A COMPARATIVE STUDY TO ASSESS THE

EFFECTIVENESS OF SITZ BATH VERSUS INFRARED

LAMP THERAPY ON EPISIOTOMY PAIN AND WOUND

HEALING AMONG POSTNATAL MOTHERS

AT SELECTED HOSPITAL,

BANGALORE.

By

Ms. SUSEN GEORGE

Dissertation Submitted to the

Rajiv Gandhi University of Health Sciences, Bangalore.

In partial fulfillment of requirement for the degree of

Master of Science in Nursing

In

Obstetrics and Gynaecological Nursing

Under the Guidance of

Mrs. Kamala J, M.Sc. (N), Ph

Associate Professor

HOD of Obstetrics and Gynaecological Nursing,

Kempegowda College of Nursing,

Bangalore-560 004.

2013

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled “A comparative study to

assess the effectiveness of sitz bath versus infrared lamp therapy on episiotomy

pain and wound healing among postnatal mothers at selected hospital,

Bangalore” bonafide and genuine research carried out by me under the guidance of

Mrs. Kamala J, M.Sc. Nursing, Ph , Associate Professor, HOD, Department of

Obstetrics and Gynaecological Nursing, Kempegowda College of Nursing, Bangalore-

560 004.

Place: Bangalore. Signature of the Candidate

Date: Feb 2013 (Ms. Susen George)

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “A comparative study to assess

the effectiveness of sitz bath versus infrared lamp therapy on episiotomy pain

and wound healing among postnatal mothers at selected hospital, Bangalore”

is bonafide research done by Ms. Susen George in partial fulfillment of the

requirement for the degree of Master of Science in Obstetrics and Gynaecological

Nursing.

Place: Bangalore. Signature of the Guide

Date: Feb 2013. Mrs. Kamala J, M.Sc. (N), Ph

Associate Professor and HOD, Dept. of

Obstetrics and Gynaecological Nursing,

Kempegowda College of Nusing

Bangalore-560 004.

ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF

THE INSTITUTION

This is to certify that the dissertation entitled is “A comparative study to

assess the effectiveness of sitz bath versus infrared lamp therapy on episiotomy

pain and wound healing among postnatal mothers at selected hospital,

Bangalore” bonafide research done by Ms. Susen George under the guidance of

Mrs. Kamala J, M.Sc.Nursing, Ph , Associate Professor, HOD, Department of

Obstetrics and Gynaecological Nursing, Kempegowda College of Nursing,

Bangalore-560 004.

Seal & Signature of the HOD Seal & Signature of the Principal

Mrs. Kamala J, M.Sc. (N), Ph Mrs. V. T. Lakshammama, M.Sc.(N), Ph

Place: Bangalore. Place: Bangalore.

Date: Feb 2013. Date: Feb 2013

COPYRIGHT

Declaration by the Candidate

I hereby declare that Rajiv Gandhi University of Health Sciences, Karnataka,

shall have the rights to preserve, use and disseminate this dissertation/thesis in print

or electronic format for academic/research purpose.

Place: Bangalore. Signature of the Candidate

Date: Feb 2013 (Ms. Susen George)

Rajiv Gandhi University of Health Sciences, Karnataka.

ACKNOWLEDGEMENTS

First of all, I thank Lord Almighty for his abundant grace and blessings that

he has showered on me throughout the course of this study.

I convey my sincere indebtedness to the Kempegowda College of Nursing,

Bangalore-04, for providing me an opportunity to be a student of this esteemed

institution and to conduct this study.

It is my privilege to express my sincere thanks and profound gratitude towards

my esteemed teacher and guide Mrs. Kamala J, M.Sc Nursing, Ph , Associate

professor, HOD, Department of Obstetrics and Gynecologcal Nursing. She is a

mentor who infused me in confidence and encouragement in my endeavour, whenever

needed. It has been my good fortune to have her as my guide. Her contagious

enthusiasm gave me a hope to surmount all the obstacles and hurdles in the study. It

has been an invaluable experience working under her. We fall short of words to

“Thank you madam”.

I extend my sincere thanks to Mrs. V. T. Lakshamamma., M.Sc. N, Ph ,

Principal and HOD, Community Health Nursing, Kempegowda College of Nursing,

Bangalore-04, for encouragement, constructive criticism and timely help to make this

research experience a rich and rewarding one.

I owe a special thanks to Medical superintendent, HOD of OBG dept, and

Nursing superintendent of Kempegowda Institute of Institute of Medical Sciences,

Hospital and Research Centre, Bangalore for granting me permission to conduct

study.

I would like to extend my deepest gratitude to all the Experts who have

contributed in the form of constructive criticism and suggestions to formulate the tool.

I extend my sincere thanks to all the M.Sc Nusing Faculty of Kempegowda

College of Nursing, Bangalore-4, for their constructive criticism and valuable

suggestions.

I express my words of appreciation to Dr. Gangaboraiah, PhD (statistics),

Department of Community Medicine, KIMS, Bangalore for his valuable suggestions

and guidance in statistical analysis.

I owe a deep sense of gratitude to all Office staffs and Librarian of our

college who have contributed for the successful completion of the study.

I would fail in my duty if I forget the postnatal mothers who participated in

this study. It is because of them this thesis has seen the light of the world.

My healthy ovation of gratitude to my beloved parents Mr. George Joseph and

Mrs. Omana George, my loving brothers Mr. Rajesh George and Mr. Rejeesh

George, my dearest sister in law Mrs. Aswathy Rejeesh who laid foundation to my

higher studies, I want to thank you for your unconditional love and unending support

across the distance.

I thank all my friends, classmates, my seniors and juniors for their co-

operation and help rendered during my study. I strongly acknowledge that they have

positively contributed to my personal growth.

Finally, I thank all those well-wishers of mine who have directly or indirectly

contributed to the success of this work.

Place: Bangalore.

Date: Ms.Susen George

ABSTRACT

Background

Episiotomy is a common surgical procedure performed during second

stage of labour to enlarge the vaginal introits and facilitate delivery. Although

episiotomy aids in safe delivery of the child, the discomfort of episiotomy is an

added concern in the already over stressed situation of puerperium. Episiotomy

pain and delayed wound healing often interferes with even basic daily activities

of the postnatal mother. Considering the high rates of episiotomy , following

vaginal deliveries, we need to offer patients treatment alternatives for perineal

pain , based on scientific evidence.

The study was undertaken to assess the effectiveness of sitz bath versus

infrared lamp therapy on episiotomy pain and wound healing in selected

hospital, Bangalore.

Objectives

i. To assess the level of pain and wound healing status among postnatal mothers

with episiotomy.

ii. To assess the effectiveness of sitz bath and infrared lamp therapy on

episiotomy pain and wound healing among postnatal mothers.

iii. To compare the effectiveness between sitz bath and infrared lamp therapy on

episiotomy pain and wound healing among postnatal mothers.

iv. To determine an association between pain level & wound healing status with

selected demographic variables.

Method

A quasi experimental prê test and post test design with a comparison group was

used for the present study. The sample size consisted of 60 postnatal mothers who had

normal delivery with episiotomy and of which 30 were assigned to control group and

30 were assigned to the experimental group. Purposive sampling technique was used

to select the samples. Data was collected by using verbal descriptive pain scale for

assessing episiotomy pain and REEDA scale for assessing wound healing. When

subjects in the control group have given with routine sitz bath, subjects in the

experimental group have administered with infrared lamp therapy which is introduced

by the investigator. Interventions continued for three days both morning and evening.

Data was analyzed using descriptive and inferential statistics.

Result

The paired ‘t’ test score shows that there is a significant difference between

pre test pain scores at 0.05 levels in both control (13.68) and experimental group

(14.69) at 0.05 level. Student ‘t’ test score (2.62) shows that there is significant

difference between control and experimental group.

The paired ‘t’ test score shows that there is a significant difference between pre

test wound scores at 0.05 levels in both control and experimental group at 0.05 level.

Student‘t’ test score shows that there is no significant difference between control and

experimental group.

There was no significant association between pre test pain & wound scores and

selected demographic variables with an exemption of religion (x2 = 8.57)which has

shown a significant association with pre test pain scores only in experimental group.

Interpretation and conclusion

Mothers who had undergone the treatment of infrared lamp therapy expressed

decreased pain intensity compared to the mothers who had undergone treatment of sitz

bath. However sitz bath and infrared therapy were found to have same effect on

episiotomy wound healing.

Key words

- Sitz bath

- Infrared lamp therapy

- Episiotomy pain

- Episiotomy wound

- Post natal mothers.

LIST OF ABBREVIATIONS

1. REEDA Scale Redness Edema Ecchymosis Discharge

Approximation Scale

2. H Hypothesis

3. n1 Number of samples in control group

4. n2 Number of samples in experimental group

5. F Frequency

6. RMLE Right mediolateral episiotomy

7. LMLE Left mediolateral episiotomy

8. SD Standard deviation

9. P Probability

10. Df Degree of freedom

11. N Number of respondents

12. Α Alpha

13. FEP Fisher’s Exact Probability

14. *S Significant

15. NS Not significant

TABLE OF CONTENTS

Sl. No.

Particulars

Page No.

1. Introduction

Background of the study

Need for the study

1-8

2. Objectives

Statement of the problem

Objectives

Operational definition

Hypothesis

Conceptual framework

9-14

3.

Review of Literature

Reviews related to episiotomy

Reviews related to effectiveness of sitz bath

Reviews related to effectiveness of infrared

lamp therapy

15-30

4. Methodology

Research approach

Research design

Research setting

Population

Sample

Sample size

sampling technique

Sampling criteria

Data collection tool

Pilot study

Data collection process

Plan for data analysis.

31-40

5.

Results

41-66

6. Discussion 67-73

7. Conclusion

Implications of the study

Limitations of the study

Recommendations

74-77

8. Summary

Statement of the problem

Objectives of the study

Hypotheses

Findings of the study.

78-82

9. Bibliography 83-89

10. Annexure

90-101

LIST OF TABLES

Sl. No. Title of the Table Page

No.

1. Distribution of Subjects by Age 44

2. Distribution of Subjects by Religion 45

3. Distribution of Subjects by Education 46

4. Distribution of Subjects by Occupation 47

5. Distribution of Subjects by Type of family 48

6. Distribution of Subjects by Diet 49

7. Distribution of Respondents by Place of living 50

8. Distribution of Respondents by Parity 51

9. Distribution of Respondents by Type of episiotomy 52

10. Assessment of episiotomy pain level 53

11. Comparison of pain scores among control and experimental

group 53

12 Pre test and post test pain scores in control group 54

13 Pre test and post test pain scores in experimental group 55

14 Comparison of post test wound scores in control and

experimental group 56

15 Association of pre test pain scores with selected demographic

variables in control group 57

16 Association of pre test pain scores with selected demographic

variables in experimental group 58

17 Assessment of episiotomy wound status 59

18 Comparison of wound scores among control and experimental

group 60

19 Pre test and post test wound scores in control group 61

20 Pre test and post test wound scores in experimental group 62

21 Comparison of post test wound scores in control and

experimental group 63

22 Association of pre test wound scores with selected

demographic variables in control group 64

23 Association of pre test wound scores with selected

demographic variables in experimental group 65

LIST OF FIGURES

Sl.

No. Title of the Figure

Page

No.

1 Conceptual Framework based on Imogene King’s Goal Attainment

theory. 11

2 Schematic Representation of the Study Design. 40

3 Distribution of Respondents by Age. 44

4 Distribution of Respondents by Sex. 45

5 Distribution of Respondents by Education. 46

6 Distribution of Respondents by Occupation. 47

7 Distribution of Respondents by Type of family 48

8 Distribution of Respondents by Diet 49

9 Distribution of Respondents by Place of living 50

10. Distribution of Respondents by Parity 51

11. Distribution of Respondents by Type of episiotomy. 52

LIST OF ANNEXURE

ANNEXURE

NO.

ANNEXURE

INDEX

CONTENTS

PAGE

NO.

1. Annexure –A Copy of letter seeking permission to

conduct the study 91

2. Annexure –B

Copy of the letter seeking expert’s opinion

for the content validity of the tool 92-93

3. Annexure –C Content validity certificate 94

4. Annexure –D

Criteria rating scale for evaluation 95-96

5. Annexure –E

List of experts consulted for content

validity of the tool 97

6. Annexure –F Copy of consent form 98

7. Annexure -G Tool used for the study 99-102

1

1. INTRODUCTION

"Women, because of their closer affinity to their children,

suffer more keenly than do men.”

(Elizabeth Braxter)

Post partum is a very special period for a woman and her family.

It is usually joyful when a pregnant mother gives birth to a baby she has

expected. Despite the pain and discomfort, birth is a long awaited grand

ending of a pregnancy and a start of a new life. A mother is the beginning

of a new chapter of human life. The process of labour not only generates

new life but also it creates new species in the world thereby makes the

world as an ever ending place for the human beings to live. That’s why

mothers are special and labour is precious1.

Following the birth of the baby and expulsion the placenta, the

mother enters a period of physical and psychological recuperation. From

a medical and physiological view point this period is called the

puerperium, which is a crucial period for the mother. During this period a

mother is going through the physiological process of uterine involution

and at the same time adapting to her new role in the family2.

Mothers experience some discomforts after delivery although they

are considered normal common discomforts of puerperium period are

after birth pain, perineal pain, fatigue, constipation, breast engorgement,

lactation suppression, headache, backache, can lead to physical

2

discomfort, psychological distress and a poor quality of life for the

mothers3.

Pain in labour is a universal experience for childbearing women.

It may be as a result of trauma during child birth, due to an episiotomy, a

spontaneous tear or a combination of both. The discomfort of episiotomy

is an added concern in the already overstressed situation3. Episiotomy

pain often interferes with basic daily activities for the woman such as

walking, sitting, and passing urine and also negatively impacts on

motherhood experiences2.

Episiotomy was not widely used until the 1920s. In addition to the

strong advocacy for the use of episiotomy of the day, changes in

maternity practices also affected the use of episiotomy. The shift from

home birth to hospital deliveries contributed to a shift in the

conceptualization of the nature of childbirth. This shift made Episiotomy

as a common surgical procedure performed during second stage of labour

to enlarge the vaginal intriotus and to shorten the second stage of labour

in cases of fetal distress. Episiotomy is protective against more severe

perineal lacerations4.

Considerable evidences of risks are also associated with

episiotomy such as pain, edema, infection, and ultimately dyspareunia.

However, appropriate treatment can resolve or reverse all these after

effects. The prompt use of the best selected treatment for any injury

3

including, an episiotomy, ensures it will heal completely, in the shortest

possible time, with the least amount of complications. So midwives have

an important role to play in the care of perineal wounds following child

birth. The maintenance of effective pain relief must be balanced with the

need to promote wound healing5.

There are several treatments for relieving perineal pain and

promoting wound healing. Pharmacological and non-pharmacological

methods are used to treat this discomfort. Pharmacological pain relief

methods include non-steroidal anti-inflammatory drugs, oral analgesics,

local anaesthetics and opioids. But this method is associated with serious

adverse effects such as constipation, gastric irritation, passage of the drug

to maternal milk, and prolonged bleeding time6

With regard to non-pharmacological methods, common practice

are the use of ice packs, and heat application. Ice packs during the first 24

hours postpartum is a traditional method used for the immediate

symptomatic relief of pain since it anesthetizes the perineum, but this

relief is generally short-lived, and there is no evidence of any long-term

benefit. After 24 hours, heat is recommended because it increases

circulation to the region. Forms of heat used are sitz bath or infrared lamp

therapy application. It helps to reduce perineal edema, to avoid the

formation of hematomas, to relieve discomfort, to promote recovery of

the wound by cleaning the perineum and anus, and reduces

inflammation7,8

4

It is vital that health professionals who care for the puerperant

patient know how to evaluate and treat perineal pain. Considering the

high rates of perineal trauma after normal deliveries that still exist in our

population, it is necessary to offer these patients alternative treatments for

perineal pain &wound healing based on scientific evidence9.

NEED FOR THE STUDY:

Labour is a wondrous act of nature, and unique to every

childbearing woman. It is a transformative event in a women’s life. The

onset of motherhood presents a unique set of physical, emotional and

psychological challenges. The post-partum phase can become even more

challenging when the new mother experiences perineal or genital tract

trauma as a result of child birth10

.

Episiotomy (“unkindest cut of all”), defined as a surgical incision

in the perineum to enlarge the vaginal opening for birth, was introduced

as an obstetric procedure more than 200 years ago and became a common

practice from the beginning 20th

century. It is the only surgical procedure

in obstetrics is performed without the patient’s specific consent11

.

Studies about the episiotomy rates around the world showed that

this surgery ranged from 9.7%(Western Europe – Sweden) to

5

96.2%(South Africa – Ecuador) with lowest episiotomy rates in English –

speaking countries(North America- Canada and United States) and it

remained high in many counties (centred south-America like Brazil:

94.2%, South Africa – 63.3% and Asia like China 82%)12.

In India, the

overall rate of episiotomy was 40.6%. Among that midwives performed

episiotomies at a lower rate (21.4%) than faculty(33.3%) and private

providers(55.6%)13

. The episiotomy rate in Karnataka is approximately

88% in women who are undergoing difficult labour. In Bangalore rates of

episiotomy for vaginal birth range from 31% to 95% of the grand total of

3590 vaginal deliveries14

.

A cross sectional study conducted on “population based study of

episiotomy” in Chennai, India among a sample of 442 women who had

vaginal delivery. The result revealed that the rate of overall episiotomies

was 67%. For women whose delivery conducted by doctors the

episiotomy rate was 77.4% and conducted by nurses it was 53.1%.

Episiotomy rate was very high (91.8%) when delivery was conducted in

private medical colleges. In conclusion, episiotomy rate in the study

population is high. The probability of episiotomy is very high when

doctors conducted the delivery and when place of delivery is private

medical college hospital15

Pain following episiotomy appears to be universal. The mother

undergoing episiotomy is characterised by greater blood loss in

6

conjunction with delivery, and there is a risk of improper wound healing

and increased pain during early puerperium2.

A study conducted to establish the prevalence of perineal pain, the

effects of pain on postnatal recovery in Royal Women’s Hospital,

Victoria, Australia. Researchers conducted structured interviews of 215

women in the postnatal ward of tertiary hospital, within 72 hours of

vaginal birth. Results revealed that 90% of women reported some peineal

pain, with 37% reporting moderate or severe pain. Over a third of women

experienced moderate or severe perineal pain, particularly when walking

(33%) or sitting (39%), while 45% noted that pain interfered with their

ability to sleep. Women reported moderate or severe perineal pain when

they undertook activities involving feeding their infant (12%) or caring

for their infant(12%). The researchers suggested that the prevalence of

peineal pain and the associated impact on women’s from childbirth

warrants midwives’ proactive care in offering a range of effective pain

relief options to women16

Various intervention are found to reduce episiotomy pain and

enhance healing process, which include administration of analgesics,

cleanliness, applying ice pack , topical application by dry heat (infra red

therapy), sitz bath, performance of Kegel’s exercise and perineal care2.

7

A sitz bath involves immersion of the perineal area/ buttocks in

warm water (medicated if ordered) at a temperature of 105 to 110 degree

F for 15 to 20 minutes. It is used to relive discomfort. The bath promotes

wound healing by cleaning the perineum and anus, increasing circulation,

and reducing inflammation, it also helps to relax local muscles.

Infrared light therapy is a unique form of treatment where the

healing effects of the light is utilized for treating episiotomy. In this

therapy, the injury site or the diseased part of the body is exposed to

infrared radiation with a light source of 245 volts at a distance of 45- 50

cm from it, and for 10 – 15 minutes which provides relief from the

discomfort. It is very simple, absolutely painless and no major side

effects17

.

A study conducted on “Pharmacological and non pharmacological

treatment for relief of perineal pain after vaginal delivery” in Brazil to

identify the types of pharmacological and non pharmacological treatment

used during hospitalization, in the relief of perineal pain after vaginal

deliveries. Result reveals that among 130 patients 98.5% used drugs, and

62.3% of them also used non- drug treatments such as Ice pack, warm

sitz bath and Hot compress. The study concluded that health care

professionals, who attend to puerperas, know how to assess and treat

peineal pain. Considering the high rates of peineal trauma, following

8

vaginal deliveries, we need to offer patients treatment alternatives for

perineal pain, based on scientific evidence18

.

Based on review of literature and clinical experience of the

investigator, it is seen that in many postnatal mothers, episiotomy pain

and discomfort dominate the feeling of motherhood and it has many

negative impacts on women’s ability to care for their newborns, their

ability for breast feeding and attending to their baby’s need would

decrease significantly. Hence the investigator rightly felt to conduct a

comparative study on the effectiveness of sitz bath versus infrared lamp

therapy in the management of episiotomy pain and wound healing among

postnatal mothers.

9

2. OBJECTIVES

This chapter consists of the statement of problem, objectives, operational

definitions & theoretical framework selected for the study.

STATEMENT OF THE PROBLEM:

“A comparative study to assess the effectiveness of sitz bath versus infra red

lamp therapy on episiotomy pain and wound healing among post natal mothers at

selected hospitals, Bangalore.”

OBJECTIVES OF THE STUDY:

i. To assess the level of pain and wound healing status among postnatal mothers with

episiotomy.

ii. To assess the effectiveness of sitz bath and infrared lamp therapy on episiotomy pain

and wound healing among postnatal mothers.

iii. To compare the effectiveness between sitz bath and infrared lamp therapy on

episiotomy pain and wound healing among postnatal mothers.

iv. To determine an association between pain level & wound healing status with selected

demographic variables.

HYPOTHESES:

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

wound healing scores in sitz bath and infrared lamp therapy group.

10

H2: There is a significant difference in the mean post test scores between sitz bath and

infrared lamp therapy group.

H3: There is a significant association between pain &wound healing scores with

selected demographic variables in sitz bath and infrared lamp therapy group.

OPERATIONAL DEFINITIONS:

Comparative: It refers to statistical measurement of difference between infrared lamp

therapy versus sitz bath on level of episiotomy pain and wound healing.

Effectiveness: Refers to the extent to which sitz bath/ infrared lamp therapy helps in

relieving episiotomy pain and enhancing wound healing in postnatal mothers which is

measured by Verbal Descriptive Pain Scale and REEDA scale (Redness, Edema,

Ecchymosis, Discharge, Approximation).

Sitz bath: A bath in which perineal area / buttocks are submerged in 4 litre of warm

water added with 5-6 drops of 10% Providone iodine (Betadine) solution having a

temperature of 105 to 110 0

F for 20 minutes for three days both morning and evening.

Infra red lamp therapy: Refers to a lamp which emits infrared rays with a light

source of 245volts (150 watts power ) and a frequency of 50 Hz, focused on

episiotomy suture site at a distance of 45-50 cm from it and lasting for a duration of

10- 15 minutes for three days both morning and evening.

Episiotomy: A surgically planned incision on the perineum and posterior vaginal wall

during the second stage of labour to enlarge the vaginal introitus to facilitate easy and

safe delivery

11

Pain: An unpleasant, subjective, sensory, and emotional experience by postnatal

mothers due to tissue damage resulted from episiotomy incision which is assessed by

Verbal Descriptive Pain scale.

Wound healing: It is a dynamic process of regaining the skin integrity of episiotomy

wound which is assessed by REEDA scale (Redness, Edema, Ecchymosis, Discharge,

Approximation).

Postnatal mothers: It denotes to a women who had normal vaginal delivery with

episiotomy, up to fourth day of childbirth, irrespective of her parity.

CONCEPTUAL FRAMEWORK

A conceptual frame work is a group of concepts and a set of prepositions that

spell out the relationship between them. The overall purpose is to make scientific

findings meaningful and generalize. Concepts are the building blocks of the theory.

Polit and Hungler states that conceptual frame work is inter related concepts or

abstractions that are assembled together in some rationale scheme by virtue relevance

to a common thing. The device that helps to stimulate research and the extension of the

knowledge of providing both direction and impetus.

It’s a frame work which provides the investigator the guidelines to proceeds in

attaining the objectives of the study based on theory. It is a scientific representation of

the steps, activities and outcome of the study19

.

The present study was aimed at assessing the effectiveness of sitz bath versus

infrared lamp therapy on episiotomy pain and wound healing among post natal

mothers with episiotomy.

12

The conceptual frame work of the present study is based on Ernestine

Wiedenbach’s helping art of clinical nursing theory (Figure-1), consists of three steps

that is central purpose, prescription and realities.

Wiedenbach proposes a prescriptive theory for nursing which is described as

conceiving of a desired situation and the ways to attain it. Prescriptive theory directs

action toward an explicit goal. A nurse develops a prescription based on a central

purpose and implements it according to the realities of the situation20

.In the present

study Weidebach, nursing practice consists of identifying the patients needed help and

validating the provided help.

Central purpose: It refers to what the nurse (investigator) wants to accomplish. It is

the overall goal which acts dynamically in relation to one’s belief.

Identification: The present health needs of postnatal mothers are the pain and delayed

healing of episiotomy wound. The nurse investigator identifies the level of pain and

wound healing status of postnatal mothers with episiotomy and sets a goal to reduce

pain and improve wound healing of post natal mothers with episiotomy.

Prescription: Refers to the plan of activity directed. It specifies the nature of the

action that will fulfil the nurse’s central purpose and the rationale for that action. A

prescription may indicate the broad general action appropriate to implementation of

the basic concepts and suggest the kind of behaviour needed to carry out these actions

in accordance with the central purposes. Here the investigator review interventions

(sitz bath and infrared lamp therapy), formulate plan for administration and develop

Verbal Descriptive Pain Scale and REEDA Scale for the episiotomy pain and wound

healing assessment.

13

Realities: Refers to the physical, physiologic, emotional and spiritual factors that

come into play in a situation involving nursing actions. The realities are

Agent – is the investigator

Recipients – are the postnatal mothers

Goal – to reduce episiotomy pain and improve episiotomy wound healing

Means : Sitz bath and infrared lamp therapy.

Frame work: Kempegowda Institute Of Mediacal Sciences and Research Centre.

In this phase the investigator carry out interventions such as sitz bath and infrared

lamp therapy.

Validation: In this phase, the episiotomy pain level and wound status reassessed by

using Verbal Pain Scale and REEDA Scale to determine the effectiveness of sitz bath

and infrared lamp therapy. The pain level is categorised in to no pain, mild pain,

moderate pain, and severe pain. Similarly wound healing status divided into no

infection, mild infection, moderate infection and severe infection. These

categorisations have been done to find out the extent of effectiveness. Reinforcement

is suggested to the subjects with positive outcome, whereas negative outcome is again

identified as a need for continuation of treatment (feedback)

SUMMARY

This chapter deals with the statement of the problem, objectives, hypothesis,

operational definitions and conceptual frame work.

14

Identifying the need for

help Validating the provided

help

Post intervention pain and wound healing

assessment done after a period of 3 days,

effectiveness of sitz bath and infrared

therapy were measured.

Administration of sitz bath to control

group and infrared lamp therapy to

experimental group of post natal

mothers for 15 minutes twice daily

Assessment of episiotomy pain and wound

healing status using verbal descriptive pain

scale and REEDA scale.

Negative outcome

Increased pain and delay wound

healing at episiotomy site.

Positive outcome

Episiotomy pain reduction and

improvement of wound healing.

Ministering the needed

help

Feed back

---------- Not included in the study

Central purpose: To assess the effect of sitz bath versus infrared therapy on episiotomy pain and wound

healing among postnatal mothers.

Figure 1: Conceptual frame work based on modified Ernestine Wiedenbach’s helping art of clinical nursing theory

15

3. REVIEW OF LITERATURE

Review of literature is a systematic identification, scrutiny and

summary of written material that contains information on research problem.

The researcher presents the review of literature, which helps to

study the problem in depth. It also serves as a valuable guide to understand

what has been done and what is still unknown and untested.

The reviewed literature provides the evidence of what has been

studied in the past and published; paving way for further study in the

chosen subject. It justifies the need for study; throws light on the feasibility

of the study, reveals methodology and relates the findings from one to

another with a hope to establish a comprehensive study of scientific

knowledge. The researcher did an extensive search of existing literature,

and organized it under following heading:

1. Reviews related to episiotomy

2. Reviews related to effectiveness of sitz bath

3. Reviews related to effectiveness of infrared lamp therapy

16

Reviews related to episiotomy

A study was conducted in Denmark to evaluate the influence of

episiotomy on the perineal state after spontaneous singleton vaginal

deliveries. Two approaches were used in the analysis. Initially the 2188

parturient were quasi randomised to one of three equally sized groups of

midwives with different attitude towards episiotomy. Secondly, the study

was continued to find out the effect of episiotomy on the state of anal

sphincter. The results revealed that women allocated in the group with

lowest rate of episiotomy were more likely to have intact perineum after

delivery (OR = 1.8(1.4-2.2)), had a tendency towards more perineal

lacerations (OR(1.3(1.0-1.5)). The study concluded with a consecutive

approach to the use of mediolateral episiotomy and suggests that

episiotomy should be used in, ‘one in five’, spontaneous vaginal

deliveries21

.

A retrospective cross sectional study was conducted to determine

the prevalence and factors associated with episiotomy in a reference

centre in Brazil. The study included 495 women who had a normal

delivery, assessed for factors such as issues preceding birth,

characteristics of labour and perinatal outcome. The study concluded that

presence of perineal lacerations was higher in the group not subject to

episiotomy and factors associated with episiotomies were maternal

disease and absence of previous vaginal delivery22

.

17

A study was conducted in UK with the objective of analysing the

significance of risk factors and the role of episiotomy in preventing

obstetric anal sphincter injury (OASI) at vaginal delivery. A study

population of 10,314 post natal women who had vaginal delivery were

assessed to identify the factors that had a significant association with

OASI. Factors included parity, age, gestation, labour induction method,

duration of second stage, use of epidural analgesia, episiotomy, method

of delivery, time and month of delivery, and birth weight. The results

revealed that parity, age, birth weight, method of delivery and shoulder

dystocia are strongly associated with obstetric and sphincter injury.

Women giving birth without a mediolateral episiotomy were 1.4 ties

more likely to experience OASI (95% CI 1.021-1.983). The study

concluded that mediolateral episiotomy appears to be protective against

OASI23

.

A population based observational study was conducted to

determine the risk factors for anal sphincter injuries during operative

vaginal delivery in Netharlands. The study included 21254 postnatal

women who underwent operative vaginal delivery. Risk factors were

determined with multivariate logistic regression analysis. The results

revealed that primiparity and occipito posterior presentation are strong

risk factors for the occurrence of anal sphincter injury during operative

vaginal delivery. Mediolateral episiotomy protected significantly for anal

18

sphincter damage in both vacuum extraction (OR 0.11, 95% CI 0.09-

0.13) and forceps delivery (OR 0.08, 95% CI 0.07-0.11) The study

concluded that highly significant protective effect of mediolateral

episiotomies in both types of operative vaginal delivery warrants the

conclusion that this type of episiotomy should be used routinely during

these interventions to protect the anal sphincters24

.

A randomised controlled trail was conducted with the objective to

assess the effects of restrictive use of episiotomy compared with routine

episiotomy during vaginal birth in Argentina. Trial quality was assessed

and data were extracted independently by two reviewers from six studies

which included 4850 samples. In the routine episiotomy group, 72.7% of

women had episiotomies while the rate in the restrictive episiotomy

group was 27.68%. The results revealed that compared with routine use,

restrictive episiotomy involved less posterior perineal trauma (RR=1.11)

and less suturing (RR=0.74), but there was increased risk of anterior

perineal wall trauma (RR=1.79) with restrictive episiotomy. In

conclusion, restrictive episiotomy is associated with increased anterior

perineal wall trauma25

.

A study was conducted to assess the relationship between hospital

episiotomy and the incidence and risk of perineal trauma among women

in Pennsylvania, USA. The relationship between episiotomy use and

perineal trauma at the hospital level was examined using regression

19

analysis. The results revealed that hospital episiotomy rates ranged from

approximately 20 to 73%. The rate of third or fourth degree perineal

lacerations varied from a low of 4% to a high of more than 13 % among

hospitals. In conclusion, rates of episiotomy were significantly correlated

with rates of third or fourth degree perineal laceration (r=0.70;

puerperium<0.001)26

.

A retrospective case control study was conducted to determine

risk factors for third degree obstetric perineal tears and to give

recommendations for prevention, in Amsterdam, Netherlands. One

hundred and twenty cases of vaginal delivery complicated by third degree

perinal tear and 702 uncomplicated vaginal deliveries were compared,

with respect to possible risk factors. The results revealed that high birth

weight, forceps delivery, induced labour, epidural anaesthesia and parity

were risk factors for anal sphincter tear. In addition, mediolateral

episiotomy was associated with fewer sphincter injuries. The study

concluded that mediolateral episiotomy may be sphincter – saving and

therefore prevent from chronic faecal incontinence27

.

A study was conducted in San Francisco to examine the

association between maternal vaginal and perineal morbidity and

episiotomy performed at operative vaginal delivery. Data obtained from

2041 consecutive operative vaginal deliveries and compared yearly rates

of episiotomy, lacerations, and potential confounders with linear

20

regression and stratified analyses. The results revealed that the use of

episiotomy for operative vaginal deliveries fell significantly (93.4% to

35.7%, R2=0.85, puerperium-0.0001). This change was associated with a

rise in the rate of vaginal lacerations (16.1% to 40.0%, R2=0.80,

puerperium=0.0002). The study concluded that a statistically and

clinically significant reduction in the use of episiotomy for operative

vaginal deliveries was associated with an increase in the rate of vaginal

lacerations28

.

A review was conducted to assess the role of episiotomy in

current obstetric practice in USA. The modern indications for episiotomy

including the procedures place at operative vaginal delivery are

discussed. Although the role of the episiotomy in modern obstetrics may

be limited, the procedure is important in situations involving non

reassuring fetal status, shoulder dystocia, and operative vaginal delivery.

The optimal type of episiotomy, if any, at forceps or vaccum delivery is

yet to be determined29

.

Reviews related to effectiveness of sitz bath

A randomized controlled clinical trial conducted to determine the

effect of Povidone Iodine sitz bath versus lavender Oil sitz bath treatment

on episiotomy wound healing in Iran. Through randomization 120

primipararous women who underwent vaginal delivery with episiotomy

21

divided into 2 groups: control (n=60) and experimental (n=60) group.

The control group took sitz bath with 5-7 drops of Povidone Iodine

whereas experimental group with 5-7 drops of lavender oil in 4 L of

water twice daily for 10 days. The study concluded that both therapies are

significantly effective (P=0.003) in treating postpartum episiotomy pain,

edema and preventing infection30

.

A Quasi experimental study was conducted on Sitz bath versus

Self perineal care on episiotomy wound healing. 40 postnatal mothers

were taken for the study. 20 postnatal mothers were given Sitz bath and

20 postnatal mothers were given Self perineal care. The findings of the

study denote that the application of sitz bath has significant influence in

episiotomy wound healing. The study revealed that the REEDA score

was significantly low (p=0.007) in the experimental group. The study

concluded that Sitz bath is effective in episiotomy healing31

.

A study conducted on “post episiotomy pain: warm versus cold

sitz bath” in Colombia. Study included 20 samples to assess the

effectiveness of a warm versus cold sitz bath in relieving post episiotomy

pain. Sensation, distress, edema, and hematoma rating were obtained pre

– and post treatments. In conclusion, both therapies were found

comparable and significantly effective in managing post episiotomy

pain32

.

22

A study was conducted to examine the effect of aroma sitz bath

therapy on postpartum mother’s perineal healing in Korea. In this clinical

trial, postnatal mothers who delivered vaginally with an episiotomy were

allocated to aroma sitz bath group and control group. The perineal

healing status was measured using the REEDA Scale and smears for

episiotomy wound were obtained. The results revealed that REEDA

Scale was significantly low in the experimental group at postpartum 5th

and 7th

days (P=.009, P=.003), respectively. Most were observed ‘few’

(5-10 bacteria per field) bacteria in the smears of episiotomy wound. In

conclusion, these findings indicate that postpartum aroma sitz bath

therapy is effective in healing the perineum33

.

An experimental study conducted at Coimbatore in Tamil Nadu to

determine the effectiveness of infrared therapy and sitz bath. 30 samples

were randomly selected for the study, out of that 15 each has been

assigned to two experimental groups. Two experimental groups were

selected for infrared therapy and sitz bath and treatment were given for

three days in the morning and in the evening. Results revealed that

mother who had undergone the treatment of infrared therapy expressed

decreased pain intensity compared to mothers who had undergone the

treatment of sitz bath. In conclusion, infrared light therapy and sitz bath

were found to have same effect in the episiotomy34

.

23

A comparative Study was conducted on effects of medicated sitz

bath and non- medicated sitz bath on the episiotomy site at Chicago. The

objective of the study was to evaluate postpartum healing of the perineum

sample of 60 subjects were taken. 30 were given with medicated sitz bath

and 30 with non-medicated sitz bath. Analysis of variance indicated no

difference in REEDA score before or two hours after treatment35

.

An experimental study was conducted to assess the effectiveness

of sitz bath at California, the objective of the study was to determine

effectiveness of sitz bath and recommendation of sitz bath in the

management of episiotomy wound. 50 articles were taken The results

showed that 36 articles were found with highlighted the physiology

benefits risks complication and techniques of sitz bath one randomized

study comparing sitz bath to placebo found. Two articles speculated that

sitz bath induces relaxation of the muscle. Cold sitz bath was reported to

decrease perineal edema more than warm bath. The study concluded that

sitz bath is recommended in the treatment of episiotomy36

.

A comparative study was conducted to assess the effectiveness of

warm sitz bath and ice pack on intensity perineal pain after episiotomy in

primipara women, in Sydney. The objective of the study is to evaluate the

effectiveness of two devices. Perineal pain after episiotomy 121

primipara mothers was chosen. The results of the study showed that

wound healing in the warm sitz bath was better when compared to the ice

24

pack on intensity perineal pain. In conclusion, warm sitz bath and ice

pack were found to have varied effect on episiotomy pain intensity37

.

A comparative study was done to find the effect of Sitzbath

versus GuggulDhupan on episiotomy pain in postnatal mother admitted

in Pune hospital. 60 postnatal mothers were used in this study, 30

postnatal mothers were given Sitzbath and 30 postnatal mothers were

given Guggul Dhupan. According to self - assessment score, maximum

(53.3%) postnatal mothers were having mild pain after giving Sitzbath

and this difference was statistically significant, maximum (63.3%)

postnatal mothers were having severe episiotomy pain before Guggul

Dhupan and 80% of postnatal mothers were having mild pain after

Guggul Dhupan. The study concluded that Sitz bath is effective in

reducing episiotomy pain38

.

A quasi randomized study was conducted to assess the effects of

water compared with other solutions for wound cleansing, in Australia.

Eleven trials were included in this review. Seven trials were identified

that compared rates of infection and healing in wounds cleansed with

water and normal saline, three trials compared cleansing with no

cleansing and one trial compared procaine spirit with water, the relative

risk of developing an infection when cleansed with tap water compared

with normal saline was 0.16, (95% CI 0.01 to 2.96). The study

25

concluded that tap water was more effective than saline in reducing the

infection rate in adults with acute wounds39

.

Reviews related to infrared therapy

An experimental study conducted at selected Hospitals in

Kovilpatti, Tamil Nadu to determine the effectiveness of infra red lamp

therapy on episiotomy wound healing and pain. The control group (n=30)

used the existing methods of episiotomy care whereas, the subjects of the

experimental group (n=30) were provided with the infrared therapy for

10 minutes for 3 days. Results reveals that the mean episiotomy pain

score of the control group participants was high on all three days in

comparison with the experimental group and 10% of the participants in

the control group developed mild infection whereas none of the

participants in the experimental group, the results was statistically

significant (p<0.001). The study concluded that infrared therapy is

effective in managing episiotomy pain and wound healing40

.

An experimental study was conducted in Coimbatore, TamilNadu,

India to assess the effectiveness of infrared therapy in healing of

episiotomy wound. Through random sampling 20 postnatal women were

divided into control and experimental group. Comparative approach

using two group quasi experimental research designs was adopted for the

26

study. The results revealed that in experimental group, 75% of the

mothers who received infrared radiations showed adequate wound

healing and 25% showed poor wound healing, where as 70% of the

mothers in control group showed poor wound healing. The calculated

value of ‘t’ was greater (4.05) than the expected value of ‘t’(1.96). Study

concluded that there was a significant difference between healing scores

of experimental and control group after the administration of infrared

radiation for three days41

.

A study aimed at developing the new effective method of

treatment with an application of magnet laser (near infrared) radiation as

a stimulating aid in healing perineum injuries in the maternity patients, in

Russia. In this study 86 maternity patient with episiotomy were studied.

In treatment, the injury on the perineum was conventionally treated by

antiseptic in 40 maternity patients (control group); the laser therapy was

applied to another 46 maternity patients in concomitantly with the

conventional method.

Study concluded that laser therapy improves

process of the healing considerably, promotes the rapid disappearance of

inflammatory signs and renders analgesic effect42

.

A study was conducted in Coimbatore, Tamil Nadu, India to

compare the effectiveness of infrared therapy and sitz bath. In this

experimental study, 30 samples were randomly assigned in to

experimental group 1 and experimental group 2 for sitz bath and infrared

27

therapy respectively. The pain and wound score were assessed after a

period of 3 days by using Verbal Descriptive pain scale and Modified

Southampton Scale . Results revealed that infrared light therapy and sitz

bath were found effective in the healing of episiotomy, but mothers who

had undergone the treatment of infrared therapy expressed decreased pain

intensity (p<0.05=1.701) compared to mothers who had undergone the

treatment of sitz bath. In conclusion, infrared light is a better pain relief

intervention in comparison with sitz bath in treating episiotomy43

.

A study conducted to estimate the contribution of phototherapy to

the treatment of episiotomies in Czech Republics. In this study the

researchers treated a total of 2,436 postnatal women with episiotomies.

The light sources were: a laser (near infrared) of a wave length 670 nm

with continuous alternations of frequencies, a polarized light source of a

400-2,000 nm wavelength and frequency 100 Hz and a monochromatic

light source of a 660 nm wave length with simultaneous application of a

magnetic field at an induction 8 mT. The study concluded that high

healing effects with minimum secondary complications in the treatment

of episiotomies using a therapeutic laser at an energy density of 2J/cm44

.

An experimental study conducted to compare the effects of ice

bag and heat lamp, for the relief of perineal discomfort and to identify the

sustaining time of each effect, in Korea. Eighty postnatal women with

28

episiotomy were randomly selected and divided into two experimental

groups. Both experimental groups received ice bag therapy and heat lamp

therapy simultaneously. Pre test was conducted prior to the study to

identify the degree of perineum discomfort. Post test was conducted soon

after each therapy. A comfort scale, 18cm graphic scale was used. The

results revealed that ice bag group showed significantly lower discomfort

(p<0.05) than the heat group at the half an hour, two hour and four hours

of the therapy45

.

An experimental study was conducted in Vellore to compare the

effect of cold pack versus infrared radiation on episiotomy wounds

among 60 postnatal mothers. They were randomly divided into cold

therapy group and infrared therapy group. One hour after the completion

of the intervention, the results reveals that 76.6 % mothers did not had

pain at all and 23.3% mothers experienced very mild pain in cold therapy

group whereas 66.6% had mild pain and 33.7% had moderate to severe

pain in infrared therapy group. This difference was statistically

significant. In conclusion, both cold pack and infrared therapy

recommended for treating episiotomy wound46

.

An experimental study was conducted in Hyderabad, to assess the

effectiveness of electric heat lamp on healing of episiotomy wound.

Samples were divided into control group and experimental group. Result

29

reveals that there was a significant difference in rates of healing between

control and experimental groups. Those who received heat lamp therapy

had faster healing compared to those mothers who did not receive

therapy47

.

A study was conducted to investigate potential effects of a newly

developed specific near infrared light source on wound repair, in Shiga

university of medical sciences, Otsu. In this .study, cultured human

keratinocytes, endothelial cells and fibroblasts were 'exposed to the light

and the production of transforming growth factor (TGF) was examined

by enzyme immuno assay. Incisional wounds were treated with rays and

the effect of rays on the wound closure was followed photographically.

The rate of wound closure was significantly accelerated by repeated

exposures. The study concluded that near infrared rays potentially

enhances wound-healing process, presumably by its bio stimulatory

effects48

A study was conducted at Japan University to review the

outcomes and estimate the usefulness of linearly polarized near infrared

rays therapy. A total of 35 consecutive patients complained of vague and

deep pain in the ano-rectum. 14 patients had a history of lower abdominal

surgery. 18 patients had disordered defecation. The linearly polarized

near infrared light was radiated to the strongly tender point on or a few

30

centimetres apart from the skin for 10 minutes. The effect of the therapy

was assessed as excellent, good, no change or worse by the patients

themselves. 5 patients estimated as excellent, 28 as good and 2 as no

change. The mean total number of rays was 18.8 and mean number of

rays for relief from pain was 2.5. Anorectal pain recurred in 4 patients,

who received the same therapy and improved. The study was concluded

that the linearly polarized near infrared rays therapy is a simple, safe and

effective modality for relief from intractable anorectal pain and

recommended for primary therapy49

.

SUMMARY

This chapter had dealt with the review of literature related to

episiotomy, sitz bath and infrared therapy. In brief the literature review

has provided an understanding and broadened the investigator’s outlook

necessary for designing the conceptual framework, research design and

construction of the tool of the study

31

4. METHODOLOGY

Methodology of research indicates the general pattern of organizing the

procedure for gathering valid and reliable data for the problems under investigation19

.

The methodology is the most important part of research as it is the framework

for conducting the study. This chapter comprises of the research approach used,

research design, setting of the study used, population, sample selection, sampling

technique, development and description of the tool, pilot study, method of data

collection and plan for data analysis. The study conducted was to compare the

effectiveness of sitz bath versus infrared lamp therapy on episiotomy pain and wound

healing among postnatal mothers.

RESEARCH APPROACH

In the view of the nature of the problem selected for the study and the

objectives to be accomplished, a comparative approach was considered an appropriate

research approach for the present study regarding the effectiveness of sitz bath versus

infrared lamp therapy on episiotomy pain and wound healing among postnatal

mothers.

RESEARCH DESIGN

Research design incorporates the most important methodological decisions that

a researcher makes in conducting a research study (Figure-2). The research design

32

selected for the present study was quasi experimental with pre-test and post-test

design with comparison group to achieve the objectives of the study.

E = O1 - X1 - O2

C = O1 - X - O2

Where as, C is the control group

E is the experimental group

O1 is the pre intervention assessment

O2 is the post intervention assessment

X is the intervention routinely administered in the hospital (sitz bath)

X1 is the intervention which is introduced by the investigator ( Infra red therapy)

SETTING OF THE STUDY:

The study subjects were selected from Kempegowda Institute Of Medical

Sciences and Research Centre.

Target Population

The target population for the present study was postnatal mothers who had

normal vaginal delivery with episiotomy.

Sample

A sample consists of a subset of the units that comprises the population.

Postnatal mothers who had normal vaginal delivery with episiotomy, admitted in

postnatal ward of Kempegowda Institute Of Medical Sciences, Hospital and Research

Centre

33

Sample Size

The sample size was 60 postnatal mothers who had vaginal delivery divided 30

each in control and experimental group.

Sampling Technique

Sampling is the process of selecting a portion of the population to represent the

entire population. In this study the purposive sampling was used to collect data from

the available samples falling under inclusion criteria.

Criteria for selection of sample

Inclusion criteria:

Mothers who had full term vaginal delivery with episiotomy.

Mothers with episiotomy who are willing to participate in the study

Exclusion criteria:

Mothers with infected perineum.

Mothers with medical disorders or abnormal purerperium.

Mothers with operative vaginal delivery

TOOL FOR RESEARCH

Data collection tools are the procedures or instruments used by the researcher

to observe or measure the key variables in the research problem

The episiotomy pain and wound healing and pain was assessed with the

following instruments: Demographic variables, Modified Verbal Descriptive Pain

Scale, REEDA Scale.

34

Modified Verbal Descriptive Pain Scale is the tool to assess the level of pain &

REEDA Scale is the tool used for recording the wound healing.

DEVELOPMENT OF THE TOOL

The tool was prepared on the basis of the objectives of the study. The

researcher did an extensive review of literature to collect relevant materials and based

on it selected the tool for the study.

The following steps were undertaken to prepare the final tool:

Tool was developed based on related literature review and experts suggestions

Demographic and clinical variables were developed to obtain baseline characteristics

Modified Verbal Descriptive Scale was developed to assess the level of pain in the

episiotomy area.

REEDA scale was developed to assess the level of wound healing in episiotomy area.

Content Validity

Content validity is the extent to which a measuring instrument provides

adequate coverage of the topic under the study. A criterion rating scale of the tool was

developed. It consisted of columns like Very relevant, Relevant, Need modification,

Not relevant and remarks for suggestions from the experts for each item regarding

accuracy, relevancy and appropriateness of the content. To establish the content

validity of the tool, the tool was given to 10 experts in the field of nursing, one expert

in the field of medicine. Modifications were made based on suggestion and comments

given by the experts and the guide.

35

Reliability

Reliability is defined as the extent to which the instrument yields the same

result on repeated measures. It is thus concerned with consistency, accuracy, stability

and homogeneity. The reliability of the Verbal Descriptive Pain Scale and REEDA

Scale was established for its equivalence by inter rater method after administering the

tool to ten postnatal mothers in selected hospitals. Karl – Pearson’s Correlation

Coefficient formula was used to find the reliability.

The reliability of Verbal descriptive pain scale is 0.89 and for the REEDA

scale reliability is 0.96, thus the tools were found to be reliable.

DESCRIPTION OF THE TOOL:

Demographic data

Demographic variables and clinical variables consisted of total 9 variables

like, age, religion, education, occupation, type of occupation, dietary pattern, place of

living, parity and type of episiotomy.

Verbal Descriptive Pain Scale

The pain scale was constructed based on the Verbal Descriptive Pain Scale

given by Jack Harich (2002). It is a pain scale ranging 0 to 3. Point 0 indicates no pain

and point 3 indicates severe pain. The maximum score is 3. It was used to identify the

level of pain in the episiotomy area. The subjects in the study were asked to specify the

point at which they feel pain.

36

REEDA Scale

The wound scoring scale was constructed based on the REEDA Scale given by

Nancy Davidson (1972). Redness, edema, ecchymosis, discharge, approximation are

the five categories of the scale. The scoring for each category ranges from 0 to 3. The

total score is 15

PILOT STUDY

After having obtained formal administrative approval from the Medical

superintendent, HOD of OBG department and Nursing Superintendent of the

Kempegowda Institute of Medical Science and Research Centre, Bangalore, the pilot

study was conducted from 3’rd

September ’2012 to 11th

September’2012 to find out the

feasibility of the study. Totally 10 postnatal mothers with episiotomy were selected by

using purposive sampling technique. Five samples are assigned to the control group

(sitz bath) and five to the experimental group (infra red lamp therapy group).The

subjects for the pilot study possessed the same characteristics as that of the sample for

the main study.

DATA COLLECTION PROCESS

Data collection was done in Kempegowda Institue Medical sciences and

Research centre, Bangalore. The data collection done from 1st of November 2012 to

30th

of November. Formal written permission obtained from the respective authorities.

37

Based on inclusion criteria, 60 postnatal mothers were selected from the postnatal

ward. Thirty(30) postnatal mothers got selected to the control group and another

thirty(30) to the experimental group. Samples were selected by purposive sampling

technique. Subjects were selected for postnatal ward on each day based on the

inclusion criteria. The mothers were intimated regarding the purpose of the study and

their consent was secured. Pre test was conducted for both control and experimental

group on the first day before starting therapy. The episiotomy pain was assessed by

Modified Verbal Descriptive pain Scale and wound healing was assessed by REEDA

scale. Sitz bath was given to control group and infrared therapy to the experimental

group for three days in the morning and evening for 15 minutes. Post test was

conducted on third day for both control group and experimental group by using the

same tool.

PLAN FOR DATA ANALYSIS

Analysis is the systematic organization and synthesis of research data and

testing of research hypothesis by using those data. A master data sheet was prepared

by the investigator to organize and compute data. The data would be analysed using

both descriptive and inferential statistics based on the objectives and hypothesis stated.

The plan of data analysis includes the following

Section I: Distribution of demographic and clinical characteristics of the subjects is

done by descriptive statistics.

38

Pain

Section II: Assessment of episiotomy pain and comparison of pain scores among

control &experimental group.

Section III: Effectiveness of sitz bath on episiotomy pain reduction among control

group is assessed by using paired t test

Section IV: Effectiveness of infrared therapy on episiotomy pain reduction among

experimental group is assessed by using paired t test.

Section V: Comparing the effectiveness between sitz bath and infrared lamp therapy

on episiotomy pain reduction among control and experimental group is assessed by

using student t test.

Section VI: Association between pre test pain scores and selected demographic and

clinical variables is done by using chi – square test.

Wound healing

Section VII: Assessment of episiotomy wound status and comparison wound healing

scores among control &experimental group is done by descriptive statistics.

Section VIII: Effectiveness of sitz bath on episiotomy wound healing among control

group is assessed by using paired t test.

Section IX: Effectiveness of infrared therapy on episiotomy wound healing among

experimental group is assessed by using paired t test.

Section X: Comparing the effectiveness between sitz bath and infrared lamp therapy

on episiotomy wound healing is done by using student t test.

39

Section XI: Association between pre test wound scores and selected demographic and

clinical variables is done by using chi – square test.

SUMMARY

This chapter deals with the methodology adopted for this study. This included

Research approach, Research design, Variables under study, Setting, Population,

Sample size, Sampling criteria, Development of tool, Validity, Reliability, Data

collection method and Plan for data analysis.

40

FIGURE :2 SCHEMATIC REPRESENTATION OF STUDY DESIGN.

Research approach: Comparative

Research design: Quasi experimental pre test post

test design with a comparison group

Target population:

Postnatal mothers

Data collection tool: Questinonnaire,

Verbal descriptive pain scale and REEDA

Scale

Data collection technique: Structured interviews

schedule & clinical assessment.

Data analysis: Descriptive and

inferential statistics

Findings and conclusion

Report writing

Accessible population: Postnatal

mothers admitted KIMS, Bangalore.

Samples:60 post

natal mothers (30

in control &30 in

experimental

group)

Sampling

technique:

Purposive

sampling

technique

Research purpose: To assess the effectiveness of sitz bath

versus infrared lamp therapy on episiotomy pain and wound

healing among postnatal mothers with episiotomy.

41

5. RESULTS

Analysis and interpretation of data

This chapter presents the results of the study conducted to compare the

effectiveness of sitz bath versus infrared therapy in reducing pain and improves wound

healing among postnatal mothers of selected hospitals, in Bangalore.

Analysis is the process of categorizing, ordering, manipulating and

summarizing of data to obtain an answer to the research question. The purpose of

analysis is to reduce the data to an intelligible and interpretable form so that relations

for the research problem can be studied and tested19

.

Objectives of the study

i. To assess the level of pain and wound healing status among postnatal mothers with

episiotomy.

ii. To assess the effectiveness of sitz bath and infrared lamp therapy on episiotomy pain

and wound healing among postnatal mothers.

iii. To compare the effectiveness between sitz bath and infrared lamp therapy on

episiotomy pain and wound healing among postnatal mothers.

iv. To determine an association between pain level & wound healing status with selected

demographic variables

42

Hypotheses:

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

wound healing scores in sitz bath and infrared lamp therapy group.

H2: There is a significant difference in the mean post test scores between sitz bath and

infrared lamp therapy group.

H3: There is a significant association between pain &wound healing scores with

selected demographic variables in sitz bath and infrared lamp therapy group.

Presentation of data:

To begin with, data were entered in a master sheet, for tabulation and statistical

processing. The findings were presented under the following heading

Section I: Distribution of demographic and clinical characteristics of the subjects.

Pain

Section II: Assessment of episiotomy pain and comparison of pain scores among

control &experimental group.

Section III: Effectiveness of sitz bath on episiotomy pain reduction among control

group.

43

Section IV: Effectiveness of infrared therapy on episiotomy pain reduction among

experimental group.

Section V: Comparing the effectiveness between sitz bath and infrared lamp therapy

on episiotomy pain reduction among control and experimental group.

Section VI: Association between pre test pain scores and selected demographic and

variables.

Wound healing

Section VII: Assessment of episiotomy wound status and comparison wound healing

scores among control &experimental group.

Section VIII: Effectiveness of sitz bath on episiotomy wound healing among control

group.

Section IX: Effectiveness of infrared therapy on episiotomy wound healing among

experimental group.

Section X: Comparing the effectiveness between sitz bath and infrared lamp therapy

on episiotomy wound healing.

Section XI: Association between pre test wound healing scores and selected

demographic variables.

44

Section I: Distribution of demographic and clinical characteristics of the subjects

Table – 1: Distribution of subjects by age

Figure 3: Distribution of samples by age

Table 1 and figure 3 depict that, 66.67% of the subjects from control group

were between the age group of 18 to 23 years where as 50% of the subjects from

experimental group were between the age group of 24 to 29 years.

0

10

20

30

40

50

60

70

18- 23yrs 24- 29yrs 30-35yrs Above 35yrs

66.67

26.67

6.67

0

46.67 50

3.33 0

Pe

rce

nta

ge (

%)

Age in years

Control group

Experimental group

Variables

Control group

n1= 30

Experimental group

n2=30

Frequenc

y

(f)

Percenta

ge

(%)

Frequenc

y

(f)

Percenta

ge

(%)

Age in years

a) 18- 23

b) 24- 29

c) 30-35

d) Above 35

20

8

2

0

66.66

26.67

6.67

0

14

15

1

0

46.66

50.00

3.33

0

Total 30 100 30 100

45

Table 2: Distribution of samples by religion

Figure 4: Distribution of samples by religion

Table 2 and figure 4 that majority of subjects in both control(66.67%) and

experimental group(70%) were Hindus.

0

10

20

30

40

50

60

70

Hindu Muslim Christian Others

66.67

26.67

6.66

0

70

20

10

0

Pe

rce

nta

ge (

%)

Religion

Control group

Experimental group

Variables

Control group

n1= 30

Experimental group

n2=30

Frequen

cy

(f)

Percenta

ge

(%)

Frequen

cy

(f)

Percenta

ge

(%)

Religion

a) Hindu

b) Muslim

c) Christian

d) Others

20

8

2

0

66.67

26.67

6.66

0

21

6

3

0

70

20

10

0

Total 30 100 30 100

46

Table 3: Distribution of samples by education

Figure 5: Distribution of samples by education

Table 3 and figure 5 depict that majority of subjects in both control(73.33%)

and experimental(83.33%) groups were having secondary/diploma education.

0 10 20 30 40 50 60 70 80 90

0

16.67

73.33

10 0

6.67

83.33

10

Pe

rce

nta

ge (

%)

Education

Control group

Experimental group

Variables

Control group

n1= 30

Experimental group

n2=30

Frequency

(f)

Percentage

(%)

Frequency

(f)

Percentage

(%)

Education

a) No formal

b) Primary

c) Secondary/Diploma

d) Graduation and above

0

5

22

3

0

16.66

73.33

10

0

2

25

3

0

6.66

83.33

10

Total 30 100 30 100

47

Table 4: Distribution of samples by occupation

Figure 6: Distribution of samples by occupation

Table 4 and figure 6 depict that both in control and experimental group

majority were housewives ie 63.33% and 70% respectively.

Variables

Control group

n1= 30

Experimental group

n2=30

Frequen

cy

(f)

Percenta

ge

(%)

Frequen

cy

(f)

Percenta

ge

(%)

Occupation

a) Housewife

b) Private

c) Government

19

10

1

63.33

33.33

03.33

21

9

0

70

30

0

Total 30 100 30 100

0

10

20

30

40

50

60

70

Housewife Private Government

63.33

33.33

3.33

70

30

0

Pe

rce

nta

ge (

%)

Occupation

Control group

Experimental group

48

Table 5: Distribution of samples by type of family

Figure 7: Distribution of subjects by type of family

Table 5 and figure 7 depict that in control group 50% of subjects belonged to

joint family whereas in experimental group 50% of subjects were from nuclear family.

0

5

10

15

20

25

30

35

40

45

50

Nuclear Joint Extended

43.33

50

6.67

50

40

10 Pe

rce

nta

ge (

%)

Type of family

Control group

Experimental group

Variables

Control group

n1= 30

Experimental group

n2=30

Frequen

cy

(f)

Percenta

ge

(%)

Frequen

cy

(f)

Percenta

ge

(%)

Type of family

a) Nuclear

b) Joint

c) Extended

13

15

02

43.33

50

6.67

15

12

03

50

40

10

Total 30 100 30 100

49

Table 6: Distribution of subjects by diet

Figure 8: Distribution of samples by diet

In relation to type of diet the data presented in above table and figure depict

that, majority of subjects (96.67% in control group &93.33 in experimental group)

belonged to mixed diet group.

0

10

20

30

40

50

60

70

80

90

100

Mixed Vegetarian

96.67

3.33

93.33

6.67

Pe

rce

nta

ge (

%)

Type of diet

Control group

Experimental group

Variables

Control group

n1= 30

Experimental group

n2=30

Frequen

cy

(f)

Percenta

ge

(%)

Frequen

cy

(f)

Percenta

ge

(%)

Dietary pattern

a) Vegetarian

b) Mixed

1

29

03.33

96.67

2

28

06.67

93.33

Total 30 100 30 100

50

Table 6: Distribution of samples by place of living

Figure 8: Distribution of samples by place of living

The table 6 and figure 8 reveals that majority of subjects from both control and

experimental group were living in urban area ie 80% and 60% respectively.

0

10

20

30

40

50

60

70

80

Urban Rural

80

20

60

40

Pe

rce

nta

ge(%

)

Place of living

control group

Experimental group

Variables

Control group

n1= 30

Experimental group

n2=30

Frequenc

y

(f)

Percenta

ge

(%)

Frequenc

y

(f)

Percenta

ge

(%)

Place of living

a) Rural

b) Urban

6

24

20

80

9

21

40

60

Total 30 100 30 100

51

Table 8: Distribution of subjects by parity

Figure 10: Distribution of subjects by parity

The table 8 and figure 10 depicts that 63.33% of subjects were primiparas and

in control group and in experimental group majority (53.33%) were multiparas

0

10

20

30

40

50

60

70

Primi Multi Grand multi

63.33

36.67

0

46.667

53.33

0

Pe

rce

nta

ge (

%)

Parity

Control group

Experimental group

Variables

Control group

n1= 30

Experimental group

n2=30

Frequenc

y

(f)

Percenta

ge

(%)

Frequenc

y

(f)

Percenta

ge

(%)

Parity

a) Primi

b) Multi

c) Grand multi

19

11

0

63.33

36.66

0.0

14

16

0

46.66

53.33

0.0

Total 30 100 30 100

52

Table 9: Distribution of samples by type of episiotomy

Figure11: Distribution of samples by type of episiotomy

It revealed from the figure 9 and table 11 that 100% subjects form control

group and 80% of subjects from experimental group were having right mediolateral

episiotomy (RMLE).

0

10

20

30

40

50

60

70

80

90

100

Median Lateral RMLE LMLE

0 0

100

0 0 0

80

20 Pe

rce

nta

ge (

%)

Type of episiotomy

Control group

Experimental group

Variables

Control group

n1= 30

Experimental group

n2=30

Frequenc

y

(f)

Percenta

ge

(%)

Frequenc

y

(f)

Percenta

ge

(%)

Type of episiotomy

a) Median

b) Lateral

c) RMLE

d) LMLE

0

0

30

0

0

0

100

0

0

0

28

2

0

0

80

20

Total 30 100 30 100

53

Section II: Assessment of episiotomy pain and comparison of pain scores among

control &experimental group.

a) Assessment of episiotomy pain level

Table 12: Pre test and post test pain level assessment in control and experimental

group

Pain

range

Control group (n1= 30) Experimental group (n2=3

Pre test Post test Pre test Post test

f % F % F % F %

Severe

Pain (3)

12 40 0 0 14 46.67 0 0

Moderate

pain(2)

16 53.33 12 40 14 46.67 4 13.33

Mild

pain(1)

2 6.67 15 50 2 6.67 8 26.67

No Pain

(0)

0 0 3 10 0 0 18 60

With regard to pre test scores, in control group majority (53.33%) reported

moderate pain and remaining reported severe (40%) and mild pain (6.67%) where as in

experimental group severe pain and moderate pain were reported by an equal

percentage of 46.67% and a minority (6.67%) reported mild pain.

Comparison of pain scores among control and experimental group

Table 13: Mean, Median, Standard deviation, Range, Mean Percentage (%) of

pre test and post test pain score in control group and experimental group.

Group Score Control Group Experimental Group

Pre test Post test Pre test Post test

Mean 2.23 1.3 2.4 0.87

Median 2 1 2 1

Standard Deviation 0.61 0.65 0.62 0.63

Range 2 2 2 2

Mean Percentage(%) 74.33 43.33 80 29

54

The data in the table shows that the mean percentage of pre-test and post-test in

control group was 74.33 and 43.33 respectively, whereas in experimental group it was

80and 29 respectively which shows that the pain score of experimental group during

post-test was lower when compared with other pain scores.

Section III: Effectiveness of sitz bath on episiotomy pain reduction among

control group

This section deals with the analysis and interpretation of pain score in postnatal

mothers in the episiotomy area. Paired ‘t’ test is done to analyse the pre test and post

test. In order to test the statistical significance null hypothesis was stated.

H0: There is no significant difference between the pre test pain scores and post test

pain scores in control group.

Table 14: Pre test and post test pain scores comparison in control group

Group Mean SD ‘t’ value Inference

Pre test 2.3 0.61 13.68

*S Post test 1.3 0.65

t(29,0.05)=1.699

The data presented in above table shows that the pre-test mean pain score was

2.3 with S.D of 0.61 and post test mean pain score was 1.3 with S.D of 0.6 which

indicates that there was decrease in the pain score during post test. The paired ‘t’ test

value (13.68) shows there is a significant difference between pre test and post test

wound score at 0.05 level. This implies that sitz bath was effective in episiotomy

wound healing.

55

Section IV: Effectiveness of infrared therapy on episiotomy pain reduction among

experimental group

This section deals with the analysis and interpretation of pain score in postnatal

mothers in the episiotomy area. Paired ‘t’ test is done to analyse the pre test and post

test. In order to test the statistical significance null hypothesis was stated.

H0: There is no significant difference between the pre test pain scores and post test

pain scores in experimental group.

Table 15: Pre test and post test pain scores comparison in experimental group

Group Mean SD ‘t’ value Inference

Pre test 2.4 0.62 14.69

*S Post test 0.87 0.63

t(29,0.05)=1.699

The data presented in above table shows that the pre-test mean pain score was

2.4 with S.D of 0.62 and post test mean pain score was 0.87 with S.D of 0.6 3 which

indicates that there was decrease in the pain score during post test. The paired ‘t’ test

value (14.69) shows there is a significant difference between pre test and post test pain

score at 0.05 level. This implies that infrared therapy was effective in episiotomy

wound healing.

The student t test shows that infrared therapy is effective in reducing

episiotomy pain as the calculated t value is greater than the table t value.

56

Section V: Comparing the effectiveness between sitz bath and infrared lamp

therapy on episiotomy pain reduction

This section deals with the analysis and interpretation of pain score after sitz bath

and infrared therapy on postnatal mothers. Student ‘t’ test was used to compare the

effectiveness between sitz bath and infrared therapy in control and experimental

group. In order to test the statistical significance null hypothesis is stated.

H0: There is no significant difference between the post-test pain scores of control and

experimental group.

Table 16: Comparison of Post test pain scores in control and experimental group

Group Mean SD ‘t’ value Inference

Control 1.3 0.65 2.62

*S

Experimental 0.87 0.63

t(58,0.05)=1.67

The data presented in above table shows that mean post test score of control

group (1.3) was higher than the experimental group score (0.87). Student‘t’ test value

(2.62) shows that there is significant difference between post- test pain scores of

control and experimental group. It means that infrared therapy was effective in

episiotomy pain reduction

57

Section VI: Association between pre test pain scores and selected demographic

and clinical variables

a) Control group

Demographic

variables

Responses Overall pre test

knowledge

Chi-

square

value

df

Below

median

Above

median

Age (yrs)

18-23 1 19

0.67NS

2 24-29 1 7

>35 0 2

Religion

Hindu 2 18

1.07NS

2 Muslim 0 8

Christian 0 2

Education

Primary 0 18

0.78NS

2 Secondary 2 8

Graduation 0 2

Occupation

House wife 2 18

1.72NS

2

Private 0 9

Family

Nuclear 1 12

1.17NS

2 Joint 1 14

Extended 0 2

Diet

Vegetarian 0 1

0.07NS

1

Mixed 2 27

Place of living

Rural 2 6

0.54NS

1

Urban 20 22

Parity Primi 1 8

0.16NS

1

Multi 1 10

58

a) Experimental group

Demographic

variables

Responses Overall pre test

knowledge

Chi-

square

value

Df

Below

median

Above

median

Age (yrs) 18-23 2 13

2.14NS

2 24-29 0 14

>35 0 1

Religion

Hindu 0 21

8.57S

2 Muslim 2 4

Christian 0 3

Education

Primary 0 2

0.43NS

2 Secondary 2 23

Graduation 0 3

Occupation House wife 1 31

0.59NS

2

Private 1 7

Family Nuclear 2 13

2.14NS

2 Joint 0 12

Extended 0 3

Diet

Vegetarian 0 2

0.15NS

1

Mixed 2 26

Place of living Rural 0 9

0.92NS

1

Urban 2 19

Parity Primi 1 `13

0.10NS

1

Multi 1 15

Episiotomy RMLE 0 2

0.15NS

1

LMLE 2 26

59

This section explains association between episiotomy pain scores and selected

demographic variables. For the purpose of establishing the association between the

demographic variables and the overall pain score is divided into two categories as

below median and above median The chi – square test analysis shows that there is no

significant association between pre test episiotomy wound scores and selected

demographic & clinical variables at 0.05 level in both control and experimental group

with an exemption of religion which has shown significant association (x2= 8.57)only

in experimental group.

WOUND HEALING GRADING

Section VII: Assessment of episiotomy wound status and comparison pain scores

among control & experimental group

a) Assessment of episiotomy wound status

Pre test and post test wound healing grading in control and experimental group

With regard to pre-test scores, all subjects (100%) had moderate wound

infection in both control and experimental group.

Wound healing Control group(n1=30) Experimental group(n2=30)

Pre test Post test Pre test Post test

f % F % F % F %

No infection

(0)

0 0 0 0 0 0 0 0

Mild infection

(1-5)

0 0 7 23.33 0 0 5 16.67

Moderate infection

(6-10)

30 100 23 76.67 30 100 25 83.33

Severe Pain

(11-15)

0 0 0 0 0 0 0 0

60

b) Comparison of wound healing scores among control & experimental group

Mean, Median, Standard deviation, Range, Mean Percentage(%) of pre test and

post test wound healing score in control group and experimental group.

Group Score Control Group(n1=30) Experimental Group(n2=30)

Pre test Post test Pre test Post test

Mean 7.97 6.90 8.13 6.90

Median 8.00 7.00 8.00 7.00

Standard Deviation 1.43 1.53 1.38 1.25

Range 4.00 6.00 4.00 4.00

Mean Percentage (%) 53.13 46.00 54.20 46.00

The data in the table shows that the mean percentage of pre-test and post-test in

control group was 53.13 and 46 respectively, whereas in experimental group it was

54.2 and 46 respectively which shows that there were no difference in post-test wound

scores among control and experimental group.

Section VIII: Effectiveness of sitz bath on episiotomy wound healing among

control group

This section deals with the analysis and interpretation of wound score in

postnatal mothers in the episiotomy area. Paired ‘t’ test is done to analyse the pre test

and post test. In order to test the statistical significance null hypothesis was stated.

H0: There is no significant difference between the pre test wound scores and post test

wound scores in control group.

61

Table 17: Pre test and post test wound healing scores in control group

Group Mean SD ‘t’ value Inference

Pre test 7.97 1.43

4.96

S Post test

6.86 1.53

t(29,0.05)=1.699

The data presented in above table shows that the pre-test mean wound score

was 7.97 with S.D of 1.43 and post test mean wound score was 6.86 with S.D of 1.53

which indicates that there was decrease in the wound score during post test. The

paired‘t’ test value (4.96) shows there is a significant difference between pre test and

post test wound score at 0.05 level. This implies that sitz bath was effective in

episiotomy wound healing.

Section IX: Effectiveness of infrared therapy on episiotomy wound healing among

experimental group

This section deals with the analysis and interpretation of wound score in postnatal

mothers in the episiotomy area. Paired ‘t’ test is done to analyse the pre test and post

test. In order to test the statistical significance null hypothesis was stated.

H0: There is no significant difference between the pre test wound scores and post test

wound scores in experimental group.

62

Table 18: Pre test and post test wound healing scores in experimental group

Group Mean SD ‘t’ value Inference

Pre test 8.13 1.38 6.59

S Post test 6.93 1.25

t (29,0.05)=1.699

The data presented in above table shows that the pre-test mean wound score

was 8.13 with S.D of 1.38 and post test mean wound score was 6.93 with S.D of 1.25

which indicates that there was decrease in the wound score during post test. The paired

‘t’ test value (6.59) shows there is a significant difference between pre test and post

test wound score at 0.05 level. This implies that infrared therapy was effective in

episiotomy wound healing.

Section X: Comparing the effectiveness between sitz bath and infrared lamp

therapy on episiotomy wound healing among control & experimental group

This section deals with the analysis and interpretation of wound healing score

after sitz bath and infrared therapy on postnatal mothers. Student ‘t’ test was used to

compare the effectiveness between sitz bath and infrared therapy in control and

experimental group. In order to test the statistical significance null hypothesis is stated.

H0: There is no significant difference between the post test wound healing scores of

control and experimental group.

63

Table 19: Post test wound healing scores in control and experimental group

Group Mean SD ‘t’ value Inference

Control 5.13 1.67 0.19

NS Experimental 5.07 1.34

t (58, 0.05)=1.67

The data presented in above table shows that mean post test score of

experimental group (5.07) was slightly lower than the control group score (5.13).

Student ‘t’ test value (0.19) shows that there is no significant difference between

post- test wound scores of control and experimental group. It means that there is no

comparable difference among sitz bath and infrared therapy in promoting episiotomy

wound healing.

64

Section XI: Association between pre test pain scores and selected demographic

and clinical variables

a) Control group

Demographic

variables

Responses Overall pre test

knowledge

Chi-

square

value

df

Below

median

Above

median

Age (yrs) 18-23 7 4

3.23NS

2 24-29 5 12

>35 0 2

Religion

Hindu 9 11

1.04NS

2 Muslim 2 6

Christian 1 1

Education

Primary 1 4

1.16NS

2 Secondary 10 12

Graduation 1 2

Occupation House wife 9 11

2.89NS

2 Private 2 7

Government 1 0

Family Nuclear 3 10

0.74NS

2 Joint 8 7

Extended 1 1

Diet

Vegetarian 0 1

0.07NS

1

Mixed 2 27

Place of living Rural 0 6

0.54NS

1

Urban 2 22

Parity Primi 1 18

0.16NS

1

Multi 1 10

65

b) Experimental group

Demographic

variables

Responses Overall pre test

knowledge

Chi-

square

value

df

Below

median

Above

median

Age (yrs) 18-23 7 8

3.77NS

2 24-29 3 11

>35 1 0

Religion

Hindu 7 14

0.57NS

2 Muslim 3 3

Christian 1 2

Education

Primary 1 1

2.01NS

2 Secondary 10 15

Graduation 0 3

Occupation House wife 9 13

0.64NS

1

Private 2 6

Family Nuclear 5 10

0.22NS

2 Joint 5 7

Extended 1 2

Diet

Vegetarian 0 2

1.24NS

1

Mixed 11 17

Place of living Rural 4 5

0.34NS

1

Urban 7 14

Parity Primi 6 8

0.43NS

1

Multi 5 11

Episiotomy LMLE 0 2

1.24NS

1

RMLE 11 17

66

This section explains association between episiotomy wound scores and selected

demographic variables. For the purpose of establishing the association between the

demographic variables and the overall wound score is divided into two categories as

below median and above median The chi – square test analysis shows that there is no

significant association between pre test episiotomy wound scores and selected

demographic & clinical variables such as age, religion, education, occupation, type of

family, diet, place of living, parity and episiotomy at 0.05 level in both control and

experimental group.

Note:

Critical value for 1 degree of freedom at 5%level of significance=3.841.

Critical value for 1 degree of freedom at 5%level of significance=5.99

SUMMARY

This chapter has dealt with the analysis and interpretation of the findings of the

study. Sitz bath were received by control group and infrared therapy was administered

for experimental group for three days after conducting pre-test. Post test conducted

after the completion of three days therapy. The data obtained was entered in the master

sheet and computed using descriptive and inferential statistics. The result concluded

that mothers who had undergone the treatment of infrared light therapy expressed

decreased pain intensity compared to mothers who had undergone the treatment of sitz

bath. With regard to wound healing, infrared light therapy and sitz bath were found to

have same effect in healing and condition of healing.

67

6. DISCUSSION

In order to find meaningful answers to research questions, the collected data

must be processed, analyzed in an orderly and coherent fashion, so that patterns and

relationship can be discussed.

The present study was done to compare the effectiveness of sitz bath versus

infrared lamp therapy on episiotomy pain and wound healing among post natal

mothers at selected hospitals, Bangalore.

In this study, quasi experimental pre-test and post-test design with a

comparison group was adopted to compare the effectiveness of sitz bath versus

infrared lamp therapy on episiotomy pain and wound healing. The study was

conducted at Kempegowda Institute of Medical Science, Hospital and Research

Centre, Bangalore. The sample size comprised of 60 postnatal mothers (30 in control

&30 in experimental group). The purposive sampling technique was used to select the

sample. Data collected from the subjected were tabulated, analyzed and interpreted by

using descriptive and inferential statistics, based on the objectives of the study.

Findings of the study: The findings of the study have been organized and

discussed under the following sections:

The findings of the study are discussed under the following headings:

1. Demographic characteristics of the subjects.

2. Assessment of level of pain and wound healing status among postnatal mothers.

3. Evaluation of effectiveness of sitz bath and infrared lamp therapy on episiotomy pain

and wound healing.

4. Association between demographic variables and pre test pain & wound healing scores.

68

5. Discussion on testing of the hypothesis.

DEMOGRAPHIC CHARACTERISTICS OF THE SUBJECTS.

The findings of the study shows that,

1. Age:

In control group, most of the subjects that is 66.66% were between 18-25 years,

26.67% belonged to 24 -29 years, and remaining 6.67 % belonged to 26-33 years.

In experimental group, most of the subjects that is 50% were between 18-25

years, 46.67% belonged to 24 -29 years, and remaining 3.33 % belonged to 26-33

years.

2. Religion:

In control group, majority 66.67% of the subjects belonged to Hindu religion,

26.67% belonged to Muslim and remaining 6.66% belonged to Christian.

Similarly in experimental group, majority 70% belonged to Hindu religion,

20% belonged to Muslim and remaining 10% belonged to Christian.

3. Education:

In control group, majority 73.33% of subjects had secondary/ Diploma

education, 16.66% had primary education, and 10% had attained graduation.

In experimental group, majority 83.33% of subjects had secondary/ Diploma

education, 6.66% had primary education, and 10% had attained graduation.

4. Occupation:

In control group, majority 63.33% were house wives, 33.33% were private

employees and remaining 03.33% were government employees.

Similarly, in experimental group, majority 70% were house wives, and

remaining 30% were private employees.

69

5. Type of family:

In control group, 50% of the subjects belonged to joint family, 43.33%

belonged to nuclear family and remaining 6.67% belonged to extended family.

In experimental group, 50% of the subjects belonged to joint family, 40%

belonged to nuclear family and remaining 10% belonged to extended family.

6. Diet:

In control group, majority 96.67% of the subjects belonged to mixed diet

group, and remaining 3.33% belonged to vegetarian diet group.

Similarly in experimental group, majority 93.33% of the subjects belonged to

mixed diet group, and remaining 6.67% belonged to vegetarian diet group.

7. Place of living:

In control group, majority of the subjects that is 80% were from urban area and

remaining 20% from rural area.

Similarly in experimental group, majority of the subjects that is 60% were from

urban area and remaining 40% from rural area.

8. Parity:

In control group, majority 63.33% of subjects were primiparas and remaining

36.67% were multiparas.

In experimental group, 53.33% of subjects were multiparas and remaining

46.67% were primiparas.

9. Type of episiotomy:

In control group, all subjects (100%) had right mediolateral episiotomy.

In experimental group, majority 80% had right mediolateral episiotomy and remaining

20% had left mediolateral episiotomy.

70

The findings are supported by a similar study conducted to identifying the

frequency, the types and the criteria adopted to recommend episiotomy, by De Oliveira

SM and Miquilini EC in Portuguese. In this study 12 doctors and 12 nurses who attend

women at birth interviewed. The results show that episiotomy was performed in 76.2%

of the normal births; the most frequent indications were perineal rigidity and

primiparity. The most mentioned type was the right medio- lateral episiotomy (92%),

and the justifications were: it was learned during academic formation(25.9%); it is

adopted routinely((19.4%); with it there is a lesser chance for causing lesions to the

anal sphincter(16.1%); with it there is a lesser risk of complications(16.1%)50

.

ASSESSMENT OF LEVEL OF PAIN AND WOUND HEALING STATUS

AMONG POSTNATAL MOTHER

The present study confirms that with regard to pre test scores, in control group

majority (53.33%) reported moderate pain and remaining reported severe (40%) and

mild pain (6.67%) where as in experimental group severe pain and moderate pain were

reported by an equal percentage of 46.67% and a minority (6.67%) reported mild pain.

All (100%) had moderate wound infection in both control and experimental group.

The findings of related to the pain level in the present study supported by a

similar study conducted by Imarengiaye CO and Andet AB in Nigeria to identify the

place of postpartum perineal pain as morbidity in the immediate postpartum period.

All women over 18 years who were delivered of a live neonate vaginally and were in

hospital for at least 3 days after delivery were studied. The results revealed that

episiotomy was twice likely to produce perineal pain than no trauma group at time of

71

discharge on day 3 (RR=2.4). The study concluded that perineal pain increased with

perineal trauma and episiotomy and the current management of post partum perineal

pain is inadequate51

.

The findings of related to the wound healing status in the present study supported

by a similar study conducted by Uygur D, Yesildaglar N in Turky to determine the

outcome of episiotomy. In the study period, there were 37 patients with episiotomy

wound dehiscence. Infection was obvious cause of dehiscence in the majority (25 out

of 37) of women. The study concluded that the rate of episiotomy wound infection was

high in the study population52

.

EVALUATION OF EFFECTIVENESS OF SITZ BATH AND INFRARED

LAMP THERAPY ON EPISIOTOMY PAIN AND WOUND HEALING.

The present study shows that there was a considerable improvement of the

episiotomy pain and wound healing scores after administration of the sitz bath and

infrared lamp therapy and is statistically established as significant. In control group,

mean post pain and wound scores (1.3 & 6.9 respectively) are lower than that of the

mean pre test pain & wound scores (2.23 & 7.9 respectively). Similarly in

experimental group, mean post pain and wound scores (0.84 & 6.9respectively) is

lower than that of the mean pre test pain & wound scores (2.4 & 8.13 respectively).

This implies that sitz bath and infrared therapy was effective in reducing episiotomy

pain and wound healing. Similar results were also found in the studies reviewed.

72

The findings of the present study supported by a similar study conducted by

V. Dhanalakshmi in Coimbatore, India to assess the effectiveness of infrared therapy

and sitz bath. Two experimental group were selected in terms of infra red lamp

therapy and sitz bath, which influence the wound healing process and pain perception.

The results revealed that sitz bath and infrared lamp therapy and sitz bath found to be

effective in healing episiotomy and mothers underwent for infra red lamp therapy

experienced decreased pain intensity (t=2.82) and the results were statistically

significant43

.

ASSOCIATION BETWEEN DEMOGRAPHIC VARIABLES AND PRE TEST

PAIN & WOUND SCORES.

In this study when demographical variables were analyzed, there was no

significant association found at 0.05 level between pre-test pain & wound scores of

postnatal mothers and demographic variables in both control and experimental group. .

However, there was a significant association only between religion and the pre-test

pain scores in experimental group (x2=8.57 is more than the table value at 0.05 level of

significance).

The finding of the present study was similar to a study conducted by John

Esther on “Effectiveness of infrared therapy on healing episiotomy wound in postnatal

mothers” in which there was no association between healing of episiotomy wound

with selected demographic and obstetrical variables such as age, education, income,

obstetrical score, mode of delivery, number of vaginal examinations, haemoglobin,

mother’s weight and previous infection41

.

73

DISCUSSION ON TESTING OF THE HYPOTHESIS.

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

wound healing scores in sitz bath and infrared lamp therapy group.

The research hypothesis H1 stated in the study is accepted since there is significant

difference between the mean pre test and post test pain & wound healing scores in

control and experimental group at P<0.05 level after administration of sitz bath and

infrared lamp therapy administration respectively.

H2: There is a significant difference in the mean post test scores between sitz bath and

infrared lamp therapy group.

The investigator accepts the research hypothesis H2 as there is significant difference in

the mean post test pain scores between sitz bath and infra red lamp therapy group.

However, significant difference in the mean post test wound scores was not evident.

H3: There is a significant association between pain &wound healing scores with

selected demographic variables in sitz bath and infrared lamp therapy group.

The investigator accepts the research hypothesis H3 because there is significant

association between religions in experimental group with pre test pain scores.

74

SUMMARY

This chapter dealt with the discussion of results under various headings.

Demographical variables discussed in the beginning section followed by effectiveness

of sitz bath and infrared therapy and its association with demographic variables. The

result was discussed in terms of objectives and the hypothesis formulated.

75

6. CONCLUSION

This chapter presents the conclusion which has drawn based on the findings of

the study. It also include the implications for nursing practice, education,

administration and research

The pain and delayed healing of the episiotomy wound are the main problems

of postnatal mothers in the puerperium. The present study was conducted in order to

find the effectiveness of sitz bath versus infrared therapy in reducing episiotomy pain

and wound healing. Administration of sitz bath and infrared therapy were found to

be effective in reducing episiotomy pain , and promoting wound healing, the result

showed significant difference between the mean scores of pain and wound healing in

both control and experimental group before and after administration of sitz bath &

infrared therapy and was demonstrated using ‘t’ test analysis. And student ‘t’ test

showed that there was significant difference between post-test scores of pain in both

control and experimental group. The computed chi- square test showed that there was

no significant association between pre test pain scores and selected baseline

characteristic in both control and experimental group with an exemption of religion

which has shown significant association with pre test pain score only in experimental

group.

Implications in Nursing

The findings of the study have several implications for nursing education,

administration, practice and research.

76

Nursing education

Nursing education prepares the nurses to function as a good educator. The

nurse educators have the responsibility to update the knowledge of the nursing

personnel in order to meet the needs of postnatal mothers and solve their difficulties

related with episiotomy wound. The use of non-pharmacological measures like

infrared therapy can be incorporated in nursing education along with other

contemporary therapies. To equip nurses to provide holistic care to their clients, the

nursing curriculum should be covered with several types of non – pharmacological

measures such as infrared therapy for episiotomy pain and wound healing. Thus the

student nurses can be guided in developing the right attitude and skills required for

caring the patients with episiotomy wound.

Continuing education is the key component to update and improve the

knowledge of the individual. It has a vital role in the field of the nursing profession.

Nursing administration

There is an increasing need for quality and holistic care in today’s health care

system. The findings of this study can be utilized by nursing personnel while providing

care for the postnatal mothers. Nursing administrator should organize periodic

educational programme for nursing staff to improve their knowledge and skill. In

collaboration with education department, nursing administrator can arrange the

periodic in service education programme for the staff nurses regarding uses of infrared

therapy. The knowledge about infrared lamp therapy will help the nurses to provide

beneficial care to the postnatal mothers during puerperium.

77

Nursing practice

Confronting with episiotomy pain and delayed wound healing are the common

problems that interfere in the care of the baby and also in the self care during the

puerperium. The appropriate measures and proper management of episiotomy pain and

wound healing will help in reducing the sufferings during postnatal period. in the area

of clinical practice, in service education programme regarding infrared therapy can be

conducted to know the various upcoming benefits of infrared therapy for providing

care for the episiotomy wound , as it was found to be one of the effective measures in

reducing pain and improves wound healing with no side effects. Since it is a new

method nurses as well as postnatal mothers need to be introduced to this method of

treatment. Each hospital can make their own practice models for this type of treatment.

Nursing research

Episiotomy pain and delayed wound healing will extent the number of days of

hospital stays among postnatal mothers with normal vaginal delivery. Therefore there

is great need for adopting more measures for the management of episiotomy during the

puerperial period. Several researches on non – pharmacological therapies like heat

therapy, cold therapy, lavender oil application and self care on episiotomy wound will

help the nurses attain more knowledge and it will initiate them to provide more quality

care for the patients. Such knowledge generated through research will help in more

popular implementation of different type of therapy in this area. For the generalization

of infrared light application, further studies could be conducted in the hospital with

increased frequency for larger samples.

78

Limitation

1. The study was confined to only 60 postnatal mothers and limited to one hospital

2. Infrared therapy was limited to three days therapy for each patient.

3. The time duration for therapy was limited to 15 minutes in morning and evening.

Recommendation

1. A similar study can be conducted with increased frequency of administration of

infrared lamp therapy which may yield more reliable result.

2. A similar study can be conducted by selecting a larger sample on a long-term basis

3. The study can be conducted in different settings with similar facilities

4. A comparative study can be conducted with hot and cold therapy

5. A comparative study can be conducted between infrared therapy and other non

pharmacological measures

6. A comparative study can be conducted between infrared therapy and pharmacological

measures.

7. A comparative study can be conducted on the effectiveness of infrared therapy

between urban and rural area

8. A comparative study can be conducted between primiparous women and multiparous

women to assess the effectiveness of infrared therapy

9. A descriptive study can be conducted on the awareness of postnatal mothers about non

pharmacological methods of care of episiotomy

79

SUMMARY

The present chapter dealt with the findings of the study related to demographic

characteristics, effectiveness of sitz bath & infrared lamp therapy and includes the

major implications of the nursing service related to nursing education, nursing

practice, nursing administration and nursing research areas.

80

8. SUMMARY

This chapter presents the summary of the study. With the increasing needs of

the postnatal mothers having episiotomy, meeting the needs of the patients becomes a

major challenge in the current nursing practice. The main aim of the study was to

assess the effectiveness of infrared therapy on episiotomy pain and wound healing.

The main objectives of the study were:-

I. To assess the level of pain and wound healing status among postnatal mothers with

episiotomy.

II. To assess the effectiveness of sitz bath and infrared lamp therapy on episiotomy pain

and wound healing among postnatal mothers.

III. To compare the effectiveness between sitz bath and infrared lamp therapy on

episiotomy pain and wound healing among postnatal mothers.

IV. To determine an association between pain level & wound healing status with selected

demographic variables.

The study attempted to examine the following research hypothesis:-

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

wound healing scores in sitz bath and infrared lamp therapy group.

H2: There is a significant difference in the mean post test scores between sitz bath and

infrared lamp therapy group.

H3: There is a significant association between pain &wound healing scores with

selected demographic variables in sitz bath and infrared lamp therapy group.

81

The conceptual frame work utilized in this study was based on Ernestine

Wiedenbach’s helping art of clinical nursing theory, consist of three steps that is

central purpose, prescription and realities.

In this study various literatures were reviewed which includes, literatures

related episiotomy, effectiveness of sitz bath and effectiveness of infrared lamp

therapy.

The research design selected for the study was quasi experimental, pre-test and

post-test design with comparison group. The independent variable was infrared

therapy and dependent variables were episiotomy pain level and wound healing status

in pre-test and post-tests.

The target population was postnatal mothers. 60 postnatal mothers were

selected by purposive sampling technique.

The tool developed and used for the data collection was Verbal descriptive pain

scale and REEDA Scale. 9 experts validated the content validity of the tools and tool

was found to be reliable and feasible. The reliability of the tools were established by

Spearman’s Brown Prophecy formula where r=0.89 for Verbal descriptive pain scale

and r=0.96 for REEDA Scale.

Pilot study was conducted on 3/10/12 to 12/10/12 as a part of the major study,

tool proved to be comprehensible, feasible and acceptable. The permission was

obtained from authorities of hospitals and consent taken from study subjects.

82

Data collection procedure for main study began from 01/11/2012 to

30/11/2012. The investigator personally explained the need and assured them of the

confidentiality of their responses.

The pre-test was administered followed by interventions (sitz bath to control

group & infrared therapy to experimental group for 3 days for twice daily); post-test

was taken after 3 days of administering the interventions by using the same Verbal

descriptive pain scale and REEDA scale used in the pre-test.

The Data gathered were analyzed and interpreted according to objectives.

Descriptive statistics like mean, median and standard deviation, and inferential

statistics like paired ‘t’ test was included to test the hypothesis and Chi-square test was

included to test the association of pain scores with demographic and clinical variables

and the data obtained are presented in the graphical form.

Major findings of the study

In control group

Majority (66.67%) of the subjects belong to the age group of 18-23 years.

Most of the subjects were Hindus (66.67%).

Majority (73.33%) were educated till secondary/diploma education .

Majority (63.33%) of subjects were housewives.

Half of the subjects (50%) were belonged to joint family and remaining to nuclear and

extended family.

All most all subjects (96.67%) were non vegetarians.

Majority of subjects (80%) resided in urban area.

Most of subjects (63.33%) were primiparas.

All subjects (100%) had right mediolateral episiotomy.

83

In experimental group

Half (50%) of the subjects belong to the age group of 24-29 years.

Majority of subjects (70%) were Hindus.

Most of the subjects (83.33%) were educated till secondary/diploma education.

Majority of the subjects (70%) were housewives.

Half of the subjects (50%) were belonged to nuclear family and 40% to joint family,

and reaming 10% were from extended family.

Majority of subjects (93.33%) were from mixed diet grop.

Majority of subjects (60%) resided in urban area.

Majority of subjects (60%) were multiparas.

Most of the subjects (80%) had right mediolateral episiotomy.

The mean percentage of pre-test and post-test in control group was 74.33 and 43.33

respectively, whereas in experimental group it was 80and 29 respectively which

shows that the pain score of experimental group during post-test was lower when

compared with other pain scores.

There was a significant difference between pre test and post test pain score and wound

healing score in both control and experimental group at 0.05 level. This implies that

sitz bath and infrared therapy was effective in reducing episiotomy pain and wound

healing.

The unpaired t test values 2.62 (pain) and 0.19 (wound healing) shows that there is

significant difference only between post test pain scores, not between post test wound

scores. It means that infrared therapy more effective than sitz bath in episiotomy pain

reduction where as with regard to wound healing, both sitz bath and infra red therapy

have same effect.

84

The association between pre test pain &wound healing scores and demographic

variables were computed by using Chi- square test. There were no significant

association between age, religion, education, occupation, family, diet, place of living,

parity and type of episiotomy with pre test pain & wound healing scores in both

control and experimental group. However, there was significant association only

between religion and the post-test pain scores in experimental group.

The investigator accepts the research hypotheses stated in the study at 0.05 level of

significance.

85

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32. Jo Lafoy, Elizabeth A. Geden.Post episiotomy pain: warm versus cold sitz bath. J of

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Center, Onancock, VA., Health line Pregnancy Guide, 2006 Feb.

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

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the treatment of episiotomy. Journal of Clinical Laser Medicine & Surgery. February

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

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

44. Rzakulieva LM, Israfilbeili SG, Gasymova G. Application of magnet laser radiation to

stimulate healing of perineum injuries in the maternity patients.

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perineal discomfort Kanho Kakhoe Chi, 1991, Apr;21(1):27-40.

46. Bowel Rina. A study to compare the effect of cold pack versus infrared radiation on

episiotomy wounds in postnatal mothers in a selected hospital, Vellore. Unpublished

thesis, the tamil nadu Dr. MGR Medial university Chennai.

47. Varalakshmi K Y. A study to compare the effect of cold pack versus infrared radiation

on episiotomy wounds in postnatal mothers in a selected hospital, Hyderabad.

Unpublished thesis. The University of Andra Pradesh.

48. K Danno, N Mori, K Toda, T Kobayashi, A Utani. Near-infrared irradiation stimulates

cutaneous wound repair: laboratory experiments on possible

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49. Bogacheva ON, Samoĭlova KA, Zhevago NA, et al. Enhancement of fibroblast growth

promoting activity of human blood after its irradiation in vivo (transcutaneously) and

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50. De olivera SM, Miquilini EC. Frequency and criteria for the indication of episiotomy.

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51. Imarengiaye CO, Andet AB. Postpartum perineal pain among Nigerian women. West

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91

ANNEXURE A

COPY OF LETTER SEEKING PERMISSION TO CONDUCT THE STUDY

92

ANNEXURE B

COPY OF THE LETTER SEEKING EXPERT’S OPINION FOR THE

CONTENT VALIDITY OF THE TOOL

From,

Mr. Susen George

II Year M.Sc Nursing

Kempegowda College of Nursing

Bangalore-560004.

To,

Forwarded through,

The Principal,

Kempegowda College of Nursing

Bangalore-560004.

Respected Sir/Madam,

Sub: Requisition for expert opinion on content validity of the research tool.

I, Susen George, a post graduate student of Kempegowda College of Nursing,

Bangalore, as a partial fulfillment of the master degree in Medical-Surgical Nursing of

Rajiv Gandhi University of Medical science, Bangalore, have selected the below

mentioned topic for the dissertation.

Title of the project: “A comparative study to assess the effectiveness of sitz bath

versus infrared lamp therapy on episiotomy pain and wound healing among post natal

mothers at selected hospitals, Bangalore”.

93

Objectives:

v. To assess the level of pain and wound healing status among postnatal mothers with

episiotomy.

vi. To assess the effectiveness of sitz bath and infrared lamp therapy on episiotomy pain

and wound healing among postnatal mothers.

vii. To compare the effectiveness between sitz bath and infrared lamp therapy on

episiotomy pain and wound healing among postnatal mothers.

viii. To determine an association between pain level & wound healing status with selected

demographic variable

With regard to this I kindly request you to validate my tool for its appropriateness and

relevancy.

Here with I am enclosing a copy of

a) Numerical intensity pain scale for diabetic foot pain

b) Criteria rating scale/ check list

c) Content validity certificate.

I request you to kindly go through the content and give your expert and valuable

suggestion in the columns given and mark ( ) if you agree.

Your expert opinion and kind cooperation will be highly appreciated and

gratefully acknowledge.

Thanking you in anticipation,

Yours faithfully

(Ms. Susen George)

Place: Bangalore

Date: Signature of Principal

94

ANNEXURE C

CONTENT VALIDITY CERTIFICATE

This is to certify that the tool developed by Ms. Susen George, II Year M.Sc Nursing

student of Kempegowda College of Nursing, Bangalore (Affiliated to Rajiv Gandhi

University of health Science) is validated by the undersigned and can proceed to

conduct the main study for dissertation entitled as “A comparative study to assess the

effectiveness sitz bath versus infra red lamp therapy on episiotomy pain and

wound healing among postnatal mothers at selected hospital, Bangalore”.

Place:

Date: (Name and signature of the expert)

95

ANNEXURE D

CRITERIA RATING SCALE FOR EVALUATION

Respected Madam/Sir,

Kindly go through the content and place the tick mark ( ) against the

questionnaire in the following columns ranging from very relevant to not relevant.

When the question is found not relevant and need modification kindly give your

opinion in the remarks column. The tool is present in two parts.

Part I: Consists of 10 items related to demographic variable under the study.

Part II: a) Verbal descriptive pain scale

b) REEDA Scale.

Part I

Demographic data

Item Very

Relevant

Relevant

Need

modification

Not

Relevant Remarks

1

2

3

4

5

6

7

8

9

10

96

Part II

a) Verbal descriptive pain scale to assess episiotomy pain.

Item Very

Relevant

Relevant

Need

modification

Not

Relevant

Remarks

1

2

3

4

b ) REEDA Scale to assess episiotomy wound healing.

Item Very

Relevant

Relevant

Need

modification

Not

Relevant

Remarks

1

2

3

4

Suggestions if any:

Over all opinion of the validator:

Signature of the validator

Name and address of the validator

97

ANNEXURE E

LIST OF EXPERTS CONSULTED FOR CONTENT VALIDITY OF THE

TOOL

1. Mrs. Lalitha Haemorrhage

Professor, Dept. of OBG

Government college of nursing

Bangalore.

7. Mrs. Sabina Monica

Associate Professor, Dept. of OBG

HMH College of nusing,

Mysore

2. Mrs. Maria Preethi Miranda

HOD of OBG dept.

Krupanidhi college of nursing

Bangalore

8. Mrs. Shenbagalakshmi

Principal, HOD of OBG dept.

Kauvery College of Nurisng

Mysore

3. Mrs. Gouri Sai

Associate Professor, Dept. of OBG

Fortis College of Nursing

Bangalore.

9. Mrs. Bhavya

Associate professor, HOD of OBG

JSS College of nursing

Mysore.

4. Mrs. Sabitha Sibbla

Assistant Professor, Dept. of OBG

Fortis college of nursing

Bangalore

10. Mr. Gangaboraiah

Professor of Statistics

KIMS,

Bangalore.

5. Mrs. Swarna Latha Puerperium

Principal, HOD of OBG dept.

BMS hospital nursing college

Banglore

11. Mrs. Rajeshwari

Associate professor

Dept. of English, V.V. Puram College

of Arts and commerce,

Bangalore

6. Mrs. Tajnisha Bhanu

Professor, HOD of OBG dept

HMH college of nursing

Mysore.

98

ANNEXURE F

COPY OF CONSENT FORM

I am voluntarily willing to participate in the study conducted by Ms. Susen

George, II year M.Sc. Nursing (OBG) student of Kempegowda College of nursing

on “A comparative study to assess the effectiveness of sitz bath versus infrared

lamp therapy on episiotomy pain and wound healing among postnatal mothers at

selected hospital, Bangalore”. I will also co-operate with the researcher in providing

necessary information. I was explained that the information provided would be kept

confidential and used only for above mentioned study purpose.

Signature of the Investigator Signature of the participant

Date:

Place: Bangalore

99

ANNEXURE - G

TOOL USED FOR THE STUDY

The data collection tool has two parts

Part- I: Questionnaire consists of 10 items related to demographic variables under

study.

Part- II:

a) Verbal descriptive pain scale to assess the episiotomy pain level

b) REEDA Scale to assess the episiotomy wound healing.

PART – I

Demographic data

Instructions to the respondent:

Dear participant,

I Susen George, II year M. Sc Nursing student would request you to answer some

questions related to your background. So listen carefully to the questions and respond

as accurately as possible. I assure you that the provided information will be exclusively

utilized for the partial fulfillment of P.G. programme and the information will be kept

confidential.

Sample code

1. Age ( in years)……………………………………………………

2. Religion

a. Hindu ( )

b. Christian ( )

c. Muslim ( )

d. Any others specify..........................................................................

3. Educational status of parents………………………………………..

4. Occupational status………………………………………………….

100

5. Type of the family

a. Nuclear ( )

b. Joint ( )

c. Extended ( )

6. Dietary pattern

a. Vegetarian ( )

b. Mixed ( )

7. Place of living

a. Rural ( )

b. Urban ( )

8. Parity

a. Primi ( )

b. Multi ( )

c. Grand multi ( )

9. Type of episiotomy

a. Median ( )

b. Lateral ( )

c. Right mediao lateral ( )

d. Left medio lateral ( )

101

PART - II

a) Verbal descriptive pain scale (Jack Harich, 2002)

POINTS LEVEL OF PAIN DESCRIPTION

0

No pain

No pain. Feeling perfectly normal.

1 Mild pain

Does not interfere with most of the activities. Able

to adapt to pain psychologically and with

medication or comfort devices.

2 Moderate pain

Interferes with many activities. Requires lifestyle

changes but patient remains independent. Unable to

adapt pain.

3 Severe pain Unable to engage in normal activities. Patient is

disable and unable to function independently.

Verbal pain scales, as the name suggests, use words to describe pain. Words

such as no pain, mild pain, moderate pain, and severe pain are used to describe pain

levels. A score from 0 to 3 is assigned to each of those word pairs and is used to

measure the pain level.

No pain - 0

Mild pain -1

Moderate pain -2

Severe Pain -3

102

b) REEDA Scale ( Nancy Davidson, 1972)

POINT

S

REDNES

S

EDEM

A

ECCHYMOS

IS

DISCHARG

E

APPROXIMATI

ON

0 None None None None Closed

1

Within

0.25 cm

of

incision

bilaterall

y

<1 cm

from

incision

Within

0.25cm

bilaterally or

0.5 cm

unilaterally

serum Skin separation

3mm or more

2

Within

0.5 cm of

incision

bilaterall

y

1-2 cm

from

incision

0.25-1cm

bilaterally or

0.5-2cm

unilaterally

Sero-

sanguinous

Skin and

subcutaneous fat

separate

3

Beyond

0.5 cm of

incision

bilaterall

y

> 2 cm

from

incision

>1 cm

bilaterally or

>2 cm

unilaterally

Bloody

purulent

Skin

subcutaneous fat

and fascia

separate

REEDA is a scientific tool to assess the episiotomy wound healing.The

REEDA scale consist 5 major items. Each item will be given a minimum score of 0

and maximum score of 3. The REEDA score ranges from 0 to 15. As the score

increases, it will indicate higher rate of infection. If the score decreases, it shows the

evidence of healing process. The maximum score is 15.

No infection - 0

Grade I -1 to 5

Grade II - 6 to 10

Grade III -11 to 15