CHAPTER – 2: REVIEW OF LITERATURE

“Books are infinite in number and time is short. The secret of knowledge
is to take what is essential. Take that and try to live up to it”
Swami Vivekananda

2.1. BACKGROUND OF THE PROBLEM

This Chapter deals with the report on the reviews of the available research
studies and relevant literature from which the problem has been formulated, designed
and studies. Review of literature in any research is done to know the depth of the
problem area. An intensive review of literature has been done from published and
unpublished materials, books reports. It has provided the researchers with a deeper
insight into the problems and has assisted in the methodology, defining the problem
construction of tool, formation of conceptual framework and analysis of data. During
the review of the literature the investigator will came across many themes directly and
indirectly relevant to the present study.

‘Review of literature’ is very necessary to develop the experimental project.

Its written literature review provide the investigators and researchers with background
for understanding what has already been done and illuminate the path ways to
perform new studies to meet the demands of unmet medical needs.

Many researchers have given the definition of review of literature in their own
way. A few say that going through the study done by others is a total information of
what are the facts which have been published and generalized on the specific study by
the university researchers. University of Toronto, has also given the same definition.

According to American Nurses Association,a review of literature is a total

text, which purposes are comprehensively go through the every bit of information on
a specific problem statement of research.

According to Best John, review of literature is a brief summary of previous

researchers and writing of recognized experts providing evidences that the
investigator is known with what facts are existing about new things and what is to be
still find out about hidden information.[7]

According to Polit and Beck, a review of related literature provides readers

with an overview of existing evidence on the problem being addressed and develops
an argument that demonstrates the need for study. The information of previous
conducted study is to produce theoretical and scientific knowledge about particular
phenomenon and finding in a production of information, which, already exists and
about the occurrence that appear.The primary purpose of reviewing literature is to
gain a broad background that available related to a problem in conducting research,
the literature review facilitates selecting a problem and purpose, developing a frame
work and formulating a lesson plan. In this study efforts has been done to review and
talk about literature.[35]

A detailed research studies and without research studies material information

has been done to increase and widen the scope of knowledge to go deep into the
information to assess and evaluate the outcome of therapy with music system versus
massage to the back to mother in order to see the level of pain, anxiety and labour
outcome in first time mothers in the beginning of the labour pain. Along with review
of books and journals the review of literature was also done through internet meddler
searcher.

Abdullah and Levine,a literature of literature gives the foundation for next
researches. It gives an account of the necessity to separate the same study. It too
assists to find out a detailed information of empirical information in any professional
subjects. The investigator followed all these steps in review of related research and
non-research information to expand her level of understanding the facts of the
study.[1]

A review of literature helps the researcher in many ways it helps to assess

about how much are the facts already existing and how much still to find out and
untested, to go through the information which is already existing is an necessary part
of the research which is done on scientific baseto expand the understanding and it
helps in gaining insight awareness is important for broaden the concept, growth an
subject to the statement of research study.

Polit and Hungler,review of related literature is an essential aspect of scientific

research. It broadens the understanding and helps gain an in insight necessary for the
development of broad conceptual context into which the problem fits. Medler search
was also utilized for the purpose to have a better understanding of the problem and to
build a foundation of the study.[34]

Review of Literature has been divided into six

1. Review related to physiology of pain.

2. Review of literature related to relieve of discomfort with hot and cold

therapy.

3. Review related to problems faced by mother after episiotomy.

4. Review related to care of episiotomy related to wound healing,relief of

pain/discomfort and complications.

5. Review of literature related to the effectiveness of cold application on

episiotomy wound healing and discomfort due to episiotomy.

6. Review of literature related to comparing the effectiveness between

cold and hot application on episiotomy wound healing and pain
relieving
 2.2. REVIEW RELATED TO PHYSIOLOGY OF PAIN

Though there are many theories of pain perceived still

1644 given by dascartes about the path of pain sensation travelled from skin to brain.
Vonfrey in nineteen century gave his theory about movement of nerve receptors from
peripheral skill receptors to the centre of brain which is known as pain centre. In this
theory importance was given to the specialize peripheral receptors. In this theory he
has explained about phantom limb. Phantom limb pain is that even though limb is
ambulated then also patient feels sensation of pain. This is also known as phantom
theory of pain.
John PaulNafe in 1934 stated in his theory that many impulses jointly travel through
the spinal cord and all together send the message to the brain. This is again an
example of phantom limb as it is aimed at the centre of the brain and not in the
periphery.

In 1965 another theory was written by MELZACK and WALL GATE

control theory of pain perception. According to them there are excessive or less
impulse send from skin to the central nervous system which is known as “open gate”.
It sends the impulses to the brain and so the brain has the receptors of pain impulses.
There is a closed path which does not allow the impulses to enter in the brain so the
patient either does not feel the pain or there will be very less sensation of the pain
perception.[39]
 Figure Error! No text of specified style in

Since 1970 this theory is commonly in practice. It comprises of very old pain
stress problems related to sex and past experience of pain.

MELZACK
MELZAC and WALL in 1999 developed one another theory about
pain in combination of discomfort
discomfo and Gate control theory which solves some
of the unsolved questions and the results which was known as
NEUROMATRIX
OMATRIX THEORY. This theory emphasises on the genetic structure
as network of neurons.[39]

The main focus of this theory was uniqueness; that every individual is
a unique and genetic structure of every individual is different, that is why
every person’s look is unique in the physical character and mental intelligence
as well as his experiences of life and so every person feels the degree of pain
in different way.
Pain pathway:
According to this theory, no receptors are present in whole body tissues but in the brain
and spinal cord but they send message to the brain. So, there is biological electrical
mechanism and thermal as well as chemical energy. Persons feel pain when this energy
e
go through canal of the spine to the main brain stems in relation to pain. Discomfort
nerve ending send the message to the back horn of the spine canal and cross over each
other and send to the brain information about discomfort. The main perception takes
place in the thalamus and then to the emotion centre. Finally pain is demonstrated in the
central part of the brain.

Figure Error! No text of

. It is divided in to 2 typesspecified
of fibresstyle in
for sending the information to the brain. Delta fibres
are longer one which produces a good clearly defined discomfort called as “FAST PAIN” or first
pain. The examples are when we feel stimuli by electric shock, phy
physical
sical blow, etc.
Transmission through these fibres is so strong that automatically our body reflexes answer to it
very fastly than the pain reflexes by which nerves and muscles of that call back very fast before
we feel the pain at that organ. Now dull pain or burning or aching sensation is the second
pathway known as “C” fibres. These are small ones as there is myelin sheath on these fibres
known as “C” fibres. These fibres give continue pain as per GATE CENTAL THEORY. Energy
of these thread travel through non discomfort energy which can block the path of pain at the
dorsal portion of the spine. For instances when beta fibres are stimulated they close the path.
That is why they catch up the message immediately whenever we have any painful situation.

Helms, Jennifer E. et al. (2008) reported in a clinical article that pain in small children
was not taken care of till 1970. The belief was that either child would not recall pain or the
noxious system was constructed immature than adults. With the results children either were not
given pain killer or very less doses of medication was given to children. This was REACHES
until 1980 later as many research studies were done so there was demand and legal issues raised
by the parents and it was concluded that the pain during childhood may have an impact on the
brain of child long lasting which affect the personality development in the child during adult life.
Many studies have proved that foetus perceive pain during 2 weeks of intra uterine life. So the
baby who experiences pain in the early life will have an permanent impact on the brain about
pain perception.[71]

For example, Taddio et al. (1997) reported that during the circumcision the babies who
did not have anaesthesia as pain killer will be very scared of pain while they get return
immunisation. Again during any operation in life if no pain killer are given after operation they
will have other type of sickness. [103]

One of the false belief that small child never feel chronic pain. Fact is that child also
suffers with chronic pain. For example regional pain syndrome, even acute type of pain for
example in case of anaemia of specific type where RBC is affected known as sickle cell anaemia.
Children are more prone to different type of pain for example abdominal cramps, chest
congestion, high fever, pain in the head, backache, limbs pain, growing lower limb etc.

Bartell, J.C., et al. (2008)conducted a study on pain perceived by children after injection on
immunisation and that was in the temperature of injection needle. They wanted to see that if we
give injection I /M to baby with chilled needle baby may perceive less pain, 80 children were
taken as sample subjects for immunisation. Standard visual analysis pain scale was used to rate
the intensity of pain. Findings indicated that need temperature have an effect on the pain
intensity.

Suhrabi, Z., et al. (2014),did a study on pain intensity during intramuscular injection. This
was two group studies to see severity of pain; Experimental & control group sample. Subjects
were from adolescents to middle age that is (15 to 55 year). Individual interview was taken in
order to seek their interest for the participation in the study. The experimental group was asked
to lie flat on their abdomen & pressure points were acupressure about 4.5kg/cm square by thumb
thrice and after that 3 ml of penicillin injection 6 lakh was injected to the gluteus muscles.[104]

In the control group also intramuscular penicillin injection 6 lakh was given as existing
practises. Data collected & analysed by use SPSS SOFURME 16. Findings of this study
indicated that according to the body mass index mean value of severity of pain was 1.50 ¬– 0.75
in thin , 1.64 – 0.75. By taking normal value, 1.38- 0.64, in obese 1.40 – 0.54, in overweight and
1- 0.0 in severely malnourished sample subjects with a total score of 1.53-0.68. There was no
variation in ANOVA and mean scores of severity as per basal metabolic Index. There was no
significance of difference in control & experimental group according to age but difference in the
severity of pain was significant T TEST also show the significant difference. It indicated that
mean degree of pain in emperical group lesser than the other group.

Esmailzadeh, M., et al. (2011),research was done to see the effect was conducted to see the
effect of cold while penicillin injection was given 12 lakh IU I/M. Total 60 sample subjects were
taken as random method of selection. In control group injection was given as routine practice
whereas in experimental group local cold ice form was applied for half a minute before giving
injection. Information was gathered by interview and visual analogue scale & test was applied.
Findings indicated that cold therapy was useful in declining the degree of discomfort in
experiment group with “P” value 0.00 as compare to the existing practices of giving injection
penicillin.

Hasanpour, et al. (2006),did a study to see effect of cold temperature by diverting the attention
of sample subject. A total of ninety samples were taken for this study and subjects were selected
method. Age of the subjects was 5 – 12 years. Those who were supposed to get routine injection
Penicillin intramuscular in government hospital. 3 groups were cold therapy, diversion therapy
and existing practices respectively. Oucher scale was used to collect data by interview, pain
severity was monitored. Mean, median and standard deviation was computed and tabulation of
data was done in frequencies and percentage. The finding of the study indicates that there was
average pain in experimental group. There was more pain in the non-experimental groups than
both the experimental groups. The result of the study was implemented in the daily practices
while giving intramuscular injection to children to apply cold and diversional therapy.

Amir, et al.did a research in 1998 to decrease discomfort and pain due to Penicillin ‘C’
injections. Investigators realised that if penicillin injection is mixed with lignocaine and diluted
may be effective in decreasing the pain in children while giving I/M injection of penicillin. Total
eighteen sample were selected for this study by random method of sample selection. Age of the
sample subjects was 11 – 19 years. Sample were divided equally into two groups. Injection
penicillin 3.2ml of distilled water was given to one group and second group was given with
lignocaine 1%. Pain severity was assessed as well as serum level was also assessed. After one
month of injection finding indicates that there was not much difference in the hydrochlorol 1%
after one month but there was low pain score in the severity of pain in the experimental group.

Sankanagoudar, Poornima P. (2011),conducted a study to observe the effect of non-thermal

therapeutic ultrasound in postnatal breastfeeding mothers. 40 postnatal mothers were taken as
sample subjects who were having breast engorgement. Sample were selected with random
method and samples were dividing half in experimental and half in the control group.

Data was collected through interviews and visual analog scale and six point engorgement scales.
Both the groups manually milk was expressed and experimental group addition non-thermal
therapeutic ultrasound was done. Data was collected for both the group and data was gathered
and analysed by influential statistics. The finding of the study indicated that there was significant
difference in the pain and engorgement of breast in the experimental group than the control
group.

Joanna Briggs Institute Information (2010), did a study and gave the finding that 34 – 96%
nipple pain is maximum during first 3 days and then it gets decreased by 1st week in primi
mothers. Breast tenderness is different 72 – 85%. In postnatal mothers 3 – 5th day and 2/3rd of
the mothers tenderness lost till 5th day. It shows that variable of the study like panty, type of
anaesthesia, delay in starting the breastfeed and use of formula feeds and mothers who has
LSCS. First time breastfeeding mothers and 2nd time breastfeeding mothers is more difficult for
mothers after LSCS because of mother’s tiredness and delay in starting the breastfeed as well as
early use of topfeed and side effect of medication to mothers.

Vinall, J.et al. (2012) conducted a study to determine whether pain experienced by babies
born prematurely influences their postnatal growth. Cohorts of 78 infants born at, or before, 32
weeks’ gestation were recruited from one neonatal intensive care unit. Infants with major
congenital disorders, those with antenatal infections, or with severe brain injury were excluded.
Infants were weighed and their head circumferences were measured at birth, at 32-weeks’
gestation and again at 40 weeks’ gestation or discharge (whichever came first). Data were
collected from records on: severity of illness; number of skin breaking procedures (used as an
indicator of neonatal pain experience); number of day’s infant reliant on mechanical ventilation;
presence of an infection; exposure to morphine or corticosteroids. The incidence of these events
was calculated across three time frames: from birth to 32 weeks post-conception; from 32 weeks
to 40 weeks post-conception; from birth to 40 weeks post-conception. Analysis of variance was
used to determine the impact of variables on weight gain and head circumference measurements
within these time frames. Painful experiences resulted in significantly reduced weight gain and
increases in head circumference in infants born very early (before 32 weeks’ gestation). These
differences exist independently of potentially confounding variables, such as illness severity and
the need for ventilation. So it was established that babies born before 32 weeks’ gestation are
particularly susceptible to pain and their growth and development may be impaired by this early
experience.[107]

Ortiz et al. (2012) conducted a study to find out the procedure which is responsible to give
and anxiety in a child. Setting of study was emergency room of a hospital admitted. Sample
subjects were 252 total. The age of the sample were between 8 – 16 years. The mean age was
10.1 years. 459 procedures were completed with 1.82 events/child. The most painfulprocedures
were selected for the study. The maximum of them were undergone the procedures of
catheterization and venous puncture. All together 32% painful procedure were rated as severe
pain 35.5% were rated as moderate pain and 31% were rated as mild pain. In 58 sample
catheterization was with severe pain 33% with moderate and 32% with mild pain whereas the
finding of the study indicated that health care provider must see the best way to take care of
psychological and pharmacological needs to reduce the pain and anxiety into children.[90]

2.3. REVIEW OF LITERATURE RELATED TO RELIEVE OF DISCOMFORT

WITH HOT AND COLD THERAPY

Arora, Smriti (2008), conducted a partial empirical research to see the effect of cabbage leaves
alternate hot and cold application for decreasing breast engorgement. Setting of this study was
postnatal ward AIIMS, New Delhi. The sample size was total sixty postnatal mothers 30 in each
group experiment to control group. In this study he experiment group was given intervention
with precooled cabbage leaf over the engorged breast whereas the control group was given
intervention of cold and hot compress alternatively. The design of the study was pretest posttest
two group design. The effects of the intervention were observed. It has been seen that in both the
experimental group there was reduction in the postnatal breast discomfort and engorgement to
the postnatal mothers. The finding of the study concluded that hot and cold compress was more
effective the cold compress only with cabbage leaf.[129]

Evan, K., et al. (2005),conducted a study to compare the two way of giving the breastfeeding.
This study was done on mothers who were having breast engorgement, mastitis and infertile
colic pain and time consumed for breastfeeding. Mothers who had taken more time to evacuate
one breast during each feed were assigned as experimental group and mothers who drained each
breast during every feed were given the name as under control. Both the sample subjects were
observed for the duration of 6 months. Size of the group was 47 in number. The findings of the
study indicated that chance of breast engorgement was declined during first week and colic pain
was under control next 6 months. There was no variation observed in the rate of mastitis and
duration of breast feed during 6 months of period. Sixty three per cent of the mothers in
experimental group needs for feeding their baby on the second breast to meet the feeding need of
her baby.

KathrynRoberts (2011)carried out a comparative study to evaluate outcome of cold by applying

chilled green cabbage leaves as well as gel packs which were kept in the refrigeration before
putting on the engorge breast of postnatal mothers. Both were kept on each breast separately to
see the effect of each one of the it for 8 hours of duration. The comparision was done with both
of the intervention, pretest and post test readings were taken. There was significance in
difference in the pretest and post test score but there was not significance in both the
intervention. Equally pain was decreased with both the intervention that was 65% of mother gave
the information that severity of the pain has been reduced but majority of mothers expressed that
they would like to have cabbage leaves as it fits to the shape of their breast.[24]

Robson, Beverley Anne (2013),conducted study to investigate the output of application of cold
therapy to then breasts which were engorged to breastfeeding mothers in the reduction of
severity of tenderness and swelling of the breasts and helps in the increase amounts of milk from
the breast while feeding their babies. The sample subjects were postoperative mother with lower
segment caesarean section 152 were in number. Out of 152 mother, 88 of them suffered with
difficulty in breastfeeding to their babies due to pain and swelling. Sample were selected as
random method in both the group control and experimental groups pretest, post test reading
were taken before and after application of cold compress to the breasts. Cold pack were applied
to mother of experimental group and control group was kept under the daily routine care in the
hospital. At the end of the day finding suggested that there was not difference in both the breasts
as far as milk production was concerned but definitely there was significance in the variation in
discomfort score of both groups. Finding indications that cold treatment is better than simple
feeding in bringing down the discomfort and swelling of the breasts than the control group.

In a study, conducted by McGuiness, M. (2001)to see the difference in wound healing. Variable
in the mother, race and parity,sex of the baby to see the association with wound healing. The
results from this study suggested that the women who were have episiotomy have shown slow in
wound healing than the mother who did not have episiotomy and there was not any impact of the
variable kept under study.

A study was conducted by Hill (2010)carried out a study total number of sample subjects were a
postnatal mother who were admitted in the hospital and there was comparision of primi and
multipar mothers regarding a postpartum hospital setting when primipara and multipara were
compared. There was no variation in discomfort and edema in the REEDA Score. Sample subject
was large baby were not having any difference in the REEDA Score. The overall reading of the
REEDA Score as compare to pain and swelling at ‘p’ value 0.001 where (r = 0.82). Swelling was
not having any relation with discomfort and duration of labour. Weight of newborn or head
circumference measurement at 0.05 levels of significance was not different. Same way labour
pain duration and size of the head was also not having effect.[71]

The research study by Claire Laurent (2008) analyzed the pain caused by episiotomy stitches in
respect of discomfort while sitting, walking and sleeping change of position, breastfeeding,
urination and defecation. The researcher concluded that the use of Histoacryl as tissue adhesive
instead of stitches dramatically reduced the pain and discomfort encountered in activities after
episiotomy repair.

Nancy, Flemming (2009) found the differences in her doctoral research between traditional
suturing and one suture non-lock non-interrupted sutures methodfor stitching the wound with the
help in bringing down the postnatal perineal discomfort. The main technique of this type of
suturing will also help to take enough tissues even with simple stitches. So it will not require
stitching the wound into many layers. There is approximation of putting the stitches below the
skin and in the sub circulation layer. The findings revealed that one suture non-lock continuous
stitch technique may reduce postpartum perineal pain.[65]

The study conducted by Lorenzi (1990) on a total of 40 subjects (20 each in control and
experimental groups) to assess the effectiveness of use of a simple relaxation technique on
episiotomy incision. The study findings revealed that the use of the simple relaxation technique
can positively affect overall discomfort and reduce episiotomy incisional pain as measured by
the amount of pain, amount of analgesia use and frequency of analgesic use.[83]

In 2005, Dr. Hill, Ashleystated that icepacks, wearing loose clothes, sitting into the tub of water
and application of soothing cream is helpful in case of slightly tender episiotomy. He further
stated that the mothers who are giving breastfeeding to their babies may be benefited even with
very less quantity of estrogen based ointment while mother is feeding to her baby there will be
declining of dose of estrogen in the cells surrounding the vaginal orifice. The study findings
revealed that in cases of bunching up of vaginal tissue, or in any abnormality surgical revision of
the area and removing the excess tissue and injections may be helpful in reducing discomfort and
pain in the episiotomy wound.
 Many non-research literature reviews stated that an antiseptic and analgesics perineal
spray could be used for the mother who had undergone episiotomy or laceration repair. Which-
hazel pads (Tucks) were helpful to reduce the swelling and discomfort associated with
episiotomies, lacerations. In a research to find out the result of moisture on the role of
epithelization after wounding Winter and Scales (1991-92) reported that a moist environment
was superior to a dry environment in promoting epithelization. The study opened the door for a
series of subsequent studies that changed scientific thinking about local environment for
epithelization and the methods available to create the environment.

Hutchins, et al (2010) stated that the compress with ice cold to perineal area, both and
application of drugs such as paracetamol and cody dranik are popular for relieving discomfort,
but have a limited effect.[73]

Sleep and Grant (2008) reported that the use of salt or savlon as an addictive to bath
water, which were popular practices in midwifery, have been shown to be quite in-effective for
prevention of infection, promotion of wound healing and reducing discomfort.[124]

Dale and Cornwell in 1994, in their evaluative study to examine the practice of
adding lavender oil in relieving perineal discomfort following childbirth, selected lavender oil
for aroma therapy as an antiseptic and healing agent. They used lavender oil while taking bath
addictive postnatal to bring down pain. A three group study was done in a hospital. Experimental
groups made use of pine and synthetic lavender oil and inert material for 10 days after normal
delivery.[57]

The study findings revealed that the pattern of discomfort scores had no statistical
differences between groups after 10 days. But those mothers using pure lavender oil showed
lower means discomfort scores within three to five postnatal days. They recommended the
successful use of 6 drops of lavender oil mixed with water daily for 10 days for giving bath
following child birth. Those mothers using this oil (6 drops) found it pleasant to use and there
were no side-effects.

Many non-research literature reviews state that almost all primigravidas experience
some degree of discomfort from an episiotomy, depending largely on the extent of the wound
and the amount of suturing done. For the most part during the first few days, local treatment in
the form of dry heat, analgesics spray or ointments is all that is necessary to alleviate the
discomfort. But if the pain is more severe on the first day or so, such treatment may not be
sufficient and analgesics medications may have to be administered by mouth or hypodermic
injection. Later on sitz bath is helpful if the discomfort persists.

Carrel, A. and Ebeling, A.H. (1989) stated that for wound healing slight irritants are
needed such as dry gauze. When a few staphylococci are introduced healing commences very
shortly as it stimulates healing.

Vanort, et al. (1996) conducted a pilot study on topical application of insulin in the
treatment of decubitus ulcers. The findings revealed that experimental group subjects who
received insulin therapy showed quicker progress than the control group. They stated that the
wound healing process depends upon provision or restoration of local circulation and formation
and deposition of collagen which involves protein as building blocks.

Sarama (1972) in her dissertation study on an investigation into the effect of early
ambulation on wound healing in normal delivery patients with episiotomy after 24, 48 and 72
hours of delivery revealed that reduced amounts of physical care are required for the patients for
early ambulation. There was no adverse effect on episiotomy wound healing for early
ambulation.[136]

Paring and Searles (2008) conducted a research study to find out the effectiveness of
diclofenac suppositories administered by rectum as a prophylactic measure to reduce the pain for
longer duration after the perineal trauma. Randomized research design was used for the study
under control conditions. Total hundred samples were taken either second degree tear or
episiotomy during SVD of full term mothers. 12 hours before repair, the suppositories were
introduced into rectum and the tear or episiotomy repair was done. Pain score by VAS was
assessed 12 hourly for first 24 hours, then after 48 hours and finally at 72 hours of duration. Six
point scoring numerical scale was taken as well as analgesic and local infiltration was done.

The findings of this study indicated that pain score at different time points, that is, 24
hours, 48 hours and 72 hours was reduced as compared with control group. There was less need
of analgesic during repair of episiotomy or tear to the group who got diclofenac as compared to
the control group. So there was need for total infiltration of perineum or pain killer medication.
Thus this study concluded that prophylactic diclofenac gives relief from pain during repair and
even upto two days later on also.

Chiarelli et al(2009) conducted a study on postpartum perineal management and best

practices. The findings revealed that 30 per cent of women had a perineal wound breakdown
which was associated with perineal oedema. They recommended perineal care, raising the foot
end, cryotherapy and regular pelvic floor exercises which are helpful to reduce perineal
oedema.[53]

David, M.P. and Avani, A. (2006) found that use of oxyphenbutazone was beneficial
as demonstrated by the overall inflammation score. The control group who were not treated
showed a poor result. The study findings revealed that edema and hyporemia and intensity of
pain were lessened by the treatment.

In a comparative study, Till Manns, H., et al. (1996) observed the course of wound
healing of 150 postpartum women with mediolateral episiotomies under intravenous
administration of Aescin during the last five days of delivery. The findings revealed that there
was a marked improvement of wound healing and a rapid regression of wound edema of the
postpartum women who were treated by ‘Aescin’.

Harvo, Noponen, M., et al. (2000)did research to see the outcome of enteric-coated
oral chymotrypsin on episiotomy wound healing. By the double blind technique no difference
was observed in respect of edema, hematoma inflammation and pain in patients receiving either
chymotrypsin or placebo.

Dutta, S.K. et. al. (2013) conducted a research to assess the wound healing property
of curacain, which is a protease in nature. Two ointments of “curacain” were prepared by
incorporating 0.5 per cent and 1.0 per cent (w/w) of “curacain” ointments were found to be better
than nitrofurazone ointment and propamidine isethiontecrea.[87]

Phanusopone, Areena (1992) conducted a comparative study of perineal wound

healing using an antiseptic solution and tap water in 60 cases with vaginal delivery in a
postpartum ward. The observation method was used to collect data. Wound healing indicated
normal or abnormal by using six criteria characteristics which were pain, edema, red, hot,
discharge and skin gapping within 2-3 days after delivery. The result showed no statistically
significant difference at the 0.05 level of significance on the wound healing between them. They
reported that tap water can be used for perineal care in order to minimize on economy and
effective postpartum care.[92]

A study was done by Bairyl, K.L., et al (1991) on the effectiveness of histamine in

wound healing. Exogenous histamine was given either intra peritoneal or locally. It was given
without any effect. As semicarbazide (histamine synthesis inhibitor) suppressed the healing
process, there was a delay in the period of epithelization. On the other hand, compound 48/80 (a
promoter or histamine forming capacity) was found to promote wound healing. The study
findings revealed that both exogenous and endogenous histamine promote the healing process.
The findings further revealed that exogeneous histamine has prohealing action only when
endogeneous histamine level is suboptimal.[43]

Low and Reed, et al. (1985, 1987, and 1990) sited that for the relief of discomfort
wound healing and relief from spasm of muscles, fastening of speed of wound healing by
increasing the blood circulation infra-red therapy is more effective.

Melzack and Wall (1992)talked that though the use of head for the relief of pain is
used but the physiology behind it is still not known by anyone. They discuss the two relief of
pain mechanism based on the construction and dilation of the lumen of the blood vessels.
Number one is that due to vasodilatation breakdown cells and chemical get collected on the
injured side and number two is that thermal sensation is perceived at wound site which is known
as pain gate theory and impulses originated to overcome the pain.[39]

Ponomarenko, G.N. et. al. (1995)conducted a research study to explore the action of
low intensity infra-red hinder in the functions of nerve endings from wound side area decline the
sensitivity to pain it effect on the conduction and excitability of the nerve end fibers. As much as
long duration of exposure is given area becomes more sensitive. Lasers radiation plays a role in
maintaining the reflecting mechanism which effect on whole body which ultimately effects to the
immune system of the individual.[94]
 Simunovic (2006)conducted a study in the clinical area. Sample subjects were 243
patients by using low-level laser therapy which was the combination of infra-red ray at 820-830
nm uninterrupted wave and nine hundred and four nm pulses on myofacial were realized. [101]

The area of that specific sensitivity and focal pain points with very high degree of
projection was as a result of reduced blood supply. The patient having different complaints such
as headache, pain on the face musculo-skeleton system, shoulder, arms, neck muscles, low
backache and radiating muscular pain to those who got low level laser therapy, with the results
microcirculation up to the peripheral area was better as it helps in the sufficient oxygenation to
air hunger tissues of the body at the trigger points. With all this mechanism waste material which
is heaped at one place get removed more than 70 per cent, acute pain is reduced and more than
60 per cent is effective clinically. It again depends upon the amount of energy applied at that
time.

In this study the investigator could not find out adverse effect on physiology of body
with the result the need of painkiller drugs was reduced. The findings of this research indicated
that infra-red rays are useful in order to manage postnatal pain as an alternative therapy.

Deriabin concluded in 1996 through a clinical study of non-coherent cold therapy on

inflammatory disease and on the microflora of purulent wounds. The result revealed that the cold
therapy has a significant healing effect on relieving inflammatory diseases.[59]

Koroter and Zogorskaia (2006) carried out an experimental clinical research “the
outcome of cold therapy on wound healing”. The findings established that cold therapy was more
potent in stimulating repair of a skin wound. This manifested in an enhanced proliferative
activity of fibroblasts and epithelial cells decreased areas of the wound.

A study was done by Jaya (2007) to evaluate the effectiveness of infra-red radiation
therapy on an episiotomy wound over the existing practice. The investigator used infra-red rays
for three consecutive days to the experimental group postnatal mothers with an episiotomy
wound and used a topical ointment to the episiotomy wound of the control group mothers as
existing practice. ‘REEDA’ score was also applied to see the wound healing status.

The study findings revealed that cold therapy quickens the process of wound healing
as compared to the topical ointment, when all other conditions remain the same for both the
groups. The findings further revealed that the cold therapy is effective in relieving episiotomy
pain more quickly than the topical ointment. The investigator reported that the cold therapy
minimizes the severity of discomfort and saves the mothers from an embarrassing situation and it
will help the mothers to feel less or no pain during voiding of urine.

Hern, et al. (2008) expressed in their study that treatment of haemorrhodial disease
(grade I and II) with infra-red photo regulation is an excellent alternative method. It is painless,
low in cost and can be suitable as an outpatient procedure.

Burke, Horqitz and Carnegic in their study in 2009 on increasing the rate of healing by
applying infra-red therapy documented different types of wounds in the limbs with infra-red
therapy, rate of healing was observed. In their study at first they used conventional management
protocols for wound healing. When these protocols were shown to be ineffective, then infra-red
protocols were instituted.

The study findings revealed that there was an early wound healing by this infra-red ray
protocol. The researcher concluded the degree and rate of scar formation on already refracted
wound with the use of infra-red therapy was due to the results of increase amount of nitric oxide
which is correlated with vasodilator and anabolic responses. The researcher stated that this
science behind infra-red energy helps in augmentation of wound healing.

Many non-research literatures state that a 25 to 40 watt perineal lamp can be used for
the mothers who have undergone episiotomies or laceration repair. This can be used several
times a day for 15 to 30 minutes intervals to improve circulation, promote healing and ease
discomfort.

2.4. REVIEW RELATED TO PROBLEMS FACED BY MOTHER AFTER

EPISIOTOMY

Roy L. et al. (2007)) did a research to see the outcome of

uninterrupted assistance given by nurse-midwife during all the stages of child birth and
incidence of operative delivery. It was control trial study. Sampling technique was randomized.
Sample subjects were 160 multiparous mothers who were total unaware about pregnancy and
labour. In experimental group number of sample were 80 interventions was uninterrupted
perineal support during child birth. 80 mothers were in control group. The both group were
homogenious according to their geographical characteristics. Results of the study indicated that
number of operative delivery were less in experimental group than the control group and need of
oxytocin was also reduced for the mother during postnatal period as well as Appagar score was
equal in both the groups. Thus, it was summarized that uninterrupted support given by nurse-
midwives at the time child birth have an effect on the length of labour and incidence of
operative delivery was also reduced so this method to be used in all the vaginal deliveries.

Menon K-. and Zeng T-J. (2011)conducted a study talked about the low backache
during the time of laboring process. In this study they have taken anatomical regions affected,
theincidence of special type of back pain, its severity intervention which will be effective and
the factors which are responsible for increase the back pain during labour. It was done on
Taiwan mothers to recognize the factors responsible for pain in the lower portion of back during
labour. In this study sample subjects were 93 mothers who were in active labour and admitted in
one of the birthing center. The measurement of low backache was done during active phase of
labour when the cervical dilatation was 5-7cms and 8-10cms respectively and it was a respected
measure. Information was gathered analyzed by tabulating the data into inferential statistics as
well as percentage and frequencies. R ANOVA repeated measure of ANOVA was applied as
well as logistic regression was taken.

The findings of the study show that 73.3 per cent of the mothers suffered with
backache in the lower portion at the time of childbirth. The average scores were thirty six to
seventy six in different stages of child birth. Severity of pain was increased with the progress of
labour as well as site of pain was also changed. The results indicative that in 54 per cent of the
mothers pain was like muscle soreness. The pattern of pain in 46 per cent of mothers was
regular type of pain with no relief of all. In 65 per cent of the mothers back massage was given
to relief the mothers from pain. The mothers those who complained about backache in the lower
part of back while pregnant (OR p value < 0.1) and had gain ody weight during stay in the
hospital OR p value=1.13, mothers suffered with backache. To summarize this research
suggested that early prevention is better than cure is very important in selected mothers for those
who suffered with backache in antenatal period and more weight gained during hospitalization.

Lowe (2007)cited that the pain impulses during the episiotomy incision are travelled
through spinal nerves the thoracic on to two and accessory nerves and lumber lower one and T3
spinal nerves. These nerve fibers originated from the body of the uterus and (cervix) lower part
of the cervix. At the time of vaginal child birth physiologically pain increase in severity
electrical impulses transmitted by the sympathetic nervous systems and pain is increased which
leads to raise the level of catecholamine in the blood stream hereby blood pressure and heart
beat fastened, respiratory pattern is changed and requirement of oxygen get changed due to
increase in consumption of its requirement. Mothers may develop alkalosis and there is
hyperventilation in the mothers. Vital parameters values are changed and anxiety is also
increased. Mothers may cry, due to discomfort and muscles excitability throughout the body.

Wilmot (1979) reported that the routine practice of episiotomy will prevent under-
stretching of the pelvic support and prolapsed in later life and episiotomy is accepted within the
obstetric and midwifery practice as a simple means of facilitating the delivery of the baby,
avoiding uncontrollable perinea lacerations and as a prophylactic measure against it. It is also
devised as an elective procedure in all primigravida for the above mentioned reasons.

Dorris Needham et al (1981) conducted a survey over a four-month period. Out of

602 women delivered in the four months of the survey, 138 delivered with episiotomy. Four
women found need of restring. The study reported that 20 women complained “moderate to
severe discomfort.” 52 women complained “mild discomfort” and 62 complained “no
discomfort” due to episiotomy.

Study was conducted by Veena (1992) to assess the effects of structured health
teaching in the prevention of an episiotomy infection. The result revealed that there was no
relationship found in the episiotomy infection with the variables i.e.duration of labour, duration
of rupture of rupture of membrane, number of per vaginal examination and type of delivery The
finding showed that health teaching had an influence on developing good health habits lie
maintenance of personal hygiene, maintenance of perinea care and ambulation which help in
preventing an episiotomy infection.
 The National Childbirth Trust (1989) reported that the reasons behind some post-
natal infection are inadequate personal hygiene and unclean episiotomy wound.

Gorden. (1998)did a research to find out the hospital policy in order to repairing of
two stages postnatal episiotomy wound or injury and not suturing the skin in one of the Trusty a
District Hospital General Hospital. Total sample subjects were 1780 postnatal mothers with
episiotomy or first or second degree team which was due to forceful unattended spontaneous or
instrumental delivery. The findings of this study indicate that two stages repair of perineal
wound and not putting skin stitches will lead to decrease postpartum episiotomy pain. It also
indicates that there were no as such any complications or disadvantages of gaping or opening of
the stitches while mother is resting or sitting for feeding her baby.

Dr. Hill Ashley D. (1995)stated that repair of an episiotomy was generally straight
forward in case if the incision is not correctly given also if the stitches are put later on which
leads to delay in healing of the stitches. Some of the mothers have normal healing with first and
second intension of wound healing. In some of the mothers a fixed area decided was a routine to
be followed as right mediolateral six-o-clock episiotomy. This can lead into severe pain when
we insert finger to do the toliting after the repair of episitomy.

Lee; 1982 reported in the British Medical Journal that 10 percent of patients with
episiotomy were experiencing pain six weeks after delivery.

Hill; (1992) reported in her findings, mothers who had undergone deliberated incision
and with injury to pelvic floor suffered high discomfort on numerical scale within 24 hours of
delivery than those with a laceration only. All these studies reflected that the post- natal mothers
with an episiotomy wound experienced problems like pain discomfort, wound infection which
requires some intervention for alleviation of those problems.

Maier, J. and Maloni. J. (1997) reported in a review study of episiotomy versus

selective procedure indicative of many side effects which occur due to deliberated incision and
high degree of perineal injuries and excessive bleeding. They reported that mothers were
complaining of pain, delayed healing, dyspareunia and psychological trauma.[84]

In the American Journal of obstetrics Thorp J. M. (1995) reported about the side-
effects of episiotomy. He stated that infection, increased pain, longer healing times, dyspareunia
are the common side- effects of episiotomy.

Thus, the investigator felt a need to search literature and non-literature review on the
care aspect of an episiotomy wound.

2.5. REVIEW RELATED TO CARE OF EPISIOTOMY RELATED TO WOUND

HEALING, RELIEF OF PAIN/DISCOMFORT AND COMPLICATIONS

Adriana, A.F., et al. (2011) did cross-sectional research on 303

postpartum mothers were involved in the data collection through interview who were delivered
with episiotomy. Finding indicate that some of the mothers had immediate complication of
vaginal delivery like infection, bleeding per vagina, hematoma and suture dehiscence that
interfere with mothers daily activities and in breastfeeding, some of the mothers even suffered
with long term complications like dyspareunia urinary and fecal incontinence. The prevalence of
perineal pain was also assessed and it was 18.5 per cent with moderate intensity (51.8%)
associated with presence of episiotomy (p = 0.001), there were 303 episiotomies. The medicine
given to kill the pain by mouth to get rid of pain what wasnot found as effective method to relief
the pain.

Calvert, S. and Fleming, V. (2000), did research regarding perineal care during
labour. Minimizing postpartum pain: the aim of the paper was to give nurse, midwives and other
health personnel with research evidence in order to focus on the mother centered approach. The
key words for the research topic were searched. [65]

All studies were randomized-controlled trials. They did review on the various suturing
material, minimizing changes of giving episiotomy and they did comparison with other studies
and found that there was no variation in discomfort degree, continuously leakage of urine and
pain during coitus. Head (1993) did study on postnatal mothers. Sample subjects were seventy
five only. It was very small study. Mothers had stitches after the vaginal birth. An interview as
conducted with mother to ask them about the discomfort and experience. It was control group
study. Information gathered from mothers, shows that mothers who were in control group and
suffered loss with pain and who did suturing have more same responses were for coitus, no
information was collected regarding wound healing in this study.

With the review of all these six studies researcher herself could learnt the significance
of measuring the wound healing with the tool which is used for the present study developed by
(Davidson, 1974) REEDA tool though investigator found difficulties to use this tool while
placing the scale to measure the area of the wound healing to evaluate condition of the wound in
terms of oedema, redness, bruising, discharge and approximation of wound edges.

Sakineh, M., et al. did a study to see the outcomes of cinnamon on perineal pain and
wound healing. It was control trial study and sample were selected with random samples
technique 144 postpartum mothers were divided into two groups by using stratified block
randomization 1 hour after repair of episiotomy wound. Cinnamon or placebo-ointment 2 ml
every 12 hourly was given for 10 days. Perineal pain and wound healing was observed by VAS
and REED scale and redness edema, ecchyannosis discharge. Approximation scale (0-15)
respectively the results of the research indicate that cinnamon was found effective in reducing
perineal pain and improving wound healing of episiotomy site.

A study was done in 2011 in the Obstetrical Unit of Mashad setting was Hospital. It
was cross-sectional study. There were one hundred and twenty seven sample subjects, which
includes midwives and nursing students as well as medical students. These all samples were
interviewed. In this study it was the type of episiotomy to be assessed as the length of incision
angle of episiotomy right or left to avoid tear and decrease the complications of episiotomy. The
comparison was done in midwives, nursing and medical students. The findings of the study show
that the length of the median episiotomy incision from midline was 2.89 + 0.95cms. It was show
that midwife was not confident about the incision and angle. Nursing students’ p value was 0.040
and length of the incision was also than the length of incision given by midwives. To summarize
this study shows that there was significantly difference in the incision given by students and
gained midwives and this difference will leads to more complications to mothers with
episiotomy.

A study done by Wagas Asraf Chaudharyon management of pain along with treatment
modality. In this study as it was a case study, a 42 years mother was a case who have problems
of constant burning and dull pain in the anus. In the beginning pain was very frequent was put on
as paracetamol and good pain relief was the result but later on frequency of pain was increased
which interfered with her daily activities and sleep during day and night. The visual analog pain
score was constant as throughout the awakeful hours but during defecation and after several
hours VAS 8/10. This mother delivered spontaneously per vaginal delivery and had episiotomy 2
days before the onset of pain. So mother with her problems went to medical help in order to get
relief from pain and discomfort.

Various investigations and modalities were tried to provide her relief from pain. It was
found that mother with old perineal pain have co-existing many various pathogenic pain
mechanisms. Different methods such as acupuncture, physiotherapy, psychotherapy, local
applications, pain killers and nerve block, cold compress and hot sitz bath was given and each of
the methods found to be effective to reduce the pain. In conclusion cold compress and warm sitz
bath is very useful to decrease the episiotomy and decrease the chances of late healing.

P. Humdoung S and Good M. (2013) conducted a study on complications of

episiotomy wound healing and pain relief. It was a controlled trial study. Total 65 sample
subjects were selected with randomized methods. This study was done on Thai primiparous
mothers during postnatal period. The gate control therapy for discomfort was used as theoretical
framework. The computerized randomization programme was used. The cold therapy was the
intervention given. Cold therapy was applied to minutes in the early postnatal period. Pain was
assessed with VAS to see the severity of discomfort was taken and then after giving the
intervention post hourly posttest was taken, one way repeated measure of ANOVA was applied
to find out the findings of the research. The results of the study indicated that group which was
given the intervention with cold therapy have less severity of pain than the control group. The F
value was (1.107), and P value .001. It was also found that severity of pain with 4 hours interval
was decreased in all group of intervention and non-intervention at p value of (p>.05). It is clear
that cold compress is effective in reducing the pain of the mother and it should be brought into
practice.[93]

Gordon and Rieman (2010)did a study on two hundred nurses working in a hospital of
USA on the nurses’ knowledge and attitude regarding pain. A modified interview schedule was
introduced items related to episiotomy pain of postnatal mothers, question regarding effect of
cold and hot was not included because these questions were not used to manage the episiotomy
pain, which occurs due to burning and the wording for 39 items was changed which was the part
of the previously used tool of (Rieman, et al., 2007). The mean survey score was 78 per cent
(ranged 35-100%). The 12 items answered wrong by many of the sample subjects regarding pain
killer and circulatory problems. There was significance difference in the score of nurses who
have the experience less than two years and who have more than 2 years’ experience at (p<0.05)
and have higher score than other subjects.

The finding of the researchshowed that the education have an effect on the proper
management of pain methods. The lacking or the weak points in this study sample subjects
express that they could not understand the medicine and its effects to reduce pain by effecting on
the circulatory and other systems of the body as well as bleeding complications during postnatal
period.

A study done byFrancke, et al. in 2010. This was a qualitative study, to find out the
need of continuing education in Dutch nurses in the one of Cancer Hospital. The survey report of
this study, indicate that nurses usually did not assess pain routinely. So that did not give proper
dose of medication to patient as nurses are not aware of many of the non-pharmacological
methods of pain management in cancer patients. Even they find lack of knowledge to provide
psychological support to cancer patients. Patients usually did not express about their pain to
nurses as they think that nurses are not able to manage their pain. By using the findings of this
study, a continue in-service education programme for nurses was developed.

MacLaren (2012) did a research to see the outcome of did active training programme
for nursing personnel who were participating in the development of methods of pain
management in children. Nursing students were also involved in this programme and assignment
was given by dividing them into two groups. Their knowledge and attitude was associated pretest
was taken and posttest was conducted after giving them the training. The findings suggested that
training have no effect on their attitude but knowledge have a gain in the score. In the role play
method of learning participant have more score. These finding suggested that brief training
programme with small role play was more effective in teaching the students about pain
management of patients with cancer and these methods were implemented in the practice.

Clong L.C., (2010),did a experiment research to see the knowledge score of nursing
staff as well as attitude of mother with episiotomy pain management after an in-service
programme in Taiwan Republic of China. The total numbers of sample subjects were 200 staff
nurses who were wearing in Taiwan Hospital. Senior staff nurses attended the 4 hours in-service
education programme. Discussion, video and case study was the methods used for teaching.
Information was gathered by the interview schedule to find out that knowledge score regarding
management of pain of episiotomy mothers with the use of pain killer medicine and without use
of pain killer with other way of management of pain. The results of the research show that there
was increase in the knowledge score of sample subjects after attending the training programme
than pretest score. So these finding suggestive is that in-service education programme to be
conducted for the nurses in order to management of patients with pain.

Mathew, L. (2011),reported in a article that pain is usually wrongly understood under

diagnosed and under estimated by medical problems and that is why it is not treated specially in
children. Medical people must properly assess the pain in children. It is also a challenging work
for nursing staff.

Now according toJCAHO,new regulations and guideline regarding pain it is

considered as “5th vital sign” and caregiver needs to continuously assess and evaluate pain and
discomfort in children as a priority need. For pain different sensation are expressed by patient to
explain about pain, so caregiver needs to understand and assess it regularly whenever patient
suffer with pain. Level of pain is not same in children even though they are with same age,
because each child perceives pain and tolerance is also different in each child. If pain is not
recognized and managed in time, it effects very strongly at the child’s mood perception, behavior
and even it interfere with child sleep, hunger attendance to school output of his study,
participation in games and sports and other extra-curricular activities. Pain in the childhood will
also effect in later life. Experience of pain in the early life accompanied with multiple changes in
the adult life. Again and again exposure to pain sometimes leads to alter the sensitivity to pain
anxiety to pain anxiety and stress and depressive disorders, attention deficit and lack of social
interaction and child may develop self destructive behavior.

So, even though there is so much effect of pain in the children still pain management
in children have not been given any routine clinical importance for decreasing perception of pain
in small children

Sparks (2007)did a study on children position while doing various procedure on

children. It was controlled trial study sample selected by random methods. It was done on the
decrease of stress in children while we put I/V cannula in children. In this study the age of the
children were 8-10 years. Triage was used for children who require emergency care. Parents
signature were taken before doing the study.

Two group study was done, with control and experimental group. Parents were given
an questionnaire related to the general information about the child and demographic information
as well as on the child’s previous experience related to pain. All intravenous cannula were
introduced by staff nurses who were admitted in the paediatric ward.

Children in the control group were positioned on the examination table and were held
in position by another health worker while putting the I/V cannula. The experimental group
children were held by their parents while cannula was introduced to them. Ice cold compress was
applied before insertion of the cannula on the site of insertion. This was an experimental study so
family members was made available to be present while putting cannula as it reduces the anxiety
of the child. After the procedure parents were given the questionnaire to be completed and each
parent completed it with great satisfaction.

There were 135 sample size but 17 of them were drop out so the data was analyzed
with only 118 sample subjects parents who applied cold compress to their children before
applying I/V cannula were helpful in bringing down the stress of children who have I/V insertion
of cannula.

Sakun Singh (1993) carried out a research to see the knowledge and attitude and
practice related to contraceptive methods as expressed by eligible women attending the rural
MCH clinic of Nepal. The study revealed, all the women had heard of contraception and
majority reported it was risky to have many children. The majority were aware of various ways
of avoiding pregnancy and know about all the methods. Most of them reported contraception is
used to stop reproduction permanently. The current users of contraceptive were 28.33% the most
commonly used was injection Depoprovera (35.29%). Most of them gave the reason for not
using contraception as a desire of a son. There was significant relationship between knowledge,
attitude and practice.[144]

Cox J. L. (1988)performed a study on socio-cultural aspects of postnatal discomfort.

He could see that Cultural rituals on postnatal mothers were done and not performing such rituals
routine was high which leads to complications. The deficiency of cultural family superstitions
leads to effect self-esteem of mothers is the leading cause of breakdown of husband wife
relationship which effects on episiotomy pain relief and wound healing.

A study performed by Adimna J. I.on 352 Nigerian women revealed that a high rate
was observed in frequency of coitus in postpartum period 1.7 times in a week in comparison to
antenatal period which was 1.5 times in a week coitus was done six to twelve weeks in 114
mothers after delivery.

Woollett A and Dosarijh Matwala N. conducted a study regarding attitudes and

experiences about postnatal care. 32 mothers in London were asked question in an interview
regarding discomfort and their condition during labour. Asian mothers expressed that taking rest
during postnatal period is better than the hospital delivery. They expressed that in this type of
environment mothers have very less time to get bonding with her baby.

Kamla Devi Ran (1989)conducted a descriptive co-relational survey to investigate

beliefs and practices regarding diet among postnatal mothers and also to identify the factors
influencing the dietary beliefs. The sample of study comprised 45 postnatal mothers from 3 sub-
centres in Himachal Pradesh. She found that all mothers believed in consuming special food like
desi ghee, milk, dry fruits, dried ginger, ajwain, ‘Gond’, ‘Kamarkas’, ‘Lugda’ and elaichi water.

Most of them believed that special foods provide strength, regain tone, prevent
‘vayu’, prevent abdominal pain, provide heat and are good for digestion. Majority of mothers
had belief that certain food items like red beans, black gram, potato, curd, pickle, fruits, egg, fish,
meat, green leafy vegetables and plain water should be avoided during postnatal period as they
are believed to cause harm to mother and baby. The overall finding indicated that nutritional
status and overall health affected wound healing output and pain relief.

Santosh Gulati (1989) conducted a descriptive study of existing pattern of breast

feeding among mothers in an urban slum, New Delhi. Major findings of the study were:[137]

Majority of them initiated first breastfeed on the 3rd day of birth of child.

Common pre-lacteal feed given was sugar or jiggery water.

Majority of them did not clean breast before feeding babies.

The reason stated for choice of breast feeding was that it is nutritious and keeps baby
unhealthy.

More than half of the mother used feeding bottles for top feeds and cleansed them with
soap and water and few cleaned with mud, which is a harmful practice.

Babu M (1990) conducted a descriptive survey to identify the occurrence of selected

health problems in postnatal mothers and new-born and the use of remedial measures in a
selected urban community in New Delhi. From her study she found that 51 home remedies were
used after pains of which are common ones was the use of cereals with other ingredients like
sugar, ghee or jaggery and spices, etc. Five home remedies were used for shivering; the most
common one is consumption of hot drinks immediately after birth. She could see that most of the
home remedies used by the respondents for the relief of common ailments were safe and
effective and very few were found to be unsafe as per the literature and expert’s opinion.[130]

According to a study conducted by Bhattia S (1981) regarding traditional child birth

practices, in a rural MCH centre, the new-born is bathed with cold water and mustard oil is
rubbed all over the body. Regular breastfeeding starts 4 days after birth until which time the
infant is fed on honey mixed with mustard oil and clean water. Full rest is allowed for the mother
for few days after delivery.
 Thompson C. S. (1983) conducted a study regarding ritual stated in the life cycle of
Hindu women in a village of central India. He could see that in many Hindu societies, the infant
and the mother is massaged with oil and turmeric. The mothers do not breastfeed for up to 3 days
and the baby is fed sugar solution. They remain in the birthing room to avoid polluting others.
The mother follows a diet according to Ayurvedic Medicines and is allowed food considered to
be warm.

Lal S and Adarsh (1980)describes that in the rural areas of Haryana, the new-born is
immediately bathed in lukewarm water. In pueperium mother is advised to spend the first 10
days in isolation, so as to keep away from evil eyes. The mother has a daily warm bath from the
second day postpartum. Abdomen is massaged with ghee or oil. She also eats a lot of ghee and
sugar, considered as hot, whereas milk is avoided. Intake of water is reduced since it is thought
to cause flabby abdomen.

Mohepatra S.S and Bagg (1982) conducted a study to assess the customs and beliefs
on neonatal care among 170 mothers in a tribal community of Orissa. Findings of the study
indicated that resuscitation of the new-born is done by the massage of the infant’s body. The
new-born is nursed by the fireside and massaged with oil daily. Breastfeeding starts within 12
hours after delivery in 83% cases. Sour food, fish and meat are restricted during lactation.

CAMPBELL 2012 states that the complications of episiotomy, wound healing has
increased the mortality rate of post natal mothers globally. The anti natal maternal mortality is
effecting the mothers health. Regarding anti natal maternal mortality, there are two things which
needed sudden steps to taken are.[11]

1. The data on the death of mothers during reproductive age is not available
properly
2. Maternal mortality rate is the important results to bring down maternal
mortality rate in order to maintain the health of mothers during reproductive
age.

There is deficiency in the proper explanation and availability of indicators of maternal mortality
for the health care provider. So they are not able to understand the data of maternal mortality.
For example: “four” as meaning of which is being is late in providing care during sickness,
making comfortable and preventing the patient from loosing of any of the organ of their body
and not able to provide the care at level of patient’s satisfaction.

CAMPBELL & MACFARIANE 2010 did research to find out episiotomy, wound
healing & discomfort of post natal mothers. They found that the helps to provide home like
environment labour room give more happiness to mothers and help in decreasing the incidence
of perineal tear and also helping the mothers for next delivery in the hospital. The findings
indicate that the institutional delivery have a effect on labour outcome and health of mother and
fetus.[11]

Carolyn m. Samselle etall 2010 expressed that vaginal delivery is considered as giving
tear to the mother and post natal perineal discomfort to episiotomy. She found out the outcome
of 130 primi mothers who had vaginal delivery without help. This was retrospective survey study
in which mothers were asked to explain about the type of pain perceived during first week of
post natal period and severity of pain as well as perineal injury and extent of episiotomy wound.
They had 28% of mothers express that spontaneous efforts and remaining 72% were directed
towards the mother’s who did efforts themselves were not having much trauma to the perineum
than the mothers who had episiotomy.

Thomast Clark 2005, every woman needs attention to perineal cleanliness in the post-
partum period to prevent infection. Women are particularly prone to this because lochia, allowed
drying and hardening on the vulva and perineum, furnishes a bed for bacterial growth. There is
always a danger that bacteria will spread from the rectum to the vagina and uterine infection as
vagina lies in close proximity to rectum.

Perineal care should be done as part of daily bath and after each voiding or bowel
movement. As soon as a women is ambulatory, she should be instructed to perform perineal care
herself. Perineal care should be a procedure that is easy to learn and not time consuming. So the
women can spend most of her time with her child not completing a ritual care. Perineal care
promotes healing of the episiotomy wound, provides comfort prevents post-partum
complications like infection and hemorrhage.
 Roy &Chitali 2009 conducted a study on post-partum perineal management and best
practices. The findings revealed that 40% of women had a perineal wound break down which
was associated with perineal oedema; they recommended maintain the personal hygiene by
raising the foot end of the bed and regular pelvic exercises which are helpful to reduce perineal
oedema. REEDA score findings were significant to reduce the wound healing scores.

Dr. Venita 2015stated that ice packs, numbering creams, sitz bath and wearing loose
clothing may help in care of slight tender episiotomy. He further stated that the mothers who are
giving breast feeding to their babies may be benefited with very less cream based on hormone
estrogen as breast feeding slows. The dose of estrogen in the vagina, or in any abnormality
surgical revision of the area and removing the excess tissues and infections may be helpful in
reducing discomfort and pain in the episiotomy wound.

Kochar. M 2010,studied causative factor and features of pelvic infections related to

gynecological incisionalprocedures in Delhi. During a period of five years, 3000 mothers were
admitted to trauma hospital and Safdarjung hospital that have undergone sterilization operations.
A comparative study was done of tubectomy and septic abortion to see the rate of infection, a
leading cause of maternal mortality.

Saearles 2012 conducted a comparative study of perineal wound healing using an

antiseptic solution and tap water. The observation method was used to collect the data. Wound
healing indicated normal or abnormal by using 6 criteria characteristics which were pain, edema,
red hot discharge and plain gapping within 3-4 days after delivery. The result showed no
statistically significant different at the .05 level of significance on the wound healing between
these. They reported that tap water can be used for perineal care in order to minimize on
economic and effective post-partum care.

Hamasha etal 2013 stated that the clients who had rectal surgery and episiotomy
during birth, bleeding piles, vaginal inflammation may be reduced wih sitz bath, a bath in which
only pelvic areas are immersed into warm fluid. Immersing the entire body causes widespread
vasodilation and nullifies the effect of local heat application to the pelvic area.
 Prural 2008 carried out a study in In Nigeria to find out the rate of maternal sickness
and death after hospital deliver. Result of the study indicate that 232 mothers out of 4081 were
suffered with complications through out the research period 6450 per lakh of birth which ratio is
eleventimes more than the maternal morbidity the major death rate per lakh of live birth.
Prolonged labour 3614, high blood pressure were 1159, hemorrhage 855 and infection during
postnatal period were 220.

2.6. REVIEW OF LITERATURE RELATED TO THE EFFECTIVENESS OF COLD

APPLICATION ON EPISIOTOMY WOUND HEALING AND DISCOMFORT
DUE TO EPISIOTOMY

A study was conducted by Curzik and Jokic-Begic, 2011To see the association of anxiety
traits with child birth the observation was done at 3 different time antenatal intranatal and
postnatal period. The sample subjects were 46 in number primipara mothers with single tone
pregnancy. The association with anxiety was highly significant (r=0.352 p<0.05) at the time of
labour whereas pain intensity was (r=0.292 p<0.05). To summarize anxiety and pain during
childbirth have significant relationship. This study can be generalized in the clinical field.

Tzeng Y-. and Su T-J. (2008) conducted a study to detailed about low backache at the
time of childbirth, its incidence body structure characteristics severity of pain, factor which leads
to its severity and management second was to find out the predisposing factors regarding low
backache during child birth. Design of the study was correlational and R Anova was used for
repeated measure. The sample subjects were 93 full term mother with low risk score setting was
one of the hospital of Taiwan. P/V examination was done during late first stage of labour to
measure the cervical dilatation at three times at the measurement of (2-4 cm), (5 to 7 cm) and (8-
10 cm), descriptive statistics was used to analyzed the information. R Anova was applied.
Finding of the study indicated that 75 per cent mothers complaints of low backache during child
birth. The average score was 36.66 and 76.20 in different phases of child birth, with the progress
of child birth severity of pain was increased. The site of pain was changed to 54 percent mothers
feels soreness of muscles and discomfort and 45 per cent have continues back pain. Intervention
done was back massage. It results that 65 per cent of mothers got relief from back ache OR=13;
p=3.23 (p<.01). To summarize this research indicated that low back ache increased with the
progress of child birth is indication for its early diagnosis and prevention to those mothers who
gave history of low back ache in antenatal period and who have more weight during hospital
stay.[105]

Lowe (2002)cited that during early stages of child birth thoracic nerve one and two
which supply to the upper lumber and lower thoracic vertebra. They send sensory nerves to this
area. These nerves start from the body of the uterus and cervix. At the time of labour pain is so
much severe that it have an physiological effect, so here sympathetic nerve fibers are involved to
control the pain and level of a catalyst in the blood is increased. As soon as pain is increased into
the severity,. The vital of the mother get changed and maternal distress may takes place.

TournaireM.,et al.(2010) conducteda study experiment among 120 primigravida

women; random sample to cold compress were taken to know the effect of cold therapy on pain
in episiotomy wound. The samples were given to cold compress every 4 hours (N=60) and
control group (n=60). The visual analogue scale was use to measure the pain in episiotomy
wound felt by mother before starting the study and every 4 hours . Thereafter the findings in the
result showed that in the cold application on episiotomy of primigravida mothers has
significantly less pain sensation that is (P<0.001).[104]

Yang, M., et al. (2009)conducted an experimental study an experimental study on

postpartum mothers to relieve anxiety with cold therapy. A randomised controlled trial method
was used. The postpartum women in experimental group who received cold therapy for 10
minutes 4 hourly for three days continuously. The participants had cold compress for continuous
three days. Research finding indicated that anxiety level of postpartum experimental group was
decreased and physiological responses were improved in postpartum in the intervention
[108]
group.

LiuY. H., (2009) did an empirical research to know the outcome of cold application
on pain sensation and anxiety of primipara mothers during puerperium period with normal
spontaneous delivery. A randomize method was used. It was control trial study.Total samples
taken were sixty for empirical were thirty and control also the same. The control group was
provided routine care only and experimental group was given care with cold therapy. A self
report VAS for pain was used to assess the effect of cold therapy on experimental group.
Another nurse rated behavioural intensity scale was used to measure the labor pain. The anxiety
was measured with a VAS for anxiety and REEDA scale for wound healing. The pain and
anxiety levels were compared in both experimental and control group during first 48 hours. The
result revealed that the experimental group had significantly lowered pain and anxiety levels in
mothers in comparison with other group. However , there was no significant variationsin both the
samples on others factors during last stage of child birth and during the early postpartum period
was less in empirical group than other group. The findings of the study supported that the cold
therapy is an effective and acceptable as non medical coping strategy for episiotomy pain and
swelling reduction.The cold application helped in bringing down discomfort and stress for
mothers who were in the beginning of postpartum period.[54]

Bharathi B Jaya. (2012), conducted a true experimental study to assess the outcome
of nursing care during child birth to first time mothers. The objectives of the study were :[46]

1) To find out the comparison pretest and posttest outcome of labour pain in both the
groups.

2) To comparison was done in the routine hospital care as such too.

A true experimental research design was used to study and quasi experimental was used before
and after (intervention) only design

The nursing intervention selected and used for the experimental group were with back massage,
deep breathing exercise and various posture were used for the primi mother in experimental
group and routine care was given for the control group. The independent variables for the study
were nursing interventions massage, breathing exercise and different positions for primigravida
mother during labour admitted in the hospital in selected hospitals of Delhi. The total sample for
the study were 80 primigravida mothers, 40 mothers for empirical group and 40 in control
groups. Sampling technique used was random by alternative patients assigned for control and
experimental group.

The visual analog scale was used for the study

The combined numerical categorical pain assessment for the primigravida mothers
during labour was used.
 The prior evaluation finding with mean was 5.66, with student deviation reading2.23
in empirical group and average value 5.75 with standard deviation 2.43 in other group. The
comparative level of discomfort in bothgroups was 2.43. The comparative feeling of pain in both
group indicated that it was not significant at P<0.001 level.

Thus the study concluded the nursing interventions for the primi mothers during
labour were effective in reducing the labour pain.

Chang MY., et al. (2011), did a research to see the result of treatment with cold
compress as remedy to set guide of discomfort of child birth with episiotomy.It was an controlled
trial study sample were selected with random methods of selection. Sample subject comprises of
nulliparous pregnant mothers with low risk, setting of the study was the referral center for
women’s health in ribeiroo preto.It was divided into the experimental group, one group was cold
therapy and other group was warm therapy and there was a third group as a control group
.Design of the study was pre-test, posttestdesign. The scale use to measure the severity of the
pain was numerical. Scale inventory used as a tool for this study was a diagram location of pain
and pain questionnaire. [52]

MC GILL reduced form a questionnaire interview schedule was administered after the
care to find out the clients satisfactorylevel. The information was collected and finding were
interpreted with linear regression model with mixed outcome as random as well as mixed one.
The findings of the study indicated that pain was relieved a ‘P’ value was <0.05% level of
statistically at 5% of level

Davim RMB., et al. 2009did a research to see the result of technique used to getside of
discomfort followed by child birth without pain killer medicine. It was a clinical trial study.
Design of the study was conducted in private maternity hospital in the city of Brazil. Sample size
was one hundred postnatal mothers. Interventions were deep breathing exercise, muscles relaxin
technique massage in the lower back and shamers.

The scale used to measure pain was VAS and data was collected. Age of the maximum
sample subjects was 20 to 30 years (60%),the educational status of the sample subjects was
primary level and family income was low socio-economic status ,.78% of the sample were
having one or two support person with them. Maximum of the mothers were under the
mechanical induction of labour 81%. Where as 15% of them did not had any medication for
induction of labour . After the study finding suggested that 15% of the mother who did not
received any medication for induction of labour were having less pain during postnatal period
than those who went under medical induction of labour.

A research was done in a clinic of Kamali hospital in Karaj. It was randomize sample
study under control conditions. To see the output of application by chilled gel pain. The
episiotomy discomfort relief was the variable under study and sample subjects were 60 Iranian
primi postnatal mothers. The treatment given was sitting in to the tub of warm water for half an
hour to the experimental group.

A research was done in a hospital at Australia. The purpose of this study was to see the
results of local cooling with cool ice pack. Cool ice bath with control group with other cooling
and without cooling management. It was controlled trial study. Sample subjects were 859. The
findings of this study showed that discomfort was relieved within 24 to first 72 hours after
delivery without intervention. This research summarized by the investigator that the cooling have
very less effect on the pain relief and wound healing. Another study was done in another setting
in the midwifery office U.K. to see the effect of ice packs and epiform at pain reduction. One
hundred and twenty sample subjects were kept under this study. Different grading was given to
the result. The findings indicated that mothers who used gel pad had higher rate of improvement
in pain relief. Researcher summarized that special made gel pad were more effective in relieving
perineal discomfort than commercial ones.

A research was done to find out the effectiveness of cold ice pack on vaginal trauma. It
was done to give cold compress first 24 hours. The material used was sterile gauze piece put
directly on the perineal wound on the swollen area. The mothers during first postnatal period get
relief and feels very comfortable while feeding their babies.

A study was done to evaluate the experience in applying ice to the child birth mothers.
Subjects were 324 young mothers. The researcher put ice on the stitches of vaginal area during
first to third postnatal day. Sample subjects were 254 in the control group. It was seen that 5 per
cent mothers in intervention and 9 per cent mothers in control group were without any
complication the effectiveness of cold application over episiotomy after delivery.

A study reported that crushed ice with a cloth put on the stitches 5-10 minutes gave
relief from discomfort for a longtime.

A survey conducted to find out the usage of icepacks in 50 maternity units and the
results found that 84% of the maternity units were using icepacks for the relief of discomfort.

Chang SR (2011)did a comparative research to assess the effect of wound on wound

discomfort, continuous dripping of urine, and coitus function 3 months postnatal period.
Findings show that wound pain increased at weeks 1, 2 and 6 post natal day and urinary
incontinence at 3, months postpartum. The researcher also recommended that knowing about
association between episiotomy and mother’s health will help health care professionals develop
policy and promote the application of restriction on vaginal operation.[52]

Serena Bertozzi (2011) did a research to see the effect of vaginal operation and its
effects on mother’s health after 6th month of postnatal period. The purpose of this research was
to find out the role of vaginal operation in protecting the perineal area from injury and see the
effect on the pelvic area as well as psychological and physical health of mother up to 6th month
of postnatal period. This study reported that vaginal operation is a protection for health of
mother. Mothers those who had vaginal operation and experience with little discomfort had good
physical health in the next 12 months follow up visit.

Adriana A. Francisco (2010)reported in a study where 303 mothers had vaginal

delivery, 18.5 per cent of them were having perineal discomfort when this study was compared
with control group. It was seen that mothers who had undergone vaginal operation they have
more pain than the control group and they used more drug to bear that pain than not taking any
pain killer medicine to get relief of discomfort, especially topic heat was used instead of
deficiency of researchable proofs. Discomfort was more when many other treatments were given.

Signorello LB et all 2007 did a study which was cohort in nature to see the leakage
among midline stitches in perineal area and postnatal leakage of fecal matter from the rectal
opening.
 The finding of this study shows that mother with episiotomy show more danger of
leakage of fecal matter 12 week to 24 week during the postnatal period in contrast with mother
who did not have episiotomy. It is also said that in contrast with mothers who had automatically
suffered mild injury during child birth had suffered three times more with continuous leakage of
urine and stool and it is also twice the chance of leakage of fecal matter 12 to 24 week after the
delivery during postnatal period. The study indicate that outcome of episiotomy was free from
the mother's age and birth weight of baby time taken during second stage of birth of baby use of
instrument and complication of childbirth.

Chou SY et al (2008)did a study, setting of the study was China GT. it was cohort
study to see find out the outcome of extremely dry and wet chilled treatment to bring down the
pain in the orthopedicpost operative patient. The sample subject was selected by assignment
method total number of subject were 27 in number. It was two experimental group study to one
group towel was used, to another group ice pad used to bring down postopeative pain. The
measurement was taken for local heat edema discomfort was assets during 1st and 2nd post
operative day. Finding of the study indicate that both information which was collected from the
patient and observation made by investigator and sign and symptom in all there two group
reported that pain and wound healing score in group one was less and in second experimental
group there was more score with one and half hour of interval. This study concludes that wet
extreme chilled temperature has highest score in bring down the pain then other type of pain
caused by operation. [54]

Yagizon A (2006)study where cold therapy was given and it is also considered is free
of cost and simple method of treatment as years together it has been considered very effective
treatment to manage pain after childbirth. It made the intensity of pain very high and bringing
down the smiling reaction and pain spasm contraction of muscle chilled temperature often used
to bring alone the pain of short duration as it taken place during trauma to soft tissue.It also result
to bring down the pain of the surgery when operations are done in case of general operation or
in case of patient who had fracture of the bone

B. Brandnder et al (1996)1996 did a study to find out the output of participation of

cooling the local injury which is usually ordered after operation by physician total simple subject
were 108 in which 30 head spinal operation it was two group study, one group watch pain killers
medication to management pain and another group was given cooling pad to control discomfort
of operation.. It was found in this study the pain score in the group who got painkiller like
Morphine was lower than local cooling of wound but patient were more happy when local
cooling was applied during just 24 hour of operation.[48]

Sheikan F et al (2011)stated that treatment with chilled temperature has indicated it

suppressed the upper layer of skin and around the area of injury by putting an effect on the nerve
fiber and by bringing down the swelling and discomfort. By lowering down the temperature of
superficial layer of the skin by 10 to 15’C with the local Ice cold compression. it bring down the
temperature 10 to 15‘Cwith lower and it effect that metabolic process within the cell and also
lower down the need for oxygen and narrow the lumen of the blood vessel and so the blood
supply to that part of body is reduced with the result the discomfort is relieved.[98]

Navvabi Rigi Sh (2011)conducted a study to assess the lower temperature and

episiotomy pain is a decreased it also effect on the day to day activities of daily living and mood
of the patient.Total number of sample were 121 in this study and the random method was used to
select the simple subject it was divided into 3 groups two experimental and one control group
that with cooling gel pack and ice pack. Sedative were given during first few hours depending on
the degree of pain the numerical rating scale was used to find out the score of pain the discomfort
during daily activity scale was 0 to 10 1st 2nd and 5th and 10th day. While we do the statistical
finding it was concluded that there was difference in the pain during 1st 2nd 3rd shift and 10th
day and good relief of discomfort with mood babysitting, social activities, urination during 10th
days passing stool in the 2nd and 5th and 10th day with ‘’p-value <0.05 it was concluded
cooling gel pad work effective than ice pack in bringing down the letter problem of episiotomy.
[88]

In during 2001 Leventhal Cdid a research on postnatal mothers. Total number of

sample subjects were114 .It was two group study control and experimental group and equal
number of sample subject were kept in this study.[119]

The intervention applied wasat controlled environment. This was applied for 20
minutes to see the outcome to bring down the degree of pain of mother who have undergone
vaginal child birth.

The findings of this study shows that pain was relieved.

Dan Wnorowski (2011)did a study where he informed that following with normal
child birth many of the mothers feel oedema of the vulval area with along with that discomfort
which is very severe in discomfort which is very severe in case mothers has undergone with
stitches and tear on the perineum.Existing practices of care of these stitches compression with
ice directly on the wound and will bring down oedema and provide comfort from that severe
discomfort which is a routine and old way of existing practical that apply ice during very first
day of child birth.[126]

To find out the maximum output of ice cold compress.It needs to be kept in places for
atleast minimum twenty minutes and then the compress to be change with new and it has to be
repeated many times.

Sharma (2010)This research was comparative one see the effect of hot and cold
treatment to alleviate the perineal pain among 40 mothers who had spontaneous delivery with an
episiotomy within 24 hours in a postnatal ward. After analysis of the effectiveness of hot and
cold in relieving perineal pain significant different was found between the two therapies and the
findings showed that cold therapy was more effective in reducing the discomfort like walking,
sitting and getting up. [142]

Copper Diana (2010) stated Ice is effective in reducing swelling and also relieves
pain because of its numbing effect. It is especially important to apply ice during the first 12 hours
after giving birth. To get the maximum output ice is applied for half an hour.[117]

Hasegawal J (2009)Did study on relief of discomfort after child birth painkiller

medicine and without medicine by applying other rising measures.In this study ninty eight
percentage of mother were given pain killer quite often means after small interval and sixty
two percentage of them were applied other measures to relief discomfort first twenty four hours
for sudden stop of discomfort of child birth and then after twenty four hours hot fomentation was
applied as it is known as physiologically it dilates the blood vessels and blood flows to that area
is increased.The recommendation given by National Institute of Health and Cinical that local
application of treatment with low temperature(cold therapy) is a very good method of bringing
down the discomfort.

American congress of obstetrics and gynaecologist, the nursing care and management
of discomfort which takes place after child birth comprise of sitting in the tub of warm water
during 1st day could give relief from such discomfort,as per assosciation women’s
health,obstetrics and neonatalogy.They gave the results of 110 mother with cold ice packs give
relief to them from bringing down pain and oedema. [114]

In 2007 East CE et alCarried out an experimental research in gynae hospital at Royal

Brisban, Australia to find out effect of chilled ice packed gel pads on episiotomy wound and to
see the adverse reaction. The intervention were three to introduce that were iced bath with no
medication cold gel pads and ice packs-samples were related with random methods.it was quasi
randomized trail study sample subject were 869.Interventions were given first day to 3 postal
natal days. The results to be find out were outcome on wound healing to mother who had
delivering followed by stitches on the perineal care.[111]

Therapy by extremely chilled compress on the episiotomy area to reduce discomfort of

pain in the perineal areas. Researcher has already referred many studies which indicated that
normally ten degree to fifteen degree centigate of temperature of the skin fall down with in ten
to twenty degree of cold compress .Many studies doneon the functional nature of body shows
that venous constriction helps in the reduction of swelling and discomfort many other methods
are also used to bring down the temperature of the body. The examples of which are the ice gel
packs and methods of bringing down temperature of the various body cell

J Periodontol. (200) stated that to inhibit signs of inflammation and achieve beneficial
result with cryotherapy, skin temperature (normally 33 degrees) needs to be reduced to 10
degrees C to 15 degrees C. Cold therapy usually decreased skin temperature to 10 degrees C to
15 degrees C with I n 10 to 20 minutes. Physiological studies indicated cryotherapy resulted in
vasoconstriction, reduction of edema, and diminished pain perception. Various methods can be
used to lower tissue temperature. Ice or gel packs are easy and efficient techniques to cool
tissues.[116]
 Punasundri did a study in 2006,conducted an experimental research to find out the
outcome of episiotomy case with cold camp versus oral painkiller drugs therapy. The sample
subject were220 postnatal mothers with episiotomy. Finding of the study revealed that
discomfort score of the mothers who got cold therapy was got higher score when the presumed
value was less than 002 and within 3hours of discomfort relieved and at 6 hour interval
presumed value has less than .ooo at 6 hour. 24.5% and 49.1% of postnatal mothers in the
group who were given oral pain killer medicine and group who got intervention of chilled cold
compress was not having any complaint of pain. It also indicated that 97.3% mother were very
comfortable with cold application and they were walking and managing daily activites normally
as well as brest feeding early. The summary of the study is that the use of cold application was
more refered in bringing down the episiotomy discomfort [122]

Michelle Briggs (2006),conducted a study to see the outcome of ooling methods to get
rid of pain. It was an experimental study conducted on postnatal mother who had spontaneous
vaginal delivery to alleviate pain. The two methods were iced cold sitz bath and the use of
cooling device. The finding of the study indicated that treatment by cooling the perineal pain of
mothers who have delivered vaginally.

In another study Lafoy J. et al in the year of 2006 conducted to see the effect of cold
versus hot. The total sample subjects were 20. The finding shows that cold as well as hot both
were equally effective in bringing down the swelling, episiotomy pain, distress and
haematoma.[80]

Julia Sanders et al (2005)conducted a study. It was experimental setting was

maternity unit in one of the hospital of United Kingdom. In the study investigator wants to see
the effect of pain killer and other measures to bring down the episiotomy pain. The sample
subjects were 210 postnatal mothers with episiotomy. The total sample subjects were 114. They
experiment with two applications hot and cold and they applied 33% of them cold compress and
21% with hot fomentation and remaining were managed with pain killer in order to reduce pain.
To summarize this study indicated that cold is helpful in bringing down the pain if therapy with
cold application is given first 24 – 48 hours and 72 hours after labour.[74]

Saeki Y has done a study in 2002 to find out the results of cold therapy or hot
application to pricking type of pain where the individual have autonomic responses. By applying
VAS/pain sensation was evaluated. The site where cold compress was applied pain stimulus was
reduced and area of the body where hot water bottle was applied sensation to pain was increased
so the finding of this study indicative of that cold reduces the sensation to pricking pain where
hot application has no effect on the reduction of the pain sensation.[97]

Dr.Mary Steen (2001)did an experimental study to find out the effect of cold therapy.
Sample subjects were 400 mothers with spontaneous vaginal delivery with 2nd degree tear and
episiotomy. The results of this study revealed that there is significant reduction in pain with ‘p’
value 0.0038 and 0.007 during the first and second day respectively after the cold application.
This study indicates that the treatment with cold therapy has effect on the reduction of pain by
changing the chemistry of superficial tissues and having effect on the nerve fibres and size of the
oedematous tissue around the tissue damage was brought down. The study shows that cold
therapy have an effect as the damaged tissue and reduce the pain[62]

Steen M et al (2000)did a study of 120 sample subjects. Setting was one of the UK
Hospital which comes under St. James University. The postnatal mothers were sample subjects.
Intervention was application of cold gel pack like a cooling maternity device. The rating scale,
good, very good, fair, poor, etc. The effectiveness of cold therapy was the focus of this
study.Other two methods used were Epifoam and Newly developed cooling device like maternity
gel pad. The finding of the research showed that the cold therapy is better in bringing down the
perineal pain than the other two methods used for this study.[99]

McKesson LLC (2000)did one of the study to see the output of the effect of keeping
ice on the wound of postnatal mothers with episiotomy. This time ice pack were wrapped in
sterile gauze piece and then it approved directly over the episiotomy wound area to bring down
pain and edema. The sample subjects were very much satisfied with the therapy and with great
satisfaction they could breastfeed their babies in sitting position.

Despodova TS (1995)conducted a study. Sample subjects were 324 young postnatal

mothers with episiotomy. This study was experimental. There was one control and one empirical
group. To the experimental group cold therapy was applied to episiotomy area just 1 to 3 days
control group. Sample were 254 after the study were complications as in postnatal mother, in the
experimental group there were 5% and in control group 9%. So the findings of the study
indicated that cold therapy is effective in reducing the complication of mothers with
episiotomy.[60]

Namhk (1991)did a study to postnatal mother with episiotomy sample subjects were
40 mother with episiotomy. Interventions applied were two. One ice bag and second was heat
lamp to bring down perineal pain. Selection of the sample was randomly assigned with pre and
post test design.[86]

Interval of the intervention was half an hour. Two hour and four hours respectively.
Scale used for this study was 18cm graphic rating scale. The finding of this study indicated that
score with cold therapy was lower than hot therapy. So the finding of the study shows that cold
therapy is more effective than hot therapy.

Hill PD (1989)did an empirical research to evaluate the outcome of hot and cold
application setting of the study was one of the hospital in Chicago. Sample subjects were 90. It
was 3 group study. Cases were postnatal mother with episiotomy and intervention were given
during first 24 hours to observe its outcome. The intervention were hot therapy, cold therapy and
warm sitz bath. The REEDA score were observed for all the three group to see its outcome on
wound healing. Pretest and posttest score were taken. The results of the study shows that there
was difference noted in all the three groups in the REEDA score while taking the REEDA
SCALE measurement.[71]

Ramler D (1986)did a study on postpartum mother to see the effect of cold and hot on
episiotomy pain an discomfort. Total sample subjects were forty postnatal mother. Setting was
postnatal ward. Intervention given were cold compress and warm perineal sitz bath. The interval
between the intervention was half an hour to one hour.

The findings of the study indicates that there were reduction in the pain score of the
group who had intervention with cold. To conclude, the finding shows that cold is more effective
in bringing down the pain of episiotomy of mothers.[95]

Rao has conducted study, setting of the study was Federal University of Rio Grande do
Norte Brazil. The intervention of the study were biostimulation with low power laser. This shows
theprocess of tissue repair. The result of the study revealed that doing the early postpartum, the
effect of biostimulant with low power laser. The investigator concluded that laser biostimulant is
more effective in the physiological changes of the healing process.

Kavilapatti Hospital has conducted a study to assess the level of discomfort and pain
due to episiotomy, it was an experimental study which comprises of 2 groups – Experimantal and
Control group. Total number of sample subjects were 60 postnatal mothers who had undergone
episiotomy. Methods of sample selection was random. The infrared ray was the intervention for
experimental study. The lamp was kept 45cm away from the perineum and rays were with 230
volts for the duration of 10minutes. Two times in a day the intervention was given that is evening
and morning regularly for 3 days. The interval was 6 hours. The findings of the study shows that
10% of the sample got mild infection in the episiotomy wound otherwise out of 90% none of the
mother had any type of infection. Investigator summarises the study that infrared radiation
seems to be the suitable therapy for mothers with episiotomy as it reduces the pain as well as
helps in early healing of the episiotomy wound.

A study was conducted in the university of south Bohemia to estimate the possible
advantage of therapeutic laser and phototherapy. It is done very frequently in obstetric
department to postnatal mothers. Total number of sample subjects were 2436. The laser was
given at energy density of 2 joules per centimetre.

The findings of the study that therapeutic laser of polarised light wave have an
effective outcome to high degree of wound healing and reducing the complications.

Burner 2009 conducted a study on the effect of cold therapy, setting of the study was
general hospital, this study was followed with pain killer and anaesthetic agent. The study was
done on the depression, to rehabilitate with physical movements, produce sleep and allows
apprehension and anxiety as well as lesion muscular tension for providing relaxation
hydrotherapy which also includes automonic nervous system. As pregnancy is considered as a
normal process of mothers life, so child birth and antenatal process should also be included in the
study. As the old method to get relieved from anxiety and tension is the cold therapy to get rid of
stress is cold and hydrotherapy, stretching of skin and muscles and enhancing the physical
comfort and joint pain. It also provide a feeling of happiness and relaxation so the cold compress
relieves stress and helps in the bringing down the tension of the muscles all over the body and
which are the important needs of an individual. Cold therapy is considered as one of the
important method of getting comfort from the pain and discomfort.

2.7. REVIEW OF LITERATURE RELATED TO COMPARING THE

EFFECTIVENESS BETWEEN COLD AND HOT APPLICATION ON
EPISIOTOMY WOUND HEALING AND PAIN RELIEVING.

Taghinejad H. et al. (2010) conducted a study on compassion of cold and hot foemtation
and get relief from intnsity of child birth discomfort in Thai mothers. Total primigravida mothers
were 101 samples and these mother were admitted in the hospital. Sample were selected by
random methods and undergone vaginal delivery. There were 2 group study, one group hot and
the other group cold as such there was no experimental group. The findings indicated that the
cold therapy group was having lower level of pain than the warm group which was significant at
‘P’ value 0.001.[103]

Kimber L., et al. (2008)conducted a small study like pilot. It was placebo controlled trial
study to get ride of pain with cold and hot treatment to a mother with episiotomy. Sample
subjects were mothers in this research study during first week of postnatal period. Methods were
cold compress and hot fomentation to episiotomy mothers to see the effectiveness of these
therapies was done. Sample selection was done by randomized method. In this study cold
therapy was applied during the treat of pain and it was repeated after the interval of one and half
hour.

This study has three dimensions: the one group was control with cold, hot with control
and third group was existing episiotomy came with control group. The placebo was given for
without giving medicine. This was the duly one difference in placebo and could intervention
group. There was not any difference in the conduction of delivery. As the practice was preparing
the mother for the child birth, so no classes were taken as per the control group. This was the
only difference. The result of this study shows that continuous cold therapy along with cold
group during 3 days episiotomy care was easily liked by mother with advantages for telling
about their pain.[76]
 There was another study conducted to see the outcome with ice bag and heat lamp
application for reducing pain of episiotomy mothers. Sample subjects were forty in number and
sample were selected with random method. A pain scale was 12cm graphic measuring scale used
for research. The findings of this study shows that pain relief score was less with cold as
compare to hot group. It also indicated that neither hot nor the past experience of mothers was
having any effect on the relief of pain. Investigator has summarized that staff nurses or health
care provider must give sufficient knowledge regarding use of ice bag in the home situation and
they should be motivated to undergo cold therapy rather than hot after episiotomy. It proved that
cold therapy is very effective in wound healing as well as in bringing down the pain.

An another study was conducted to educate the workers on self perineal care. It was the
content of the PTP that local thermal application is having very much treat mental effect on the
blood circulation, body metabolism and local nervous system as well as muscular system. It
effects to movement also as it effect the musculo-skeletal system also it was found in this study
that sample liked hot fomentation rather than cold one. Still it was found that physiological effect
was better energetic for preservation of energy in the body tissue rather than the therapeutic
effect of local heat was less effective in protecting the body cell damage.

An experimental study was done in one of the hospital at Columbia. It was two group
study, where mothers were given cold sitz bath versus warm sitz bath to find out the output of
both hot and cold application. The findings of this study shows that cold sitz bath was more
effective in reducing pain and swelling on the site of stitches than the warm therapy.

A study was done to see the effect of hot and chilled application on episiotomy wound to
find out the outcome of wound healing and bringing down the pain. The sample subjects were
ninety postnatal mothers with episiotomy. Sample selection was with randomize technique.
Intervention was given during first 24 hours. intervention was given with warm perineal
compress, cold compress and warm sitz bath. Repeated ANOVA was applied to see the findings
statistically as it was three group study. REEDA scale was applied to see the wound healing and
person co-related was also applied to see the association with laceration and birth weight of the
baby. The research shows that chilled pack was very effective in reducing the pain, but there was
no co-relation with baby birth weight and laceration.
 Pamela D. Hill (1988) conducted a study to find out the outcome of hot and cold therapy
when applied to episiotomy or lacreation. In her study she used three treatment methods i.e.
application of cold and warm compress and sitz bath. The duration was twenty minutes
respectively to three groups of postnatal mothers. The researcher used REEDA score for
measurement of wound healing. The significance tests were done by applying chi-square. The
findings of the study reveals that no difference was found in all the three groups in respect to
REEDA score and neither in decreasing the swelling on the episiotomy though there are many
other application which can be implemented on the stitches site to get rid of discomforts of
episiotomy to postnatal mothers.[71]

In 1988 Sleep and Grant, did a study by survey method. The sample subjects were
English maternity unit. Total were fifty in number. Findings of the study shows that 60 per cent
of units were using epiform, 36 per cent units were having therapeutic ultrasound and 84 per
cent were very common who use ice cold chilled pack to bring down episiotomy pain.[124]

Pring. D.W. and Salmanin one of their study which was carried out in York District
Hospital. They used painkiller before conducting the vaginal delivery. It was observed in this
study the seventy nine percentage of mothers talked about perineal pain during first 3 days
postnatal period whereas forty five percentage got no painkiller and forty eight percentage got
only PCM or ice packs. Five per cent of mothers were given ultrasound and mothers who
complain of severe pain were given co-proximol 2% . The statistical findings on the mothers
with severe pain indicated that thirty percentage could not needed painkiller whereas forth six
percentage got only cold compress or PCM. The researcher believed that quality of care to be
provided to mothers during postnatal period.

Jensen and Bobek (1985) stated that cold therapy by using ice packs to the perineum
immediately after delivery diminishes edema formationwhich contributes to discomfort. Cold
also provides an anesthetic effect. Regarding heat therapy, they stated that it had a soothing
effect and promotes healing by increasing circulation to the area. Moist heat (sitz bath) may be
used once the women is ambulating; twice a day or more often which will help in relieving pain
and discomfort due to the episiotomy wound.[23]

Lafoy and Feden (1989) in a research to see the effect of cold and warm water on
perineal care and indicated that a cold sitz bath may be just as effective as a warm one in
promoting comfort and post-partum episiotomy pain can be relieved.[80]

Cochrane, in her article (1992) stated that ice packs should not be used for perineal
trauma as they reduce bold flow. Thus, ice pack is not effective in wound healing pain relieving
of perineal trauma.[55]

Potter and Perry (1993) stated the client had rectal and vaginal surgery, painful
hemorrhoids or vaginal inflammation may benefit from a sitz bath, a bath in which only the
pelvic area is immersed in warm fluid. Immersing the entire body causes widespread
vasodilatation and nullifies the effect of local heat application to the pelvic area.[36]

Varalakshmi, K.V. (1992)conducted a study. It was an experimental study to see the

outcome of sodium bicarbonate mixture of many intervention to see its effects. Total samples
were 30 postnatal mothers who were primi with episiotomy. The methods of selection was
purposive method. Two groups were experimental and control group. The design used for the
study was pretest-posttest design with baking. In baking was independent variable and wound
healing was dependent variable. The tests were used two kolmogorox and simirnove. One way
analysis of variance were computed. [144]

Major findings of the study was taken by using ‘t’ test. Results of the study, shows that
healing was almost completed within six days and irrespective of experimental and control
group. Also there was variation in the degree of healing in the control and experimental group.

Phanusopone, Arena (1991), did a research to find out the outcome of hot and cold
compress in order to get rid of discomfort during post natal period after the interval of 12-18
hours of episiotomy repair.The total samples were 40 in number primi para mothers who took
both cold and hot compress.Total samples were divided into two groups 50% got hot compress
and 50% cold compress. [91]