Proforma for Registration of Subjects For

Rajiv Gandhi University of Health Sciences, Bangalore

Karnataka

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1. Name of the candidate and JASLINE P GEORGE

address 1ST YEAR MSc NURSING

KRUPANIDHI COLLEGE OF NURSING, No.12/1,CHIKKA BELLANDUR VILLAGE, CARMELARAM POST, VARTHUR HOBLI, BANGALORE-560035 2. Name of the institution Krupanidhi College of

Nursing, Bangalore. 3. Course of study and M.Sc.Nursing

subject Obstetrics and

Gynaecological Nursing 4. Date of admission to course 16-06-2010

1 5 . TITLE OF THE TOPIC:

A STUDY TO ASSESS THE EFFECTIVENESS OF INFRARED THERAPY ON

EPISIOTOMY PAIN AND WOUND HEALING AMONG POSTNATAL

MOTHERS IN A SELECTED HOSPITAL, BANAGLORE.

6. BRIEF RESUME OF THE INTENDED WORK:

6.1 NEED FOR THE STUDY

“The moment a child is born, the mother is also born.

She never existed before.

The women existed, but the mother, never.

A mother is something absolutely new”.

( Rajneesh)

Motherhood is the only act that manifests in human form the cosmic wonder of creation. Imagine a life growing within the body of the mother, nurtured with her lifeblood. And then there is the greatest wonder of all, this vague motion within her womb blooms into two tiny hands, reaching out.1 The very process of giving birth is the most beautiful one on earth and the mother attains unique capacities and true nobility through childbirth.

The fulfilment of the motherhood is acquired through labour. Labour is one of the greatest events in every woman’s life. Even though labour is the fulfilment of her dreams the suffering due to pain in the perineal area after the delivery is unbearable.

Childbirth and labour are never the same but different for different women may. Pain

2 and suffering is an ever present image and experience among women from the dawn of history to the present time.2

The pain in the perineal region after the birth is mainly due to the surgical incision or perineal tear. The surgical incision is termed as episiotomy. Episiotomy is a common surgical procedure performed during the second stage of labour. The purposes of episiotomy are to enlarge the vaginal introitus so as to facilitate easy and safe delivery and to minimise overstretching and rupture of the perineal muscles. The first performance of episiotomy was done in 1742, when perineal incisions were used to facilitate deliveries.3 It is performed widely today to prevent lacerations and shorten the second stage of labour. It also reduces incidence of uterine prolapse in subsequent deliveries if performed before tissues are over stretched. Episiotomy is also performed for majority of forceps deliveries especially in Axis Traction

Forceps.4

The worldwide episiotomy rate is about 27% and; 54% are nulliparous and 6% in multiparous women. Use of episiotomy varies across the world.11 In India the birth rate is very high. Fifty six percentage of Indian women had an episiotomy compared to the forty six percentage of White women. The difference between these percentages (10%) is a measure of the excess frequency in Indian women.5 A study was conducted to calculate the percentage of episiotomy performed in the US. Out of all vaginal deliveries it was found to be 19.4%. Episiotomy rate was higher among white women (32.4%) than African American women (11.2%).6

The episiotomy rate in Karnataka is very high that is, about 88% in women who are undergoing difficult labour. In Bangalore rates of episiotomy for vaginal birth ranged from 31% to 95% of the grand total of 3590 vaginal deliveries.7 3 Perineal soreness or pain is a common occurrence and is frequently reported following episiotomy. The majority of women who deliver vaginally experience some degree of pain following delivery usually related to the type and extent of the trauma. Pain causes stress and hampers the women’s ability to give care for their infant.8

The acronym REEDA is used as a reminder that the site of episiotomy or a perineum laceration should be assessed for these five signs. Redness of the wound may indicate the usual inflammatory response to injury. If it is accompanied by pain or tenderness, it may indicate beginning of localised infection. Ecchymosis or oedema indicates soft tissue damage that can delay healing. There should not be discharge from the wound and rapid healing necessitates the edges of the wound should be clearly approximate.9

The area of the episiotomy may be uncomfortable or even painful for several days.

Several practices can relieve some of the pain. The remedies like moist heat application such as sitz bath and hot packs were in practice before. As advancement in science took place, dry heat application came into existence like electric heat lamps, perilights etc. The dry heat application are more effective than moist heat application and the effect of dry heat lasts for a longer time and keeps the wound dry and improves healing. Heat from the lamp increases blood circulation to the sutures and reduces the oedema hence the patient is more comfortable.10

A critical part of solar energy is infrared light, an invisible healing energy emitted from the sun. Unlike ultraviolet light, which can provoke sunburns or sun cancers infrared light does not damage the skin, but instead supports healing and repair of cells and tissues. Living things require sunlight in order to grow and thrive. Infrared 4 light, the safest segment of energy that comes from the sun, offers a wide array of therapeutic benefits for health conditions. Studies demonstrated that infrared light helps to enhance circulation in the skin, modulate sleep, ease pain, protect against oxidative stress, and relieve inflammation.10

Infrared light therapy is a very old form of medical care. It is a unique healing process where infrared rays are used for treatment of diseases. In this process, the injury sites are exposed to infrared radiation for a specific amount of time which results in rapid relief from discomfort. Infrared light is an electromagnetic radiation whose wavelength is longer than visible light and shorter than radio waves. A distinguishing trait of infrared light is that it has all the benefits of natural rays of the sun without any harmful effects of solar radiation. Based on wavelength, infrared light can be divided into three types - short, medium and long. Infrared light can be obtained from thermal radiation. Any kind of radiation that we perceive as heat; be it from the sun, fire or a light bulb, are actually transmitted by infra-red rays. Infrared light can penetrate 2-3 centimetres deep into our body.10

Infrared light therapy is a form of photo therapy where infrared light is directly applied to our body to cure illness. Drugs are of no use in this process. These rays, on penetrating the skin, help in the release of nitric oxide thus relaxing the blood vessels and preventing blood clots due to injury/illness. In this way, blood circulation to the affected area improves. As a result, more blood can reach the injured tissue, which in turn, increases the supply of oxygen and valuable nutrients to it. These essential components of the body speed up the healing process and provide comfort to the patient.10

5 An experimental study with pre test and post test design was conducted in Kovilpadi,

Tamil Nadu, India. The objective of the study was to assess the effect of infrared light therapy and sitz bath on episiotomy in pain reduction and wound healing. Sixty postnatal mothers were selected randomly, of which 30 were assigned into experimental group and 30 were assigned into control group. The investigator used a demographic variable proforma, pain intensity scale for episiotomy pain, REEDA scales on wound healing and structured interview schedule on the knowledge regarding episiotomy care and infrared therapy. Majority of the participants in the experimental group expressed no pain on observation by the end of third day, whereas few of them (20%) in control group and majority of them (83.3%) in experimental group expressed mild pain in observation on the third day. On the third day only 10% of the participants in the experimental group expressed no pain in observation. Mother who had undergone the treatment of infrared light therapy expressed decreased pain intensity compared to mothers who had undergone the treatment of sitzbath.13

The heat application in the episiotomy area will reduce pain and improves wound healing. The investigator herself, during her clinical experience period, has come across many postnatal mothers with episiotomy wound and receiving only perineal care. The investigator felt the need for application of dry heat by infrared lamp which will help in fast healing of the wound and pain reduction. This procedure provides the maximum satisfaction to the patients. The aim of the investigator was to check the effectiveness of dry heat on episiotomy pain and wound healing.

6.2 REVIEW OF LITERATURE

6 The present study is undertaken to assess the effectiveness of infrared light therapy on episiotomy pain and wound healing. The investigator did an extensive search of the existing literature and organised it under the following heading.

1. Effectiveness of infrared therapy on episiotomy pain and wound healing.

2. Effectiveness of infrared therapy on pain and wound healing.

1. Effectiveness of infrared therapy on episiotomy pain and wound healing.

An experimental study was conducted in Coimbatore, Tamil Nadu, India to assess the effectiveness of infrared therapy and sitz bath. Thirty samples were randomly selected for the study, out of that 15 each has been assigned to two experimental groups. Two experimental groups were selected for infrared therapy and sitz bath and treatment were given for three days in the morning and in the evening. The wound score was obtained by using modified Southampton scale and a verbal descriptive scale. Results revealed that mother who had undergone the treatment of infrared therapy expressed decreased pain intensity compared to mothers who had undergone the treatment of sitz bath.11

An experimental study was conducted in Coimbatore, Tamil Nadu, India to assess the effectiveness of infrared therapy in healing of episiotomy wound. The study sample consisted of 20 postnatal women. Randomly the samples have been divided into experimental and control group equally. The demographic and obstetrical data, record analysis and modified Episiotomy Wound Assessment Scales were used to collect data through interview technique. It was found that in experimental group

75% of the mothers who received infrared radiations showed adequate wound

7 healing and 25% showed poor wound healing, whereas, 70% of the mothers in control group showed poor wound healing.12

An experimental study with pre-test and post-test design was conducted in Kovilpadi,

Tamil Nadu, India. The sample size was 60 and was selected by random sampling method, of which 30 were assigned into control group and 30 were assigned into experimental group. The investigator used a demographic variable performa, pain intensity scale for episiotomy pain, REEDA scales on wound healing and structured interview schedule on the knowledge regarding episiotomy care and infrared therapy.

Majority of the participants in both the control group and experimental group had moderate pain during observation on first day, whereas few of them (20%) in control group and majority of them (83.3%) in experimental group expressed mild pain on observation on the third day. On the third day only 10% of the participants in the control group and all of the participants in the experimental group expressed no pain on observation.13

An experimental study was conducted in Czech Republic to assess the effectiveness of phototherapy to the treatment of episiotomies. The sample size consisted of 2,436 postnatal mothers and the woman were divided into four groups as follows: first group as a control group, for second group polarized light of 400 – 2000 nm was used, monochromatic light (600 nm) and pulse magnetic field (100 Hz) were applied simultaneously for third group and for the fourth group therapeutic laser (685 nm) was used. The result showed that the work demonstrated high healing effect of minimum secondary complications in the treatment of episiotomies using a therapeutic laser at an energy density of 2 J/cm2. The application of polarized light at an energy density of 5 J/cm2also exerted favourable therapeutic effects.14

8 2. Effectiveness of infrared therapy on pain and wound healing

An experimental study was conducted among 40 patients with chronic low back pain of over six years duration who were attending the Rothbart Pain Management Clinic,

North York, Ontario. Twenty patients received infrared therapy and 20 received placebo therapy. The mean (Numerical Rating Scale) NRS scores in the treatment group fell from 6.9 of 10 to 3 of 10 at the end of the study. The mean NRS in the placebo group fell from 7.4 of 10 to 6 of 10. The infrared therapy unit used was demonstrated to be effective in reducing chronic low back pain and no adverse effects were observed.15

A randomized controlled crossover study was conducted in Australia to examine the effect of infrared radiation of a tiled stove on patients with hand osteoarthritis (OA).

A total of 45 patients with hand OA were randomly assigned to two groups: (i) group

A -- [first 3 hours spent 3 times a week during 3 weeks in a heated tiled stove room

('Stove Period') and after 2 weeks without treatment this group was observed for another 3 weeks ('control period')]; and (ii) group B (first assigned to the control period and the stove period following the treatment-free period). Assessments included the Visual Analogue Scale (VAS) for general pain, pain in the hands, global hand function and grip strength. A total of 14 (31 %) patients improved on the VAS for general pain at the end of the tiled stove period as compared to 10 patients (22 %) during the control period (p = 0.314). The Australian / Canadian Osteoarthritis Hand

Index (AUSCAN) pain domain showed a significant improvement after the tiled stove period (p = 0.034). Other pain parameters analyzed (VAS for pain in hands and

SF-36 bodily pain) showed moderate but not significant improvement (p = 0.682 and 9 p = 0.237, respectively) compared to the control period. The numerical improvement in all pain measures suggests some possible positive effects on this symptom of hand

An experimental study was conducted in Russia to assess the effectiveness of laser radiation in the infrared range in the treatment of aseptic postoperative wounds. The study consisted of 85 patients subjected to planned operations for calculus cholecystitis and inguinal hernias. With the application of high-energy CO2 and

YAG laser, surgical scalpel was performed. For local treatment of the aseptic wounds radiation of semi conduction arsenide gallium laser "Uzor" was used. Results of the investigation suggest that laser infrared radiation promotes rapid liquidation of acute inflammatory symptoms, quicker healing and smooth course of the postoperative period. The method was recommended for wide introduction into clinical practice.17

A study was conducted to assess the effectiveness of low level laser therapy for wound healing when combined with the Extendicare Wound Prevention and

Management Program. Sixteen residents at a Canadian Extendicare nursing home had a total of 27 sites treated consisting of open wounds and 4 'at risk' areas. Of the

23 open wounds, two wounds in between toes were not able to be 'traced' and deemed 'immeasurable' wounds, resulting in 21 open, measured wounds. The four 'at risk' (closed) areas were treated preventatively. Pressure, venous insufficiency and diabetic wounds were included. The majority (12/21) or 57·1%, of the wounds were chronic (≥3 months duration) and 42·9% were acute (<3 months duration). Outcome measures were employed to understand better the potential barriers to successful integration into clinical practice. Feedback on the effectiveness of low level laser

10 therapy, the education program and determinations of hands-on relevance was sought from staff. At the end of the 9-week trial, the majority (61·9%) of the 21 wounds achieved significant improvement (≥50% wound closure). Nine (42·8%) had 100% closure. Some improvement was seen in 14·3% and 23·8% of wounds demonstrated no change. Chronic and acute wounds had similar improvement. None of the wounds in this debilitated, frail population deteriorated during the study and no negative consequences of treatment were encountered.18

6.3 PROBLEM STATEMENT

A study to assess the effectiveness of infrared therapy on episiotomy pain and wound healing among postnatal mothers in a selected hospital, Bangalore.

6.4 OBJECTIVES OF THE STUDY

1. To compare the episiotomy pain scores between experimental group and control group.

2. To compare the status of wound healing in experimental group and control group.

6.5 OPERATIONAL DEFINITION

Effectiveness

11 Refers to the extent to which infrared therapy helps in reducing the episiotomy pain and promoting wound healing in postnatal mothers and is measured by Verbal

Descriptive Pain Scale and Southampton Wound Scoring System.

Infrared therapy

Refers to light therapy applied to the suture area on the perineum at a distance of

45cm with 230 volts for three days for ten minutes both morning and evening to improve wound healing and pain reduction.

Episiotomy

It is a surgical incision on the perineum and the posterior vaginal wall during the second stage of labour after crowning to enlarge the vaginal introits and also to minimise the overstretching and rupture of the perineal muscles.

It is an unpleasant, subjective sensory and emotional experience by the postnatal mothers due to tissue damage related to episiotomy which is assessed by Verbal

Descriptive Pain Scale.

Wound healing

It is the process of regaining of the skin continuity in the episiotomy wound which is assessed by Southampton Wound Scoring System.

Postnatal mother

The women who has given birth to a baby by normal delivery with episiotomy.

12 6.6 ASSUMPTIONS

1. All the postnatal mothers experience pain in the episiotomy area.

2. Infrared therapy can reduce pain and improve wound healing.

6.7 HYPOTHESIS

H1: There is a significant difference between the mean pre-test and post-test pain

scores in experimental and control group.

H2: There is a significant difference between the mean pre-test and post-test wound

healing scores in experimental and control group.

H3: There is a significant association between pain scores and selected demographic

variable.

6.8 DELIMITATION

The study will be limited to the postnatal mothers who are admitted to the selected maternity hospital Bangalore.

6.9 PROJECTED OUTCOME

13 The present study reveals the effect of infrared therapy on episiotomy pain and wound healing. If found to be effective this can be practiced on regular basis while providing perineal care for pain reduction and to enhance wound healing

7. MATERIALS AND METHOD:

7.1 SOURCES OF DATA

7.1.1 Research Design

A quasi experimental research design with pre-test and post-test design will be used to achieve the objectives of the study.

E O1 X O2

C O1 O2

E….experimental group C….control group

x….intervention

O1....Pre- test O2….Post-test

7.1.2 Setting

The study will be conducted in Banasankari Referral Hospital, Banasankari 2nd Stage,

Bangalore. It is a Government Hospital. The hospital has the bed capacity of 50 and the bed occupancy is 20 to 30. Approximately 120 normal deliveries and 50 caesarean sections are conducted in a month. 14 7.1.3 Population

The population in the study comprises of postnatal mothers with episiotomy who are admitted in the hospital.

7.1.4 Sampling procedure

Purposive sampling technique will be used for present study.

7.1.5 Sample size

The sample size will be 60 postnatal mothers who had normal delivery with episiotomy and of which 30 will be assigned to the experimental group and 30 will be assigned to the control group.

7.1.6 Inclusion criteria

Postnatal mothers who

1. had normal delivery and instrumental delivery with episiotomy

2. are willing to participate in the study. 3. are able to communicate in English or Kannada.

7.1.7Exclusion criteria

Postnatal mother who

15 1. had normal delivery.

7.2 METHOD OF COLLECTION OF DATA

7.2.1 Instrument used

The wound healing and pain can be assessed with the following instruments and it consists of three sections:

Section 1: Demographic variables.

Section 2: Modified Southampton Wound Scoring System to assess the wound healing. The score can be given as follows, normal healing-0, normal healing with mild bruising or erythema-1, erythema plus other signs of inflammation-2, clear or haemoserous discharge-3, pus-4, deep or severe wound infection with or without tissue breakdown; haematoma requiring aspiration-5.

Section 3: Verbal descriptive scale for assessing pain. The score can be given as, 0 no pain, 1 mild pain, 2 discomforting, 3 distressing, 4 intense, 5 excruciating.

7.2.2 Data collection method

After securing written permission from the respective authorities based on inclusion criteria 60 postnatal mothers will be selected from the postnatal ward. Thirty postnatal mothers to the experimental group and 30 postnatal mothers to the control group will be randomly assigned. The mothers will be intimated as to the purpose of the study and their consent will be secured. Pre test will be conducted for both control and experimental group. Infrared therapy will be given for experimental 16 group for three days in the morning and evening for 10 minutes. The wound will be

assessed by Southampton Wound Scoring System and pain will be assessed by

Verbal Descriptive Scale. Post test will be conducted on third day for both control

group and experimental group by using the same tool.

7.2.3 Data analysis plan

Descriptive and inferential statistics will be used for data analysis according to the

objectives.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS

OR INTERVENTIONS TO BE CONDUCTED ON

PATIENTS OR OTHER HUMANS OR ANIMALS?

Infrared light therapy will be administered to the patients for 3 days as the part of the

study.

7.4 HAS ETHICAL CLEARENCE BEEN OBTAINED FROM

YOUR INSTITUTION?

Yes, ethical clearance will be obtained from the hospital. Prior permission from the

respective authority is obtained and individual consent will be taken from the

participants prior to the study.

8. LIST OF REFERENCES:

1.Motherhood. Available from:URL:http://www.lifepositive.com/body/natural.

Accessed September 23, 2010. 17 2.Labour and delivery. Available from:URL:http://www.healthline.com. Accessed

August 11, 2010.

3.First performance of delivery. Available from:URL:http://findaticles.com/p/articles/

miqa4036/is…/a_n942693. Accessed August 11, 2010.

4.Purpose of episiotomy. Available from:URL:http://www.glowm.com/index.html.

Accessed September 21, 2010.

5.Episiotomy rate in India. Available from:URL:http://jpubhealth.oxfordjournals.org/.

Accessed July 30, 2010.

6.Episiotomy rate in US. Available from:URL:http://www.surgeryencyclopedia.com/

Ce_Fi/Episiotomy.html. Accessed August 11, 2010.

7.EpisiotomyrateinBangalore.Available from:URL:http://www.jabfmorg/cgi/content/

full/18/1/18. Accessed July 30, 2010.

8.Labour and pain. Available from:URL:www.pregnancy.com. Accessed August 23,

9.REEDA. Available from:URL:www.all.acronyms.com. Accessed August 29, 2010.

10.Infrared light therapy. Available from:URL:www.GoAcupuncture.com. Accessed

August 23, 2010.

18 11.Dhanalakshmi.V. Best remedial measure after Episiotomy? Sitz bath? Or Infrared

Light Therapy?. Nightingale Nursing Times 2010 Mar;5(12):12-6.

12.John Esther, R.Sheeba, M.Vimiji, S. Seena. Effectiveness of infrared radiations in

Healing of Episiotomy Wound in Postnatal mothers. Nightingale Nursing Times

2009 Feb;4(11):60-1,67.

13.Venkadalakshmi.V, Venkatesan Latha, Perdita M.Helen. Effectiveness of infrared

therapy upon Episiotomy pain and Wound healing in postnatal mothers. The Official

Journal of Trained Nurses’ Association of India 2009Jul-Sep;4(3):19-25.

14.Treatment of episiotomy using different forms of phototherapy. Available

from:URL:www.laser.nu/lllt/lllt-science6.htm. Accessed September 12, 2010.

15.Effectiveness of infrared therapy in pain. Available

from:URL:http://www.ncbi.n/m.nih.gov/pmc/articles/PMC2539004. Accessed July

08, 2010.

16.Stange-Rezende L, Stamm TA, Schiffert T, Sahinbegovic E, Gaiger A, Smolen J et

al. Clinical study on the effect of infrared radiation of a tilled stove on patients with

hand osteoarthritis. Scand Journal Rheumatol 2006 Nov-Dec;35(6):476-80.

17.Efendiev AI, Sarosek IuK, Dadashev AI, Efendiev NI. Laser radiation in the infrared

range in the treatment of aseptic postoperative wounds. Vestn Khir Im I I Greek 1992

Mar;148(3):291-3.

18.Skopin MD, Molitor SC. Effect of near-infared laser exposure in a cellular model of

wound healing. Photodermal Photoimmunol Photomed 2009 Apr;25(2):75-80.

9. Signature of candidate 10. Remarks of the guide

20 11. Name & Designation of

11.1 Guide Mrs. G.UMAPARVATHI

ASSISTANT PROFESSOR

11.2Signature

11.3 Head of Department Mrs. G.UMAPARVATHI ASSISTANT PROFESSOR

11.4 Signature 12. 12.1 Remarks of the

principal

12.2 Signature