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, Bangalore560 004.

Place: Bangalore. Date: Feb 2013

Signature of the Candidate (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. Date: Feb 2013.

Signature of the Guide

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 , Associate Professor, HOD, Department of

Mrs. Kamala J, M.Sc.Nursing, Ph

Obstetrics and Gynaecological Nursing, Kempegowda College of Nursing, Bangalore-560 004.

Seal & Signature of the HOD

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

Seal & Signature of the Principal

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

Place: Bangalore. Date: Feb 2013.

Place: Bangalore. 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. Date: Feb 2013

Signature of the Candidate (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 cooperation 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 pr 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. Studentt 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. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

REEDA Scale H n1 n2 F RMLE LMLE SD P Df N FEP *S NS

Redness Edema Ecchymosis Discharge Approximation Scale Hypothesis Number of samples in control group Number of samples in experimental group Frequency Right mediolateral episiotomy Left mediolateral episiotomy Standard deviation Probability Degree of freedom Number of respondents Alpha Fishers Exact Probability Significant Not significant

TABLE OF CONTENTS

Sl. No. 1.

Particulars Introduction Background of the study Need for the study Objectives Statement of the problem Objectives Operational definition Hypothesis Conceptual framework Review of Literature Reviews related to episiotomy Reviews related to effectiveness of sitz bath Reviews related to effectiveness of infrared lamp therapy 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. Results

Page No. 1-8

2.

9-14

15-30 3.

4.

31-40

41-66 5. 6. 7. 67-73 Discussion 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. Bibliography

78-82

83-89 9. 10. 90-101 Annexure

LIST OF TABLES

Sl. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12 13 14 15 16 17 18

Title of the Table Distribution of Subjects by Age Distribution of Subjects by Religion Distribution of Subjects by Education Distribution of Subjects by Occupation Distribution of Subjects by Type of family Distribution of Subjects by Diet Distribution of Respondents by Place of living Distribution of Respondents by Parity Distribution of Respondents by Type of episiotomy Assessment of episiotomy pain level Comparison of pain scores among control and experimental group Pre test and post test pain scores in control group Pre test and post test pain scores in experimental group Comparison of post test wound scores in control and experimental group Association of pre test pain scores with selected demographic variables in control group Association of pre test pain scores with selected demographic variables in experimental group Assessment of episiotomy wound status Comparison of wound scores among control and experimental group

Page No. 44 45 46 47 48 49 50 51 52 53 53 54 55 56 57 58 59 60

19 20 21 22 23

Pre test and post test wound scores in control group Pre test and post test wound scores in experimental group Comparison of post test wound scores in control and experimental group Association of pre test wound scores with selected demographic variables in control group Association of pre test wound scores with selected demographic variables in experimental group

61 62 63 64 65

LIST OF FIGURES

Sl. No. 1 2 3 4 5 6 7 8 9 10. 11.

Title of the Figure Conceptual Framework based on Imogene Kings Goal Attainment theory. Schematic Representation of the Study Design. Distribution of Respondents by Age. Distribution of Respondents by Sex. Distribution of Respondents by Education. Distribution of Respondents by Occupation. Distribution of Respondents by Type of family Distribution of Respondents by Diet Distribution of Respondents by Place of living Distribution of Respondents by Parity Distribution of Respondents by Type of episiotomy.

Page No. 11 40 44 45 46 47 48 49 50 51 52

LIST OF ANNEXURE

ANNEXURE ANNEXURE NO. 1. INDEX Annexure A Annexure B 2. Annexure C Annexure D Annexure E 5. Annexure F Annexure -G

CONTENTS Copy of letter seeking permission to conduct the study Copy of the letter seeking experts opinion for the content validity of the tool Content validity certificate Criteria rating scale for evaluation List of experts consulted for content validity of the tool Copy of consent form Tool used for the study

PAGE NO. 91

92-93

3. 4.

94 95-96

97

6. 7.

98 99-102

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. Thats 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
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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

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

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 womens 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 20thcentury. It is the only surgical procedure in obstetrics is performed without the patients specific consent11.

Studies about the episiotomy rates around the world showed that this surgery ranged from 9.7%(Western Europe Sweden) to

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
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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 Womens 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 womens 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 Kegels exercise and perineal care2.

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

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 womens ability to care for their newborns, their ability for breast feeding and attending to their babys 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.

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.

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

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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. Its 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.

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The conceptual frame work of the present study is based on Ernestine Wiedenbachs 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 ones 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 nurses 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.

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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.

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Central purpose: To assess the effect of sitz bath versus infrared therapy on episiotomy pain and wound healing among postnatal mothers.

Ministering the needed help Identifying the need for help Validating the provided help

Assessment of episiotomy pain and wound healing status using verbal descriptive pain scale and REEDA scale.

Administration of sitz bath to control group and infrared lamp therapy to experimental group of post natal mothers for 15 minutes twice daily

Post intervention pain and wound healing assessment done after a period of 3 days, effectiveness of sitz bath and infrared therapy were measured.

Feed back

Negative outcome Increased pain and delay wound healing at episiotomy site.

Positive outcome Episiotomy pain reduction and improvement of wound healing.

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

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

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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.

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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

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sphincter damage in both vacuum extraction (OR 0.11, 95% CI 0.090.13) 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

18

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

19

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
20

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.

21

A study was conducted to examine the effect of aroma sitz bath therapy on postpartum mothers 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.

22

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
23

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

24

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

25

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
26

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

27

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

28

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

29

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 investigators outlook necessary for designing the conceptual framework, research design and construction of the tool of the study

30

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
31

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

32

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.

33

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.

34

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 Pearsons 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.

35

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 3rd September 2012 to 11th September2012 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.
36

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.

37

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.

38

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.

39

Research purpose: To assess the effectiveness of sitz bath versus infrared lamp therapy on episiotomy pain and wound healing among postnatal mothers with episiotomy.

Research approach: Comparative

Research design: Quasi experimental pre test post test design with a comparison group

Samples:60 post natal mothers (30 in control &30 in experimental group)

Target population: Postnatal mothers

Sampling technique: Purposive sampling technique

Accessible population: Postnatal mothers admitted KIMS, Bangalore.

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

FIGURE :2 SCHEMATIC REPRESENTATION OF STUDY DESIGN.

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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

41

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.

42

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.

43

Section I: Distribution of demographic and clinical characteristics of the subjects Table 1: Distribution of subjects by age Variables Control group n1= 30 Frequenc Percenta y ge (f) (%) Age in years a) 18- 23 b) 24- 29 c) 30-35 d) Above 35 Total 20 8 2 0 30 66.66 26.67 6.67 0 100 14 15 1 0 30 46.66 50.00 3.33 0 100 Experimental group n2=30 Frequenc Percenta y ge (f) (%)

Figure 3: Distribution of samples by age

66.67 50

70 60 Percentage (%) 50 40 30 20 10 0

46.67

Control group
Experimental group

26.67

6.67

3.33

18- 23yrs

24- 29yrs

30-35yrs

Above 35yrs

Age in years

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.

44

Table 2: Distribution of samples by religion

Variables

Control group n1= 30 Frequen cy (f)

Experimental group n2=30 Frequen cy (f) 21 6 3 0 30

Percenta ge (%) 66.67 26.67 6.66 0 100

Percenta ge (%) 70 20 10 0 100

Religion a) Hindu b) Muslim c) Christian d) Others Total 20 8 2 0 30

Figure 4: Distribution of samples by religion

70

70 60 Percentage (%) 50 40

66.67

Control group Experimental group

26.67 30 20 10 0 Hindu Muslim Religion Christian Others 6.66 0 0 20 10

Table 2 and figure 4 that majority of subjects in both control(66.67%) and experimental group(70%) were Hindus.

45

Table 3: Distribution of samples by education

Variables

Control group Frequency (f) n1= 30 Percentage (%) 0 16.66 73.33 10 100

Experimental group Frequency (f) 0 2 25 3 30 n2=30 Percentage (%) 0 6.66 83.33 10 100

a) b) c) d)

Education No formal Primary Secondary/Diploma Graduation and above Total

0 5 22 3 30

Figure 5: Distribution of samples by education

90 80 70 60 50 40 30 20 10 0

83.33 73.33

Control group Experimental group

Percentage (%)

16.67 0 0 6.67

10

10

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.

46

Table 4: Distribution of samples by occupation

Variables

Control group n1= 30 Frequen cy (f)

Experimental group n2=30 Frequen cy (f) 21 9 0 30

Percenta ge (%) 63.33 33.33 03.33 100

Percenta ge (%) 70 30 0 100

Occupation a) Housewife b) Private c) Government Total 19 10 1 30

Figure 6: Distribution of samples by occupation

70 70 60 Percentage (%) 50 40 30 20 10 0 Housewife Private Occupation Government 3.33 0 33.33 30 63.33

Control group
Experimental group

Table 4 and figure 6 depict that both in control and experimental group majority were housewives ie 63.33% and 70% respectively.

47

Table 5: Distribution of samples by type of family

Variables

Control group n1= 30 Frequen cy (f)

Experimental group n2=30 Frequen cy (f)

Percenta ge (%)

Percenta ge (%)

Type of family a) Nuclear b) Joint c) Extended Total 13 15 02 30 43.33 50 6.67 100 15 12 03 30 50 40 10 100

Figure 7: Distribution of subjects by type of family

50 50 45 40 35 30 25 20 15 10 5 0 43.33 40 Control group Experimental group 50

Percentage (%)

6.67

10

Nuclear

Joint
Type of family

Extended

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.

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Table 6: Distribution of subjects by diet

Variables

Control group n1= 30 Frequen cy (f)

Experimental group n2=30 Frequen cy (f)

Percenta ge (%)

Percenta ge (%)

Dietary pattern a) Vegetarian b) Mixed Total 1 29 30 03.33 96.67 100 2 28 30 06.67 93.33 100

Figure 8: Distribution of samples by diet

96.67 100 90 80 70 60 50 40 30 20 10 0 Mixed

93.33 Control group Experimental group

Percentage (%)

3.33

6.67

Vegetarian Type of 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.

49

Table 6: Distribution of samples by place of living

Variables

Control group n1= 30 Frequenc Percenta y ge (f) (%)

Experimental group n2=30 Frequenc Percenta y ge (f) (%)

Place of living a) Rural b) Urban Total 6 24 30 20 80 100 9 21 30 40 60 100

Figure 8: Distribution of samples by place of living

80 80 70 Percentage(%) 60 50 40 30 20 40 60 control group Experimental group

20
10 0 Urban Place of living Rural

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.

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Table 8: Distribution of subjects by parity

Variables

Control group n1= 30 Frequenc Percenta y ge (f) (%)

Experimental group n2=30 Frequenc Percenta y ge (f) (%)

Parity a) Primi b) Multi c) Grand multi Total 19 11 0 30 63.33 36.66 0.0 100 14 16 0 30 46.66 53.33 0.0 100

Figure 10: Distribution of subjects by parity

70 60

63.33 53.33 46.667 36.67 Control group Experimental group

Percentage (%)

50 40 30 20 10 0 Primi

0 Multi Parity

Grand multi

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

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Table 9: Distribution of samples by type of episiotomy

Variables

Control group n1= 30 Frequenc Percenta y ge (f) (%)

Experimental group n2=30 Frequenc Percenta y ge (f) (%) 0 0 28 2 30 0 0 80 20 100

Type of episiotomy a) Median b) Lateral c) RMLE d) LMLE Total 0 0 30 0 30 0 0 100 0 100

Figure11: Distribution of samples by type of episiotomy

100 100 90 80 70 60 50 40 30 20 10 0 80 Control group Experimental group

Percentage (%)

20 0 0 0 0 RMLE 0 LMLE

Median

Lateral

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).
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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 Severe Pain (3) Control group (n1= 30) Pre test Post test f % F % 12 40 0 0 53.33 6.67 0 12 15 3 40 50 10 Experimental group (n2=3 Pre test Post test F % F % 14 46.67 0 0 14 2 0 46.67 6.67 0 4 8 18 13.33 26.67 60

Moderate 16 pain(2) Mild pain(1) No Pain (0) 2 0

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 Mean Median Standard Deviation Range Mean Percentage(%) Control Group Pre test 2.23 2 0.61 2 74.33 Post test 1.3 1 0.65 2 43.33 Experimental Group Pre test 2.4 2 0.62 2 80 Post test 0.87 1 0.63 2 29

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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 control group

sitz bath on episiotomy pain reduction among

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 Pre test Post test Mean 2.3 1.3 SD 0.61 0.65 t value Inference

13.68

*S 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.

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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 Pre test Post test Mean 2.4 0.87 SD 0.62 0.63 t value Inference

14.69

*S 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.

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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 Control Experimental Mean 1.3 0.87 SD 0.65 0.63 t value Inference

2.62

*S

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). Studentt 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

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Section VI: Association between pre test pain scores and selected demographic and clinical variables a) Control group
Demographic variables Responses Overall knowledge Below median 18-23 Age (yrs) 24-29 >35 Hindu Religion Muslim Christian Primary Education Secondary Graduation House wife Occupation Private Nuclear Family Joint Extended Diet Vegetarian Mixed Rural Place of living Urban Parity Primi Multi 20 1 1 22 8 0.16NS 10 1 0 1 1 0 0 2 2 9 12 14 2 1 0.07NS 27 6 0.54NS 1 1 1.17NS 2 1 1 0 2 0 0 0 2 0 2 Above median 19 7 2 18 8 2 18 8 2 18 1.72NS 2 0.78NS 2 1.07NS 2 0.67NS 2 pre test Chisquare value df

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a) Experimental group
Demographic variables Responses Overall knowledge Below median Age (yrs) 18-23 24-29 >35 Hindu Religion Muslim Christian Primary Education Secondary Graduation Occupation House wife Private Family Nuclear Joint Extended Diet Vegetarian Mixed Place of living Rural Urban Parity Primi Multi Episiotomy RMLE LMLE 2 0 0 0 2 0 0 2 0 1 1 2 0 0 0 2 0 2 1 1 0 2 Above median 13 14 1 21 4 3 2 23 3 31 0.59NS 7 13 12 3 2 0.15NS 26 9 0.92NS 19 `13 0.10NS 15 2 0.15NS 26 1 1 1 1 2.14NS 2 2 0.43NS 2 8.57S 2 2.14NS 2 pre test Chisquare value Df

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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

Wound healing

No infection (0) Mild infection (1-5)

Control group(n1=30) Pre test Post test f % F % 0 0 0 0 0 0 100 0 7 23 0 23.33 76.67 0

Experimental group(n2=30) Pre test Post test F % F % 0 0 0 0 0 30 0 0 100 0 5 25 0 16.67 83.33 0

Moderate infection 30 (6-10) Severe Pain (11-15) 0

With regard to pre-test scores, all subjects (100%) had moderate wound infection in both control and experimental group.

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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) Pre test Mean Median Standard Deviation Range Mean Percentage (%) 7.97 8.00 1.43 4.00 53.13 Post test 6.90 7.00 1.53 6.00 46.00 Experimental Group(n2=30) Pre test 8.13 8.00 1.38 4.00 54.20 Post test 6.90 7.00 1.25 4.00 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.

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Table 17: Pre test and post test wound healing scores in control group Group Pre test Post test 6.86 Mean SD t value Inference

7.97

1.43 1.53 4.96 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 pairedt 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.

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Table 18: Pre test and post test wound healing scores in experimental group Group Pre test Post test Mean 8.13 6.93 SD 1.38 1.25 t value Inference

6.59

S 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.

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Table 19: Post test wound healing scores in control and experimental group Group Control Experimental Mean 5.13 5.07 SD 1.67 1.34 t value Inference

0.19

NS 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.

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Section XI: Association between pre test pain scores and selected demographic and clinical variables a) Control group
Demographic variables Responses Overall knowledge Below median Age (yrs) 18-23 24-29 >35 Hindu Religion Muslim Christian Primary Education Secondary Graduation Occupation House wife Private Government Family Nuclear Joint Extended Diet Vegetarian Mixed Place of living Rural Urban Parity Primi Multi 7 5 0 9 2 1 1 10 1 9 2 1 3 8 1 0 2 0 2 1 1 Above median 4 12 2 11 6 1 4 12 2 11 7 0 10 7 1 1 0.07NS 27 6 0.54NS 22 18 0.16NS 10 1 1 1 0.74NS 2 2.89NS 2 1.16NS 2 1.04NS 2 3.23NS 2 pre test Chisquare value df

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b) Experimental group
Demographic variables Responses Overall knowledge Below median Age (yrs) 18-23 24-29 >35 Hindu Religion Muslim Christian Primary Education Secondary Graduation Occupation House wife Private Family Nuclear Joint Extended Diet Vegetarian Mixed Place of living Rural Urban Parity Primi Multi Episiotomy LMLE RMLE 7 3 1 7 3 1 1 10 0 9 2 5 5 1 0 11 4 7 6 5 0 11 Above median 8 11 0 14 3 2 1 15 3 13 0.64NS 6 10 7 2 2 1.24NS 17 5 0.34NS 14 8 0.43NS 11 2 1.24NS 17 1 1 1 1 0.22NS 2 1 2.01NS 2 0.57NS 2 3.77NS 2 pre test Chisquare value df

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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.

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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.

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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% remaining 30% were private employees. were house wives, and

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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.

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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

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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.

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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, mothers weight and previous infection41.

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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.

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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.

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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.

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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 todays 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.

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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.
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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

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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.

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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.

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The conceptual frame work utilized in this study was based on Ernestine Wiedenbachs 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 Spearmans 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.

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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.

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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.

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 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.

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9. BIBLIOGRAPHY
1. Z Zainur. Postpartum morbidity - What we can do Med J Malaysia 2006 Dec 61(5) 2. Fraser D M, Cooper M.A. Myles text book for midwives. 14th ed: Philadelphia; Churchill Livingstone;2003.P .632 3. Noronha Judith. Effectiveness of self perineal care on Episiotomy wound healing. The Indian Journal of Nursing and Midwifery 2003 Sep; 6(1): 25-39 4. Thacker SB, Banta HD Benefits and risks of episiotomy; an interpretive review of the English language literature 1860 Obst Gynecol.Survey 1983: 38(6): 322-338. 5. Thorpe H, Bowes W, Brame R, et al :Selected use of : Effect on perineal trauma. Obstet Gynecol 79: 945 949,1992 6. Ana Carolina Sartorato Beleza, Cristine Homsi Jorge, Ferreira, Ligia de Sousa, Ana Mrcia Span Nakano. Measurement and characteristics of pain after episiotomy and its relationship with the activity limitations. Rev. bras. enferm. vol.65(2). 7. Robinson S, Thompson A. Midwives, research and childbirth. In: Sleep J. Perineal care: a series of five randomised controlled trials. London: Champman & Hall; 2007. p. 199-251. 8. Enkin M, Keirse MJNC, Neilson J, Crowther C, Duley L, Hodnett E, Hofmeyr J. A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. Oxford: Oxford University Press, 2000 9. Joyce Hasegwa, Lucila Coca Levenhal. Pharmacological and non pharmacological treatment for relief of perineal pain after vaginal delivery. Einstein. 2009; 7(2):194-20 10. Therapy for management of childbirth perineal tears. Available from:

URL:http://www.practicalpainmanagement.com Januvary 1, 2011

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11. John Martin Munro Kerr, Thomas F Baskett, Andrew A Calder, Sabaratnam Arul kumaran. Munro. Kerrs operative obstetrics, 11th ed. London. Elsevier Sounders; 2009. P 253 12. Graham, I.D, G. Carroli, C. Davies, and J.M. Medves, 2005, Episiotomy rates around the world: An update. Birth, 32: 219-22 13. Episiotomy rate in India: URL:http://jpubhealth.oxfordjournals.org/.Accessed2010 14. EpisiotomyrateinBangalore:URL:http://www.jabfmorg/cgi/content/full/18/1/18.2010 15. B.W.C. Sathiyasekaran, Gopal Palani, Ramesh Harihara Iyer, Shanthi Edward, Chithraa Devi Dharmappal et al. Popualtion based study of episiotomy. Sriramachandra journal of medicine. 2007 Nov 16. East CE, Sherburn M, Nagle C, Said J, Forster D. Perineal pain following childbirth: Prevalence, effects on postnatal recovery and analgesia usage. Midwifery. 2011 Jan; 17. Annamma Jacob, Rekha R, Jadhav Sonali Tarachand. Clinical nursing procedures: The arts of nursing practice. 1st ed: New delhi; Jaypee publications 2007.P.105-106. 18. Joyce Hasegawa, Lucila Coca Leventhal. Pharmacological and non pharmacological treatment for relief of pain after vaginal delivery. Einstein, 2009; (7): 194 200. 19. Denise F Polit, Bernadette P. Hungler. Nursing research. 6th ed. Philadelphia: Lippincott company; 1999.P.155-159 20. George B Julia B. Nursing theroies. 4th ed. Non walk: Appleton and Lange publishers; 1977.P. 179-191 21. HenriksenTB, BekKM, HedegaardM, SecherNJ.Episiotomy and perineal lesions spontaneous vaginal deliveries Br J Obstet Gynaecol. 1992 Dec; 99(12): 950-4 22. CarvalhoCC, SouzaAS, MoraesFilhoOB.Prevalence and factors associated with practice of episiotomy at a maternity school in Recife, Pernambuco, Brazil. Rev Assoc Med Bras. 2010 May-Jun;56(3):333-9 in

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23. Revicky

V, Nirmal

D, Mukhopadhyay

S, Morris

EP, Nieto

JJ.

Could

mediolateral episiotomy prevent obstetric anal sphincter injury? Eur J Obstet Gynecol Reprod Biol. 2010 Jun;150(2):142-6. 24. De Leeuw JW, De Wit C, Kuijken JP, Bruinse HW. Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery. BJOG. 2008 Jan;115(1):104-8. 25. Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev. 2009 Jan 21;(1). 26. Webb DA, Culhane J. Hospital variation in episiotomy use and the risk of perineal trauma during childbirth. Birth. 2002 Jun;29(2):132-6 27. Poen AC, Felt-Bersma RJ, Dekker GA, Devill W, Cuesta MA, Meuwissen SG. Third degree obstetric perineal tears: risk factors and the preventive role of mediolateral episiotomy. Br J Obstet Gynaecol. 1997 May;104(5):563-6 28. Ecker JL, Tan WM, Bansal RK, Bishop JT, Kilpatrick SJ. Is there a benefit to episiotomy at operative vaginal delivery? Observations over ten years in a stable population. Am J Obstet Gynecol. 1997 Feb;176(2):411-4 29. Cleary-Goldman J, Robinson JN. The role of episiotomy in current obstetric practice. Semin Perinatol. 2003 Feb;27(1):3-12. 30. Katayon Vakilian, Mahtab Atarha , Reza Bekhradi, Reza Chaman. Healing advantages of lavender essential oil during episiotomy recovery: A clinical trial. Complementary Therapies in Clinical Practice 2011;(17): 50-52 31. Ramler D, Roberts J. A comparison of cold and warm sitz baths for relief of

postpartum perineal pain. .Journal of Obstetrics Gynecol ogy and Neonatal Nurse. 1986 November-December. 15(6):471-4.

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32. Jo Lafoy, Elizabeth A. Geden.Post episiotomy pain: warm versus cold sitz bath. J of obstet gynecol neonat nsg 2006 Jan Feb: 19 (1): 13. 33. Hur MH, Han SH. Clinical trial of Aromotherapy on postpartum mothers perineal healing, Taechan Kanho Hakhoe Chi 2004 Feb; 34(1): 53-62. 34. Rakel D. Episiotomy discomforts relief using infrared light therapy. Nursing Times 2010 Mar;9(6):14-5. 35. Hill PD. Effects of heat and cold perineum after episiotomy laceration. Journal of heat and cold on the perineum after episiotomy. J Obstet Gynecol Neonatal Nurs. March April; 18(2) 124-9 36. Talar tejirian. An experimental study to assess the effectiveness of sitz bath department of obg surgery California publication 2005 June. 37. Oan Lingen, Department of Obstetrics and Gynecology, Onley Community Health Center, Onancock, VA., Health line Pregnancy Guide, 2006 Feb. 38. Anita Sali. Effect of sitz bath versus guggul dhupan on pain related to episiotomy in postnatal mothers. Journal of Nursing research Society of India 2007 Oct-Nov; No-2, Vol-1, 19-21. 39. Henton J, Jain A. Cochrane corner: water for wound cleansing. J Hand Surg Eur Vol. 2012 May;37(4):375-6. 40. Venkadalakshmi.V, Venkatesan Latha, Perdita M.Helen. Effectiveness of infrared therapy upon Episiotomy pain and Wound healing in postnatal mothers. The Official Journal of Trained Nurses Association of India 2009Jul-Sep;4(3):19 41. John Esther, R Sheeba, M. Vimiji, S. Seena. Effectiveness of infrared radiations in healing of episiotomy wound in postnatal mothers. Nightingale Nursing Times 2009; Feb; 4(11): 60-1,67. Nightingale

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42. Jaroslava Kymplova, Leos Navratil, and Jirl Knizek. Contribution of phototherapy to the treatment of episiotomy. Journal of Clinical Laser Medicine & Surgery. February 2003, 21(1): 35-39. 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.

GeorgiaMedNews. 2006Sep;(138):71-3. 45. Nam HK, Park YS. A study on comparison of ice bag and heat lamp for the relief of perineal discomfort Kanho Kakhoe Chi, 1991, Apr;21(1):27-40. 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

mechanisms.Photodermatol PhotoimmunolPhotomed. 2001 Dec;17(6) 49. Bogacheva ON, Samolova KA, Zhevago NA, et al. Enhancement of fibroblast growth promoting activity of human blood after its irradiation in vivo (transcutaneously) and in vitro with visible and infrared polarized light. Tsitologiia 2004; 46(2):159-71. 50. De olivera SM, Miquilini EC. Frequency and criteria for the indication of episiotomy. Rev Esc Enferm USP 2005 Sep; 39(3): 288-95

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51. Imarengiaye CO, Andet AB. Postpartum perineal pain among Nigerian women. West Afr J Med. 2008 Jul;27(3):148 52. UygurD, YesildaglarN, KisS, SipahiT.Earlyrepairof episiotomy dehiscence. AustN Z J Obstet Gynaecol. 2004 Jun;44(3):24

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ANNEXURE A COPY OF LETTER SEEKING PERMISSION TO CONDUCT THE STUDY

91

ANNEXURE B COPY OF THE LETTER SEEKING EXPERTS 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.

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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

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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)

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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 1 2 3 4 5 6 7 8 9 10 Very Relevant Relevant Need modification Not Relevant Remarks

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Part II a) Verbal descriptive pain scale to assess episiotomy pain. Item 1 2 3 4 Very Relevant Relevant Need modification Not Relevant Remarks

b ) REEDA Scale to assess episiotomy wound healing. Item 1 2 3 4 Very Relevant Relevant Need modification Not Relevant Remarks

Suggestions if any:

Over all opinion of the validator:

Signature of the validator

Name and address of the validator

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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.

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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

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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. a. b. c. d. Religion Hindu ( Christian ( Muslim ( Any others specify..........................................................................

) ) )

3. Educational status of parents.. 4. Occupational status.

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5. a. b. c.

Type of the family Nuclear Joint Extended

( ( (

) ) )

6. Dietary pattern a. Vegetarian b. Mixed 7. Place of living a. Rural b. Urban 8. a. b. c. 9. a. b. c. d. Parity Primi Multi Grand multi Type of episiotomy Median Lateral Right mediao lateral Left medio lateral

( (

) )

( (

) )

( ( (

) ) )

( ( ( (

) ) ) )

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PART - II a) Verbal descriptive pain scale (Jack Harich, 2002)

POINTS

LEVEL OF PAIN

DESCRIPTION

No pain

No pain. Feeling perfectly normal. Does not interfere with most of the activities. Able

Mild pain

to adapt to pain

psychologically and with

medication or comfort devices. Interferes with many activities. Requires lifestyle 2 Moderate pain 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 Mild pain Moderate pain Severe Pain -0 -1 -2 -3

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b) REEDA Scale ( Nancy Davidson, 1972) POINT S 0 REDNES S None Within 0.25 cm of incision bilaterall y Within 0.5 cm of incision bilaterall y Beyond 0.5 cm of incision bilaterall y EDEM A None ECCHYMOS IS None DISCHARG APPROXIMATI E ON None Closed

Within <1 cm 0.25cm from bilaterally or serum incision 0.5 cm unilaterally 0.25-1cm 1-2 cm bilaterally or Serofrom 0.5-2cm sanguinous incision unilaterally >1 cm > 2 cm bilaterally or Bloody from >2 cm purulent incision unilaterally

Skin separation 3mm or more

Skin and subcutaneous fat separate 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 Grade II Grade III -1 to 5 - 6 to 10 -11 to 15

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