RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
A STUDY TO EVALUATE THE EFFECTIVENESS OF SITZ
BATH IN REDUCTION OF EPISIOTOMY PAIN AMONG
POSTNATAL MOTHERS IN SELECTED
HOSPITALS, KOLAR DISTRICT,
KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
Ms. SEETHI SUSEELA
A.E & C.S PAVAN COLLEGE OF NURSING
KOLAR
1
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1.
NAME OF THE
CANDIDATE &
ADDRESS
MS. SEETHI SUSEELA
1ST YEAR M.SC(NURSING),
A.E & C.S PAVAN COLLEGE OF
NURSING,
BANGALORE-CHENNAI BYEPASS
ROAD, KOLAR – 563101.
2.
NAME OF THE
INSTITUTION
A.E & C.S PAVAN COLLEGE OF
NURSING, KOLAR – 563101
3.
COURSE OF THE
STUDY AND
SUBJECT
M.Sc (NURSING)
OBSTETRICS AND
GYNECOLOGICAL NURSING
4.
DATE OF
ADMISSION
04-06-2008
“A
STUDY
TO EVALUATE
THE
EFFECTIVENESS OF SITZ BATH IN
5.
TITLE OF THE
TOPIC
REDUCTION OF EPISIOTOMY PAIN
AMONG POSTNATAL MOTHERS IN
SELECTED
HOSPITALS,
DISTRICT, KARNATAKA.”
2
KOLAR
6. BRIEF RESUME OF INTENDED WORK
INTRODUCTION
“A stitch intime saves nine”
(k.park)
The postpartum period is a crucial stage for both the mother and baby.
Generally postpartum women experience relatively little discomfort and are
most concerned with rest, relieving perineal discomfort and learning about the
new born.1
Episiotomy is a surgical procedure that involves cutting the
perineum (skin between the vagina and the anus) during labour to enlarge the
vaginal opening. The procedure is intended to prevent vaginal tears during
delivery.2
Episiotomy is a common surgical procedure performed during the
second stage of labour. The first performance of episiotomy was done in 1742,
when perineal incisions were used to facilitate deliveries.3
In India, the birth rate becoming very high, 72.3 per thousand birth
(WHO 1998).The incidence of episiotomy was high.4
More moderate forms of genital cutting which account for an
estimated 80% of the practice worldwide.5
Although the frequency of performing an episiotomy is
decreasing, 30% to 50% of women may still receive episiotomy. Sutures for
this can be sore and painful. Although relatively small in size, an episiotomy
can cause considerable discomfort because the perineum is an extremely tender
area. The muscles of the perineum are involved in many activities like (sitting,
walking, squatting, bending, urinating, and defecating). Thus, an incision in
this area causes a great deal of discomfort.6
3
Pritchard, Mac-Donald and Gant 1985, described that episiotomy
reduces the incidence of cystocele, rectocele and stress incontinence. In cases
where an episiotomy is indicated, a medio lateral incision may be preferable to
a median (midline) incision as the latter is associated with a higher risk of
injury to the anal sphincter and the rectum .7
An article on postpartum care stated that the perineum must stretch far
beyond its ordinary limits as the baby was born. In order to prevent tears during
stretching an episiotomy was performed. Discomfort from an episiotomy was a
problem during postnatal period, sometimes up to months. For relief of
discomfort caused by the episiotomy, ice pack or warm water cleaning was
found to be effective .8
Many physicians and nurse midwives order a soothing cream or
anesthetic spray to be applied to a suture line to reduce discomfort. A cortisone
based cream or sitz bath helps to decrease inflammation and, thus tension in the
area .6
Each year, more than 200,000 women in the U.K and over 1.5 million in
the U.S undergo an episiotomy. In many countries, this operation has been
adopted as routine and standard obstetrical pratice.9
Episiotomies have stitches in a very tender area and need some time to
heal. Using ice packs on perineal area immediately after the birth to numb the
area and to prevent or reduce swelling. Some other techniques that can speed
healing and ease soreness includes 24 hours after delivery , start taking warm
soaks in the tub or in a sitz bath . A sitz bath is a shallow plastic basin that fills
with warm water and position over toilet seat. It makes it convenient to soak
bottom several times a day without having to fill a tub full of water and
completely undress each time. Most hospitals will provide sitz bath while in
hospital .10
4
6.1 NEED FOR THE STUDY:
Postnatal women are prone for puerperial infection, which can be
prevented by proper hygienic measures, especially perineal care. Any trauma
such as episiotomy, tear and laceration will increase the tendency for the
development of infection in the postnatal period. Proper care of episiotomy
incision should be encouraged to ensure that the trauma is healing
satisfactorily. Pain and discomfort from episiotomies can be reduced by
providing therapeutic cleansing soak, such as warm water sitz bath to promote
blood flow to the episiotomy for rapid healing .11
Episiotomy is one of the most widely performed surgical procedure.
The rate of episiotomy ranges from 50-90% in developing countries. In various
countries routine episiotomy has been accepted medical practice for many
years.12
As of 2007, the average birth rate for the whole world is 20.3 per
1000 total population, which for a world population of 6.6 billion comes to 134
million babies per year .13
A study was conducted to determine the frequency of perineal pain in
the 6 weeks after vaginal delivery and to assess the association between
perineal trauma and perineal pain Results showed that perineal trauma was
more common among primiparous women, those with operative vaginal
deliveries and epidural analgesia during the second stage of labour. Perineal
pain was more frequent and severe for women with increased perineal
trauma.14
In 2000, one study calculated the percentage of episiotomies
performed in the United States out of all vaginal deliveries to be 19.4%. This
was a dramatic reduction from the 1983 rate of 69.4% Episiotomy rates were
5
higher among white women (32.1%) than African American women (11.2%) .
Similar differences have been reported in other obstetric procedures (eg.
Caesarean section and epidural use).15
A study was conducted on relaxing in a tub of water, either a shallow
sitz bath or a deep regular bath, the results shows relief, and another study to
compare cold sitz baths with warm ones found that the women who took the
cold ones had less pain afterward. Cold acts as an analgesic. But warm water
feels better. Warmth increases circulation on the area and aids healing.16
A study was conducted on role of the midwife in perineal wound care
following child birth. A wide variety of practices are carried out in this area.
However, midwives must realize the relevance of their care and potential
impact, both positive and negative of advocated treatments in wound healing.
The maintenance of effective pain relief must be balanced with the need to
promote wound healing.17
In many hospitals, episiotomy becomes a normal procedure on every
women delivering her first child to avoid perineal laceration and damage to
pelvic floor and to reduce birth trauma.
In S.N.R hospital, Kolar district, Karnataka, in the year 2007 there was
1531 normal vaginal deliveries were conducted, out of this, 100% incidence of
episiotomy among primigravida women and 50% incidence of episiotomy
among multigravida women during the second stage of labour.
Warm water relaxes and soothes the sore tissues, keeps the area clean
and prevents infection and helps with circulation. Sitzing may begin 24 hours
after birth, when a mother can be up and about more comfortably sit on the
6
bath for 10-20 minutes,1-3 times a day or as needed, until the soreness is
relieved.18
Based on the review of literature and the personal experience of the
investigator during her clinical posting found that in many hospitals episiotomy
care involves several practices such as perineal wash, sitz bath, application of
infra red lamp, antibiotics to relieve pain and discomfort and to promote faster
wound healing. Hence the investigator is interested to conduct the study on
effectiveness of sitz bath in reduction of episiotomy pain.
7
6. 2: REVIEW OF LITERATURE:
Review of literature is a key step in research process. It refers to
extensive exhaustive and systematic examinations of publications relevant to
the research project. The researcher analysis existing knowledge before delving
into a new area of study while conducting a study, when interpreting the results
of the study, and when making judgments about applications at a new
knowledge in nursing practice.
The review of literature is defined as a broad, comprehensive in depth,
systematic and critical review of scholarly publications, unpublished scholarly
print materials, audio visual materials and personal communications.19
The related literature is organized and presented under the following
headings.
Section I: Studies related to episiotomy
Section II: Studies related to various methods used for episiotomy.
Section III: Studies related to effect of sitz bath in reduction of
episiotomy pain.
Section I: Studies related to Episiotomy
A study was conducted on pudendal nerve block for pain relief
after episiotomy. Randomized double-blind, controlled trail was used. Forty
women who gave birth vaginally with mediolateral episiotomy were
randomized to receive pudendal nerve block with 15ml of either ropivacaine
7.5 mg/ml [Pudendal group] or normal saline [Control group] after repair at the
episiotomy. Episiotomy pain was assessed with a visual analog scale. Patient in
the pudendal group reported significantly lower pain scores at rest than those in
the control group.20
8
A study was conducted on episiotomy and increases the risk of
spontaneous obstetric laceration in the subsequent delivery. A total of 6,052
patients were included, of whom 47.8% had episiotomy at first delivery.
Spontaneous second degree laceration at the time of second delivery occurred
in 51.3% of women with history of episiotomy at first delivery compared with
26.7% without history of episiotomy (p<.001).Severe lacerations occurred in
4.8% of women with history of episiotomy at first delivery compared with
1.7% without history of episiotomy (p<.001).Prior episiotomy remained a
significant risk factor for second degree and severe obstetric lacerations in the
second vaginal delivery. It was showed that episiotomy at first vaginal delivery
increases the risk of spontaneous obstetric laceration in the subsequent
delivery.21
A study was conducted to assess the extent of post partum pain, 445
women who delivered babies vaginally were selected from the hospital in
Toronto, Canada. Results showed that 75% of women with an intact perineum
reported pain one day after child birth, and 38% a week later. 95% of women
with 1st and 2nd degree tears in the perineum. 97% of women who had an
episiotomy reported perineal pain 1 day after child birth, 21%, 7 days later.
The study suggested that the mothers need to have awareness regarding
perineal pain need to use pain relievers to ease their pain.22
A study was conducted to assess the effectiveness of teaching on
episiotomy and perineal care among primipara women of selected hospitals in
Karnataka, by using convenient sampling technique. The study was conducted
in 2 phases.
The phase I of the study, the data were collected from 30
primipara women to identify learning needs of primipara mothers in terms of
knowledge and ability to perform self perineal care. The phase 2 of the study
consisted of 25 subjects in the experimental group, 30 subject in control group.
The results showed that planned teaching programme was effective in
9
increasing the knowledge (t=23) and ability (t=24.34) of the experimental
group.23
A retrospective study was conducted to examine the association of
episiotomy with the frequency and severity of perineal trauma in women
undergoing forceps delivery in semmelweis women’s hospital.Results showed
that the frequency and severity of perineal tears were significantly lower in
forceps deliveries when an episiotomy was performed.Mediolateral episiotomy
is the more protective against perineal trauma in women undergoing forceps
delivery.24
Section II: Studies related to various methods used for episiotomy care.
A study was conducted to define post delivery care after episiotomy.
A survey of the literature done between 1990 and 2005 in medline and
Cochrane library results showed that personal hygiene is a key to healing, but
no specific treatment has been accepted. The treatment of pain by non medical
as well as topically is not very efficient. NSAIDS were the most studied
among medical treatments and have shown an effect on pain, some of them can
be used during maternal breast feeding. The study suggested that the medical
staff must emphasize the importance of self care and perineal hygiene. The
pain of episiotomy is a crucial element to treat, and it is most effectively done
medically.25
A study was conducted to investigate the use of pharmacological
and non-pharmacological methods of perineal analgesia used by midwives
during the second stage of labour and perineal repair in the U.K. Postal survey
design was used self-complete questionnaires were sent to Heads of midwifery
in all 219 maternity units.
Midwives reported using a variety of non-
pharmacological analgesic methods to control pain at the end of the second
10
stage of labour. Hot packs were used in 70(33%) maternity units, cold packs in
44(21%) and perineal massage in 109 (52%) midwives in 131 (62%) maternity
units used injectable local anesthetics to control perineal pain.26
A study was conducted on clinical trial of aromatherapy on
postpartum mothers perineal healing in Korea. By using a clinical trial method
the aromatherapy were applied with sitz both or soap application using
essential oils with lavender, rose, grape fruit, orange. The experiment was
applied to postpartum mothers who delivered vaginally with an episiotomy.
The study was conducted in 3 groups, 1st group for Aroma-sitz bath, 2nd group
for aroma-soap application, 3rd group was control group, The effect of aroma
therapy on perineal healing was measured by using REEDA scale an smears of
episiotomy wound were obtained.
Results showed that the postpartum
aromatherapy for perineal care could be effective in healing the perineum.27
A study was conducted to determine the effect of a simple
relaxation technique on postpartum patients episiotomy incisional pain and
overall discomfort by post test only experimental design. 40 subjects (20 in
experimental group and 20 in the control group) participated in the study only
the experimental group was taught the relaxation technique and told to use it
whenever they had pain or discomfort in their episiotomy incision. Results
showed that for the subjects who used the relaxation technique, there was a
general trend for decreased pain and discomfort.28
A study was conducted to compare the effect of ice bag and heat
lamp for the relief of perineal discomfort. Forty took ice bag and heat lamp
with random assignment of initial therapy. Women was rated the degree of
perineal discomfort before and after each therapy and at half-hour, two hour
and four hour intervals after each therapy. A discomfort scale, 18cm graphic
rating scale was used. Results showed that the ice bag group significantly lower
11
discomfort score than the heat lamp group. Therefore ice bag was significantly
more effective in relieving perineal discomfort than heat lamp.29
An experimental study was conducted on effect of heat and cold
applications on the perineum after episiotomy during the first 24 hours after
delivery in Chicago. 90 patients were selected randomly to one of the three
treatment groups 30 patients were treated with warm perineal pack and another
30 patients were treated with cold perineal pack and remaining 30 were treated
with warm sitz bath. The redness, edema, ecchymosis, discharge,
approximation (REEDA) tool was used to evaluate the episiotomy wound
healing. Results showed that no difference in the REEDA score before or 2
hours after treatment.30
Section III: Studies related to effect of sitz bath in reduction of episiotomy
pain:
A study was conducted to compare the effect of sitz bath versus
guggul dhupan on episiotomy pain in selected hospitals, Pune. Quasi
experimental approach was used.
The sample consisted of 60 postnatal
mothers, 30 were selected for treatment with sitz both (group A) and 30 with
guggul dhupan (Group B). Results showed that (53.3%) postnatal mothers were
having severe episiotomy pain before giving sitz bath and 56.7% of postnatal
mothers were having mild pain after sitz bath and the difference was
statistically significant 63.3% postnatal mothers were having severe episiotomy
pain before guggul dhupan and 80% of postnatal mother were having mild pain
after guggul. The analysis showed that sitz bath was effective in reducing
episiotomy pain.31
12
A study was conducted on effectiveness of sitz bath versus self
perineal care on episiotomy wound healing among postnatal mothers in
Jayanagar general hospital, Bangalore. Quasi-experimental design was used, 40
samples were selected by purposive sampling. The results showed that
application of sitz bath has significant influence in episiotomy wound healing.
This is represented by a reduction of mean score from 4.7 to 0.015 and SD
from 0.66 to 0.37. Application of self perineal care is not much effective as
sitz bath in episiotomy wound healing.32
A study was conducted on post episiotomy pain with warm versus
cold sitz bath. A repeated measure experimental design (N=20) was used.
Sensation, distress, Edema and hematoma ratings were obtained pre and post
treatments. Both therapies were found comparable, with the exception that the
cold bath was significantly more effective in reducing edema.33
A study was conducted on effect of cold sitz bath for relieving post
episiotomy perineal pain, forty postnatal mothers were selected randomly both
cold and warm sitz baths. Perineal pain was recorded before and after each sitz
bath and at half-hour and one-hour intervals after each bath. A pain scale using
0-5, 0 representing no pain and 5 representing extreme pain was used.
Analysis of pain scale scores by a two-way analysis of variance with
replications showed that cold sitz baths were significantly more effective in
relieving perineal pain. 34
13
PROBLEM STATEMENT:
“A study to evaluate the effectiveness of sitz bath in reduction of
episiotomy pain among postnatal mothers in selected hospitals at Kolar
District, Karnataka”.
6.3 OBEJCTIVES OF THE STUDY:-
1. To assess the intensity of episiotomy pain among postnatal mothers before
sitz bath.
2. To evaluate the effectiveness of sitz bath in reduction of episiotomy pain
after sitz bath.
3. To find the association between the reduction of episiotomy pain after sitz
bath with their selected demographic variables.
6.4 OPERATIONAL DEFINITIONS:-
Evaluate: Refers to determine the effectiveness of sitz bath in reduction of
episiotomy pain by Visual Analog Scale.
Effectiveness:Refers to the desired changes brought by the sitz bath in reduction of
episiotomy pain.
Sitz Bath:It is a clean procedure with warm water in a basin given to the postnatal
mothers to immerse episiotomy wound for 15-20 mts, 1-3 times a day.
14
Episiotomy:It is the surgical incision made on the perineum either right or left medio
lateral incision performed during the II stage of labour.
Pain:-Refers to feeling of distress on episiotomy wound among postnatal
mothers.
Postnatal mothers:Refers to women who delivered vaginally with left or right mediolateral
episiotomy. Those who are in 1st-3rd postnatal day.
6.5 HYPOTHESES :H1 – The mean post intensity score of episiotomy pain will be significantly less
than the mean pre intensity score of episiotomy pain in postnatal mothers who
had sitz bath.
H2 – There will be significant association between reduction of episiotomy pain
with their selected demographic variables.
6.6
VARIABLES :
6.6.1 Independent Variable :Sitz Bath
6.6.2 Dependent Variable :
Reduction of episiotomy pain
15
7. MATERIAL AND METHODS:-
7.1 Source of Data:Postnatal mothers who delivered vaginally with right and left
mediolateral episiotomy in selected hospitals at Kolar District.
7.2 METHOD OF DATA COLLECTION:
7.2.1: Research Design:
Quasi – Experimental design [Non equivalent control group]
7.2.2 : Settings :-The study will be conducted in two hospitals namely Sri
Narasimha Raja Hospital [SNR], Kolar which is situated 2 kms away
from pavan college of nursing, have 500 bed strength and R.L. Jalappa
Hospital and Research centre, Tamaka, Kolar District situated 5
Kms away from pavan college of nursing having 850 bed strength.
7.2.3 Population :
The population for the present study comprises of postnatal mothers
who delivered vaginally in selected hospitals at Kolar District.
7.2.4 Sample :Postnatal mothers who delivered vaginally with right or left mediolateral
episiotomy in selected hospitals at Kolar District.
7.2.5 Sample Size :
The total sample:
60
Experimental group: 30
Control Group:
30
16
7.2.6 Sampling Technique:
Convenient sampling technique will be used to select the samples for
the study.
7.2.7 Sampling Criteria:1. Inclusion Criteria :Postnatal mothers:
-
Includes both primi and multi mothers who had a vaginal delivery with left
or right medio lateral episiotomy.
-
Who are in 1st-3rd postnatal day.
-
Who are able to communicate in Kannada or English.
-
Who are willing to participate in the study.
2. Exclusion Criteria :
Postnatal mothers:
-
With infected or lateral episiotomy wound and perineal tear.
-
Who are not willing to participate in the study.
-
Who are not able to communicate in Kannada or English.
7.2.8 Tool for Data Collection :
Structured interview schedule will be used for the data collection and
visual analog scale is used to assess the intensity of episiotomy pain.
Tool consists of 2 sections namely section A and Section B.
Section A:Part I: It consists of demographic data of subjects such as age,
education, occupation, income, type of family, source of information.
Part II: It consists of obstetric data of subjects such as parity, type of
episiotomy, duration of labour, No of postnatal day.
17
Section B:
It consists of visual analog scale to assess intensity of episiotomy pain
visual analog scale comprises of a 10 cm horizontal line with end points
marked as “No Pain” and “Worst Possible Pain”.
0 cm
No Pain
1
2
3
4
5
6
7
8
10 cm
9 worst possible pain
It consists of following description
No Pain
If the woman marks on 0cm
Mild Pain
If the woman marks between 0-2 cms
Moderate Pain
If the woman marks between 2-4 cms
Severe pain
If the woman marks between 4-6 cms
Very severe pain
If the woman marks between 6-8 cms
Worst possible pain
If the woman marks between 8-10 cms
7.2.9 Method of Data Collection :
Structured interview schedule will be used for the data collection. Visual
Analog Scale will be used to assess the intensity of episiotomy pain.
The purpose of the study will be explained and consent of the participant
will be obtained to involve in the study.
The tentative period of data collection will be 6 weeks, before that tool
for data collection will be prepared and after validation by experts, the further
refinement of the tool will be done. After that the pilot study will be
conducted.
7.2.10 Data analysis and interpretation :Data will be analyzed on the basis of objectives and hypotheses by using
descriptive and inferential statistics. Descriptive statistics will be used for
frequencies, percentage, mean and standard deviation. Inferential statistics will
be used by chi-square test and t-test and will be interpreted in the form of
tables, graphs and diagrams.
18
7.3 Does the study require any investigation or intervention to be
conducted on patients or other humans or animals?
Yes. The study will be conducted on postnatal mothers in selected
hospitals at Kolar District. Since it is Quasi – Experimental study, it
requires intervention to relieve episiotomy pain by sitz bath. It is a part
of episiotomy care; it will not have any harm to mothers.
7.4 Has Ethical Clearance been obtained from your institution?
Yes. Prior permission will be obtained from the concerned authorities of
selected hospitals of Kolar District to conduct a study and also from
research committee of Pavan College of Nursing Kolar. The purpose of
the study will be explained to the postnatal mothers of the selected
hospitals. Scientific objectivity of the study will be maintained with
honesty.
19
8. LIST OF REFERENCES:
1. Collins N. Normal postpartum care. AMJ Obstetrics, Gynecology. 2000
Jan; 182(1): 76-80.
2. Wikipedia Org, Definition, overview and description about episiotomy.
3. Grass, dunn and stys. Episiotomy. The nursing journal of India. 1986
Vol, XCV No: 5, 105-106.
4. World health organization (WHO) 1998, Report.
5. World Health organization (WHO) 2000, Report
6. Pillitteri Adele, Maternal and child health Nursing, 4th edition, lippincott
publishers, Philadelphia, 2003; 512, 612-14.
7. Episiotomy. ACOG, Practice Bulletin No:71, American College of
obstetricians and gynecologists, obstet Gynecol 2006; 107;957-62.
8. Winfred F. Post Partum Perineal care, Moon dragon birthing services
2002 April: 18(1), 744-55.
9. Episiotomy, Challenging obstetrics interventions, www.infiteam.com
10. Episiotomy after care, www.Google.com
11. Fleming, calvert. Minimizing postpartum pain, Journal of Advanced
Nursing 2000 Feb: 32(2):407-15.
12. Signorello LB, Harlow BL, Chekos AK, Repke JT. Midline episiotomy
and anal incontinence, Retrospective study, British medical Journal
2000;320:86-90.
13. Baby centre medical advisory Board, Episiotomy.
www.Babycentre.com
14. Macarthur AJ, Macarthur C. Incidence, severity and determinants of
perineal pain after vaginal delivery. AMJ obstet, gynecol 2004, Oct;
191(4):199-204.
15. Incidence of episiotomy. Drink a lot of wate demographics.
www.incidenceofepisiotomy.com.
20
16. Barry.
Episiotomy
pain,
Heal
tender
tissues,
sitz
it
1998,
www.episiotomypain.com.
17. Graundy L. The role of midwife in perineal wound care following child
birth. British Journal of Nursing 1997 Mar; 6(10): 584-8.
18. Naomi. Healing from child birth, 2008, July 12, www.ivillage.com.
19. Basavanthappa B T. Nursing Research, 2nd Edition, Jaypee brother’s
publications, New Delhi 2007:92.
20. Aissaoui Y, Bruyere R, Mustapha H, Bry D, Kamili ND, Miller C. A
randomized controlled trial pudendal nerve block for pain relief after
episiotomy. Anesth analog 2008 Aug; 107(2) 625-9
21. Alperin M, Krohn MA, Parviainen K, Episiotomy and increase in the
risk of obstetric laceration in a subsequent vaginal delivery. Obstet
gynecol 2008 Jun;111(6) 1274-78.
22. Ronnie Falcao LM MS. Postpartum pain may linger for weeks after
vaginal
delivery.2004
Nov
3;
Web
MD
medical
news,
www.gentlebirth.org.
23. Judith Angelita, Noronha. Effectiveness of teaching on episiotomy and
perineal care among primipara women of selected hospitals in
Karnataka. Nursing Journal of India 2004.
24. Bodner, Adler-B. Association of episiotomy with the frequency and
severity of perineal trauma in woman undergoing forceps delivery,
Journal on reproductive medicine 2003 Apr; 48(4); 239-42.
25. Faruel-Fosse H. Post delivery care after episiotomy. Gynecol obstet Biol
Reprod 2006 Feb; 35(1 Suppl): 1552-58.
26. Sanders J, Peters TJ, campbell R. Techniques to reduce perineal pain
during spontaneous vaginal delivery and perineal suturing midwifery
2005 Jun; 21(2):154-60.
27. Hur MH, Han SH. Clinical trial of Aromotherapy on postpartum
mothers perineal healing, Taechan Kanho Hakhoe Chi 2004 Feb; 34(1):
53-62.
21
28. Lorenzi EA. Relaxation, episiotomy, incisional pain and overall
discomfort. Journal of Advanced nursing 1991 Jun; 16(6):701-09.
29. NAM HK, Park YS. A study on comparison of ice bag and heat lamp
for the relief of perineal discomfort Kanho Kakhoe Chi, 1991,
Apr;21(1):27-40.
30. Hill PD. Effects of heat and cold on the perineum after episiotomy
laceration. Journal on obstetric Gynecological and Neonatal Nursing,
1989; 18(2); 124-29.
31. Anita Sali. Effect of sitz bath versus guggul dhupan on pain related to
episiotomy in postnatal mothers. Journal of Nursing research Society of
India 2007 Oct-Nov; No-2, Vol-1, 19-21.
32. Sophia Michel. Effect of sitz bath versus self perineal care on
episiotomy wound healing (dissertation) RGUHS 2006.
33. Lafoy J, Geden EA. Post episiotomy pain, warm versus cold sitz bath. J
obstet Gunecol Neonatal Nurs 1989 Sep-Oct; 18(5):399-403.
34. Ramler D, Roberts J. A comparison of cold and warm sitz baths for
relief of postpartum perineal pain. J obstet Gynecol Neonatal Nurs 1986
Nov-Dec; 15(6); 471-74.
22
9
10
11
SIGNATURE OF THE
CANDIDATE
REMARKS OF THE GUIDE
NAME AND
DESIGNATION OF
11.1 GUIDE
11.2 SIGNATURE
11.3 CO-GUIDE
11.4 SIGNATURE
11.5 HEAD OF THE
DEPARTMENT
11.6 SIGNATURE
12
12.1 REMARKS OF
CHAIRMAN AND
PRINCIPAL
12.2 SIGNATURE
23