of subjects in group 1 (dry heat) had clean and dry episiotomy sutures on day 7 as compared to subjects in group 2 (moist heat).

Table 6: Comparison of wound healing scores at the episiotomy site within the groups

N=86

Comparison of wound healing scores at different days of assessment Group 1 (Hair drier) Group 2 (Sitz bath)
  Mean difference of wound healing scores SD Z, p-value Mean difference of wound healing scores SD Z, p-value
Baseline vs. Day 1

Baseline vs. Day 7

3.59±1.2 -5.111, 0.0001 2.42±0.9 -4.627, 0.0001
Baseline vs. Day 14 3.91±1.8 -4.733, 0.0001 3.99±0.6 -4.220, 0.0001
Day 1 vs. Day 7 3.59±1.2 -5.111, 0.0001 2.42±0.9 -4.627, 0.0001
Day 1 vs. Day 14 3.91±1.8 -4.733, 0.0001 3.99±0.6 -4.220, 0.0001
Day 7 vs. Day 14 0.32±0.6 -2.449, 0.014 1.57±0.7 -4.008, 0.0001

Discussion

In Indian scenario, obstetricians and midwives are over burdened and hence find themselves incapacitated to attend to perineal discomforts after episiotomy. Postpartum pain also hinders physical mobility and it is challenging for the mothers to sit in a tub for sitz bath with a painful episiotomy. Simultaneously, sitz bath becomes a time- consuming procedure for both the mother and midwives. Moreover, question arises on hygiene during sitz bath. Perineal area is already moist with lochial discharge and further moisture with sitz bath may become a cause of delayed wound healing.On the other hand, dry heat can be practiced in hospital as well as home without any problems since it is not time-consuming and can be done on hospital bed. Moreover, at home mother can use hair drier in bathroom after each urination and stitches can be easily dried without touching.

In a previous study, all the available evidences in the literature were prioritized for postpartum perineal wound management and gave a careful emphasis on perineal hygiene, cryotherapy, elevation of foot end of bed in presence of perineal edema and regularly performed pelvic floor exercises.3 Whereas, in present study, dry heat with hair drier has been evidenced as an effective intervention compared to moist heat (Sitz Bath). If only sitz bath is taken into account, it was found to be effective in reducing pain in this study which is consistent with findings of an earlier study which revealed significant relief of episiotomy pain with sitz bath (p<0.001).7 In present study, warm sitz bath was used, whereas a previous study with a repeated measure experimental design (N=20) has compared warm versus cold sitz bath in which results revealed that both findings were found comparable with exception that cold sitz bath was significantly more effective in reducing edema.6 This study gives a pathway for comparing dry heat with cold therapy in future research studies because in a similar kind of study ice bag has been found significantly more effective than heat lamp for relieving perineal discomfort after vaginal delivery.8

Another study in literature also has findings similar to present study. It supports the use of dry heat by using infra-red lamp which was found to be effective in reducing episiotomy pain and enhancing wound healing among postnatal mothers (p<0.001).9 In present study dry heat was given by a hair drier which decreased duration of wound healing from 14 to 7 days and also reduced pain (p<0.001).

According to the literature, there is no definitive winner and loser in this debate of dry heat and moist heat for episiotomy pain and wound healing but the present study proves that dry heat with a hair drier is more effective than moist heat. The null hypothesis is rejected which stated that dry heat has no significant effect on episiotomy pain relief compared to moist heat at 0.05 level of significance. In present study, both the interventions (dry heat and moist heat) were effective but dry heat with hair drier was more effective than moist heat with sitz bath in relieving pain and promoting wound healing at the episiotomy site among postnatal mothers. Dry heat with hair drier enhances wound healing process and reduces duration of episiotomy healing from 14 days to 7 days. Hence, it is recommended to practice at hospital as well as home after discharge and similar kind of study can be replicated on a larger sample to compare the effect of dry heat with hair drier compared to other interventions.

References

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