A comparison of cold and warm sitz baths for relief of postpartum perineal pain

Management of postpartum perineal wound complications

PURPOSE OF REVIEW

Perineal wound complications occur in up to 25% of postpartum patients. Wound complications are most common after obstetric anal sphincter injuries (OASIS) but can occur after any laceration. It is imperative that any provider caring for postpartum patients understand the best evidence-based practices to recognize and manage these complications. We present a review of the available literature on the management of postpartum perineal wound complications.

RECENT FINDINGS

There is a paucity of new publications on the management of postpartum perineal wound complications, despite an increased emphasis on postpartum recovery in women's health. The role of topical estrogen in healing of perineal wounds was investigated in a pilot study, demonstrating that granulation tissue does express estrogen receptors, and the use of estrogen increases cell proliferation. Progression of perineal wound healing by secondary intention was evaluated in an observational study. Wound healing was delayed in 30% of women, with the initial wound area, perimeter, bacterial colonization, and OASIS being associated with delayed healing.

SUMMARY

Evidence based practices on timing of follow-up, addressing wound care and analgesia, administrating antibiotics, timing secondary repair, and surgical technique all play a role in optimizing recovery and reducing morbidity in patients with postpartum perineal wound complications.

Clinical effects of Kneipp hydrotherapy: a systematic review of randomised controlled trials

OBJECTIVE

Hydrotherapy is a traditional prevention and treatment strategy. This study's aim is to systematically review all available randomised controlled trials (RCTs) investigating clinical effects of hydrotherapy according to Kneipp which is characterised by cold water applications.

METHODS

RCTs on disease therapy and prevention with Kneipp hydrotherapy were included. Study participants were patients and healthy volunteers of all age groups. MEDLINE (via PubMed), Scopus, Central, CAMbase, and opengrey.eu were systematically searched through April 2021 without language restrictions and updated by searching PubMed until April 6th 2023. Risk of bias was assessed using the Cochrane tool version 1.ResultsTwenty RCTs (N=4247) were included. Due to high heterogeneity of the RCTs, no meta-analysis was performed. Risk of bias was rated as unclear in most of the domains. Of 132 comparisons, 46 showed significant positive effects in favour of hydrotherapy on chronic venous insufficiency, menopausal symptoms, fever, cognition, emotional function and sickness absenteeism. However, 81 comparisons showed no differences between groups and 5 were in favour of the respective control group. Only half of the studies reported safety issues.

CONCLUSION

Although RCTs on Kneipp hydrotherapy seem to show positive effects in some conditions and outcomes, it remains difficult to ascertain treatment effects due to the high risk of bias and heterogeneity of most of the considered studies. Further high-quality RCTs on Kneipp hydrotherapy are urgently warranted.

PROSPERO REGISTRATION NUMBER

CRD42021237611.

Effectiveness of Cold Pack Application on Reduction of Pain Perception during Active Phase of Labour among Parturient Mothers

Pregnancy is the period of gestation from the fertilization of an egg, through development of a fetus, and ending at birth of the baby. A woman’s desire for, and cold pack of, pain relief during labour are influenced by many factors, including her expectations, the complexity of her labour and the severity of her pain. Objectives: To assess the pre-test and post-test level of pain perception during active phase of labour among parturient mothers both in experimental and control group, effectiveness of cold pack on reduction of pain perception during active phase of labour among parturient mothers in the experimental group, association between the level of pain perception during active phase of labour among parturient mothers with their selected demographic variables. Methods: An experimental research design was adopted for the study with 60 samples who met the inclusion criteria were selected by purposive sampling technique. Semi structured interview method was used to collect the demographical and obstetrical data, Wong Baker Scale tool was used to measure the level of pain. Result: The study shows that there is a significant difference between the posttest levels of pain perception during active phase of labour among parturient mothers in the experimental group than in the control group. Conclusion: There was a significant association in the post test level of pain perception among parturient mother in the experimental group than in the control group at p<0.01 and p<0.001 level. Thus the cold pack application is an effective non-pharmacological method which can be used to manage the level of pain perception during labour.

Local cooling for relieving pain from perineal trauma sustained during childbirth

BACKGROUND

Perineal trauma is common during childbirth and may be painful. Contemporary maternity practice includes offering women numerous forms of pain relief, including the local application of cooling treatments. This Cochrane Review is an update of a review last updated in 2012.

OBJECTIVES

To evaluate the effectiveness of localised cooling treatments compared with no treatment, placebo, or other cooling treatments applied to the perineum for pain relief following perineal trauma sustained during childbirth.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (7 October 2019) and reference lists of retrieved studies.

SELECTION CRITERIA

Published and unpublished randomised and quasi-randomised trials (RCTs) that compared a localised cooling treatment applied to the perineum with no treatment, placebo, or another cooling treatment applied to relieve pain related to perineal trauma sustained during childbirth.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of included studies. Data were double checked for accuracy. The certainty of the evidence was assessed using the GRADE approach.

MAIN RESULTS

We included 10 RCTs that enrolled 1233 women randomised to the use of one cooling treatment (ice, cold gel pad, cooling plus compression, cooling plus compression plus (being) horizontal) compared with another cooling treatment, no treatment, or placebo (water pack, compression). The included trials were at low or uncertain risk of bias overall, with the exception that the inability to blind participants and personnel to group allocation meant that we rated all trials at unclear or high risk for this domain. We undertook a number of comparisons to evaluate the different treatments. Cooling treatment (ice pack or cold gel pad) versus no treatment There was limited very low-certainty evidence that cooling treatment may reduce women's self-reported perineal pain within four to six hours (mean difference (MD) -4.46, 95% confidence interval (CI) -5.07 to -3.85 on a 10-point scale; 1 study, 100 participants) or between 24 and 48 hours of giving birth (risk ratio (RR) 0.73, 95% CI 0.57 to 0.94; 1 study, 316 participants). The evidence is very uncertain about the various measures of wound healing, for example, wound edges gaping when inspected five days after giving birth (RR 2.56, 95% CI 0.58 to 11.33; 1 study, 315 participants). Women generally rated their satisfaction with perineal care similarly following cooling or no treatment. The potential exception was that there may be a trivially lower mean difference of -0.1 on a five-point scale of psychospiritual comfort with cooling treatment, that is unlikely to be of clinical importance. Cooling treatment (cold gel pad) + compression versus placebo (gel pad + compression) There was limited low-certainty evidence that there may be a trivial MD of -0.43 in pain on a 10-point scale at 24 to 48 hours after giving birth (95% CI -0.73 to -0.13; 1 study, 250 participants) when a cooling treatment plus compression from a well-secured perineal pad was compared with the placebo. Levels of perineal oedema may be similar for the two groups (low-certainty evidence) and perineal bruising was not observed. There was low-certainty evidence that women may rate their satisfaction as being slightly higher with perineal care in the cold gel pad and compression group (MD 0.88, 95% CI 0.38 to 1.38; 1 trial, 250 participants). Cooling treatment (ice pack) versus placebo (water pack) One study reported that no women reported pain after using an ice pack or a water pack when asked within 24 hours of giving birth. There was low-certainty evidence that oedema may be similar for the two groups when assessed at four to six hours (RR 0.96, 95% CI 0.50 to 1.86; 1 study, 63 participants) or within 24 hours of giving birth (RR 0.36, 95% CI 0.08 to 1.59). No women were observed to have perineal bruising at these times. The trialists reported that no women in either group experienced any adverse effects on wound healing. There was very low-certainty evidence that women may rate their views and experiences with the treatments similarly (for example, satisfied with treatment: RR 0.91, 95% CI 0.77 to 1.08; 63 participants). Cooling treatment (ice pack) versus cooling treatment (cold gel pad) The evidence is very uncertain about the effects of using ice packs or cold gel pads on women's self-rated perineal pain, on perineal bruising, or on perineal oedema at four to six hours or within 24 hours of giving birth. Perineal oedema may persist 24 to 48 hours after giving birth in women using the ice packs (RR 1.69, 95% CI 1.03 to 2.7; 2 trials, 264 participants; very low-certainty). The risk of gaping wound edges five days after giving birth may be decreased in women who had used ice packs (RR 0.22, 95% CI 0.05 to 1.01; 215 participants; very low-certainty). However, this did not appear to persist to day 10 (RR 3.06, 95% CI 0.63 to 14.81; 214 participants). Women may rate their opinion of treatment less favourably following the use of ice packs five days after giving birth (RR 0.33, 95% CI 0.17 to 0.68; 1 study, 49 participants) and when assessed on day 10 (RR 0.82, 95% CI 0.73 to 0.92; 1 study, 208 participants), both very low-certainty.

AUTHORS' CONCLUSIONS

There is limited very low-certainty evidence that may support the use of cooling treatments, in the form or ice packs or cold gel pads, for the relief of perineal pain in the first two days following childbirth. It is likely that concurrent use of several treatments is required to adequately address this issue, including prescription and non-prescription analgesia. Studies included in this review involved the use of cooling treatments for 10 to 20 minutes, and although no adverse effects were noted, these findings came from studies of relatively small numbers of women, or were not reported at all. The continued lack of high-certainty evidence of the benefits of cooling treatments should be viewed with caution, and further well-designed trials should be conducted.

Xiaozhi decoction reduced posthemorrhoidectomy pain and analgesic medication consumption: a prospective study

Objective

The aim of this study was to investigate the effect of Xiaozhi decoction (XZD) on posthemorrhoidectomy pain and analgesic medication consumption.

Methods

From May 2013 to March 2015, 315 patients who underwent open hemorrhoidectomy in our hospital were enrolled in this study, of whom, 160 patients were randomly assigned to accept sitz bath with warm water after hemorrhoidectomy (control group) and 155 patients were randomly assigned to accept sitz bath with XZD (XZD group) after hemorrhoidectomy. Postoperative pain at 12 hours after surgery and on postoperative days (PODs) 1, 2, 7, 14 and 28 was evaluated by Visual Analog Scale (VAS). Pain on defecation on PODs 1, 2, 7, 14 and 28 was also recorded using the VAS. The consumption of analgesics was also analyzed.

Results

No significant difference was found in baseline characteristics between the two groups. Postoperative pain score of the XZD group was significantly lower on POD 2 (6.04±1.11 vs 6.33±1.14, P=0.0229), POD 7 (3.35±0.75 vs 4.22±0.87, P=0.0000) and POD 14 (2.87±0.64 vs 3.64±0.77, P=0.0000) than that of the control group. Similarly, patients in the XZD group experienced significantly less pain on defecation on POD 2 (5.02±1.34 vs 5.43±1.56, P=0.0130), POD 7 (3.08±1.17 vs 3.52±1.29, P=0.0017) and POD 14 (2.31±0.85 vs 2.68±0.99, P=0.0004). Patients in the XZD group consumed significantly less analgesic medication on POD 2 (P=0.0136), POD 7 (P=0.0074) and POD 14 (P=0.0046) than the control group.

Conclusion

XZD could effectively relieve postoperative pain and reduce analgesic medication consumption after hemorrhoidectomy.

Best Practices in Management of Postpartum Pain

Pain has been documented as a major concern for women in the postpartum period. Management of postpartum pain, however, is a relatively neglected area of clinical research. As a result, evidence to support interventions to alleviate the discomforts associated with childbirth is sparse. This paucity of research on postpartum pain management is particularly surprising given that in the United States alone nearly 4 million women give birth each year. Inadequate pain relief in the hours to months following childbirth can interfere with maternal-newborn bonding and feeding and, by impeding mobility, can increase the risk of postpartum complications. In addition, pain that is not adequately managed may increase the risk of chronic pain that lasts beyond the postpartum period. In this article, the more common causes of pain following childbirth are reviewed and recommendations for pain management based on available evidence are outlined. Considerations for pain management in lactating women and for hospital discharge are discussed.

PERINEAL PAIN RELIEF THERAPIES AFTER POSTPARTUM

ABSTRACT Objective: identifying therapies for treating perineal pain after vaginal birth and to verify indication, technique and duration of local cooling. Method: an exploratory study (survey) conducted in 32 public maternity hospitals in the city of São Paulo (Brazil). A nurse or midwife who provided direct care to the woman was interviewed in each maternity ward. We investigated: institutional characterization, professional qualification, pain relief method, criterion for administration of therapies, indication, contraindication, method, local cooling technique and interval. A descriptive analysis was also carried out. Results: pharmacological and non-pharmacological methods were used for perineal pain relief, despite the use of non-pharmacological therapies not having protocols in these institutions. Among the pharmacological-based methods, analgesics and anti-inflammatories were the most common. Local cooling was the most used non-pharmacological method, and its main indication was perineal edema. Application time and local cooling interval ranged from 10-30 min and 3-8 h, respectively. Ice cubes in latex gloves were the main cooling technique. Conclusion: drug therapies predominated for control of perineal pain. Considering the advantages of non-pharmacological therapies, it is necessary to develop protocols to ensure their safe and effective use in maternity care.

The Effect of Early Warm Plastic Bag Application on Postoperative Pain after Hemorrhoidectomy: A Prospective Randomized Controlled Trial

Hemorrhoidectomy is used for the surgical treatment of high-grade hemorrhoids. The most prominent complaint after hemorrhoidectomy is pain. Postoperative pain management is still a big problem after surgery in patients with hemorrhoidectomy. The aim of the study was to assess the effect of early application of warm bag on postoperative pain after hemorrhoidectomy. All patients were randomly divided into warm plastic bag and control groups by using sealed envelopes, which were prepared preoperatively. After standard spinal anesthesia, all patients underwent standard Milligan-Morgan hemorrhoidectomy using Ligasure™. Although the study group received the warm bag application, the control group did not receive such a treatment. Two separate visual analog scale (VAS) measurements were performed for postoperative pain assessments on postoperative days, one during the resting state and the other one during the straining phase after the onset of peristaltic bowel movement. Postoperative VAS scores were significantly lower among the warm plastic bag group as compared with the control group on Days 1 and 3 for the resting state and on Day 3 for defecation. Additionally, a significant difference existed between the two groups in terms of the need for additional anesthesia. Local thermal application appears to be a safe and effective method for pain relief after hemorrhoidectomy.

Scientific evidence-based effects of hydrotherapy on various systems of the body

The use of water for various treatments (hydrotherapy) is probably as old as mankind. Hydrotherapy is one of the basic methods of treatment widely used in the system of natural medicine, which is also called as water therapy, aquatic therapy, pool therapy, and balneotherapy. Use of water in various forms and in various temperatures can produce different effects on different system of the body. Many studies/reviews reported the effects of hydrotherapy only on very few systems and there is lack of studies/reviews in reporting the evidence-based effects of hydrotherapy on various systems. We performed PubMed and PubMed central search to review relevant articles in English literature based on "effects of hydrotherapy/balneotherapy" on various systems of the body. Based on the available literature this review suggests that the hydrotherapy has a scientific evidence-based effect on various systems of the body.

The influence of cold pack on labour pain relief and birth outcomes: a randomised controlled trial

AIMS AND OBJECTIVES

(1) To evaluate the influence of local cold on severity of labour pain and (2) to identify the effect of local cold on maternal and neonatal outcomes.

BACKGROUND

Fear of labour pain results in an increase in pain and duration of labour, maternal discontent and demand for caesarean section. Regarding maternal and foetal complications of analgesic medications, the attention to application of nonpharmacological methods including cold therapy is increased.

DESIGN

Randomised controlled trial.

METHODS

Sixty-four pregnant women, at initiation of active phase of labour, were allocated randomly to cold therapy and control groups (n = 64). Null parity, term pregnancy, presence of single foetus, cephalic presentation and completing informed consent were considered as inclusion criteria. Administration of analgesic and anaesthesia, foetal distress, skin lesions in regions of cold therapy and high-risk pregnancy provided exclusion criteria. Cold pack was applied over abdomen and back, for 10 minutes every 30 minutes during first phase of labour. Additionally, cold pack was placed over perineum, for 5 minutes every 15 minutes during second phase. Pain severity was assessed based on the visual analogue scale.

RESULTS

The two groups were not significantly different considering demographic data, gestational age, foetal weight, rupture of membranes and primary severity of pain. Degree of pain was lower in cold therapy group during all parts of active phase and second stage. Duration of all phases was shorter in cold therapy group in all phases. Foetal heart rate, perineal laceration, type of birth, application of oxytocin and APGAR score were not significantly different between two groups.

CONCLUSION

Labour pain is probably reduced based on gate theory using cold. Pain control by cold maybe improves labour progression without affecting mother and foetus adversely.

RELEVANCE TO CLINICAL PRACTICE

Local cold therapy could be included in labour pain management.

Local cooling for relieving pain from perineal trauma sustained during childbirth

BACKGROUND

Perineal trauma is common during childbirth and may be painful. Contemporary maternity practice includes offering women numerous forms of pain relief, including the local application of cooling treatments.

OBJECTIVES

To evaluate the effectiveness and side effects of localised cooling treatments compared with no treatment, other forms of cooling treatments and non-cooling treatments.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (10 January 2012), CINAHL (1982 to 10 January 2012), the Australian New Zealand Clinical Trials Register (10 January 2012) and contacted experts in the field.

SELECTION CRITERIA

Published and unpublished randomised and quasi-randomised trials (RCTs) that compared localised cooling treatment applied to the perineum with no treatment or other treatments applied to relieve pain related to perineal trauma sustained during childbirth.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trials for inclusion, assessed trial quality and extracted data. A sub-set of data were double checked for accuracy. Analyses were performed on an intention-to-treat basis where data allowed. We sought additional information from the authors of three trials.

MAIN RESULTS

Ten published RCTs were included (involving 1825 women). Comparisons were local cooling treatments (ice packs, cold gel pads (with or without compression) or cold/iced baths) with no treatment, gel pads with compression, hamamelis water (witch hazel), pulsed electromagnetic energy (PET), hydrocortisone/pramoxine foam (Epifoam), oral paracetamol or warm baths. Ice packs provided improved pain relief 24 to 72 hours after birth compared with no treatment (risk ratio (RR) 0.61; 95% confidence interval (CI) 0.41 to 0.91; one study, n = 208). Women preferred the utility of the gel pads compared with ice packs or no treatment (RR 0.82; 95% CI 0.73, 0.92). Differences detected in a composite of perineal oedema and bruising and overall wound healing were noted in one small study, favouring cold gel pads (n = 37) over ice (n = 35, mean difference (MD) 0.63 on a scale of 0 to 15; 95% CI 0.20 to 1.06) or no treatment (n = 39, MD -2.10; 95% CI -3.80 to -0.40) three to 14 days after giving birth. Women reported more pain (RR 5.60; 95% CI 2.35 to 13.33; one study, 100 women) and used more additional analgesia (RR 4.00; 95% CI 1.44 to 11.13; one study, 100 women) following the application of ice packs compared with PET.

AUTHORS' CONCLUSIONS

There is only limited evidence to support the effectiveness of local cooling treatments (ice packs, cold gel pads, cold/iced baths) applied to the perineum following childbirth to relieve pain.

A qualitative study exploring women's personal experiences of their perineum after childbirth: expectations, reality and returning to normality

OBJECTIVE

to explore the feelings, perceptions and experiences of women in relation to their perineum following childbirth in the early postnatal period.

DESIGN

a qualitative study using grounded theory. Data were collected using diaries and interviews and analysed using constant comparative method.

SETTING

hospital and community setting in the South of England.

PARTICIPANTS

women (n=11) aged 20-42 years who had a vaginal birth.

FINDINGS

one core category, 'Striving for normality' and five major categories emerged: (1) 'preparing for the unknown', (2) 'experiencing the unexpected', (3) 'adjusting to reality', (4) 'getting back to normal' and (5) 'recovery of self'. 'Striving for normality' was where women wanted to be able to do normal things and feel like their normal selves soon after the birth of their baby. Much of what the women described doing during the early postnatal period was related to achieving this goal.

KEY CONCLUSIONS

the initial impact of childbirth on the perineum and surrounding area meant that in the first few postnatal days women largely concentrated on managing the effects of this. The impact however, went beyond the immediacy of coping with bodily functions extending into other daily activities in terms of managing and completing them. Examples of daily living activities in this context include bathing, eating, walking as well as completing household chores. Returning to normal following childbirth is significant for women and successfully achieving daily living activities is part of this process. However, women in this study seemed unprepared for the reality of this experience.

IMPLICATIONS FOR PRACTICE

women may be poorly prepared for the impact that perineal pain and discomfort can have on their lives especially related to successfully completing daily living activities in the early postnatal period. Consideration should be given to finding different ways of communicating the impact to women such as in the early postnatal period, rather than during pregnancy. The underpinning philosophy of care for the postnatal period should encapsulate a holistic approach, where physical symptoms of perineal pain and discomfort experienced by women are not tackled in isolation from any psychosocial impact this may also have.

The effectiveness of sitz bath in managing adult patients with anorectal disorders: A systematic review

BACKGROUND

Sitz bath is commonly prescribed for anorectal disorders in conjunction with dietary and pharmacological therapies. However, the effectiveness of sitz bath for anorectal disorders is not certain and there has been no previous examination of the evidence using a systematic approach.

OBJECTIVE

The objective of this review was to critically analyse and systematically review the evidence to determine the effectiveness of sitz bath in managing adult patients with anorectal disorders.

INCLUSION CRITERIA

Types of participants The participants of interest included adults over 18 years of age with diagnosis of anorectal disorders with or without surgical interventions. The participants who underwent episiotomy were excluded from the review.Types of interventions Intervention of interest was sitz bath with or without the combination of pharmacological and dietary therapies.Types of outcome measures The outcomes of interest included overall intensity of pain; post-operative pain score; post-defecation pain score; acceleration of fissure/wound healing; patients' satisfaction level and presence of complications.Types of studies The review considered only randomised controlled trials (RCTs) and quasi-RCTs.

SEARCH STRATEGY

Initially, mesh terms from PubMed were established and were used to search in MEDLINE and CINAHL for analysis of the text words contained in the title and abstract, and the text terms used to describe the article. A second search using all the identified keywords and the search terms were utilised across all accessible and relevant databases from Year 1990 to November 2009 in English language only. Thirdly, the relevant lists of all identified articles were searched for additional studies.

METHODOLOGICAL QUALITY

Selected articles were appraised by 2 reviewers independently for methodological validity using the standardised critical appraisal instruments from Joanna Briggs Institute Systems Meta Analysis of Statistical Assessment and Review Instrument (JBI-MAStARI).

DATA COLLECTION/EXTRACTION

Data were extracted from the articles included in the review using standardised data extraction tools from the JBI-MAStARI.

DATA SYNTHESIS

The findings were presented in narrative form as statistical pooling was not possible due to clinical heterogeneity.

RESULTS

A total of 4 RCTs were included in the review. The use of sitz bath had no significant impact in reducing overall intensity of pain and post operative pain. Conflicting findings for post defecation pain were reported. It had no impact in accelerating fissure or wound healing. However, patients were satisfied using sitz bath and no severe complications were reported.

CONCLUSION

There was no strong evidence to support the use of sitz bath for pain relief, and accelerate fissure or wound healing among adult patients with anorectal disorders, however no complications were reported.

IMPLICATIONS FOR PRACTICE

The benefit of sitz bath is limited to the patients' satisfaction based on the current evidence. Use of water spray as alternative method to sitz bath could be considered for future research.

IMPLICATIONS FOR RESEARCH

More rigorous research methodology and standardisation tool for outcome measurement are needed for future investigations.

Comparison of clinical effects between warm water spray and sitz bath in post-hemorrhoidectomy period

BACKGROUND

Warm water sitz bath is advised for a variety of anorectal disorders. However, preparation of the sitz bath is sometimes difficult for patients. As an alternative to the sitz bath, we have adapted a water spray method. A randomized, controlled study was conducted to determine if the water spray method has similar effects to the sitz bath in the post-hemorrhoidectomy period and it is easy to carry out.

METHODS

A total of 120 patients were randomly assigned to water spray or sitz bath groups. All patients received analgesics and a fiber-rich diet after hemorrhoidectomy. Clinical parameters including pain, irritation (burning or itching sensations), hygiene, convenience, and overall satisfaction were evaluated by a visual analog scale to assess treatment outcome in both groups.

RESULTS

There was no obvious difference in age, gender distribution, body mass index, or duration of disease between groups. There were no significant difference in scores for postoperative pain (p = 0.23), irritation (p = 0.48), or hygiene (p = 0.725) between groups. However, the water spray group reported significantly greater convenience (p < 0.05) and higher overall satisfaction (p < 0.05) compared with the sitz bath group. At the end of the 4-week postoperative follow-up period, 90% of patients in the watery spray group and 93% of patients in the sitz bath group showed complete wound healing. There were no significant differences in postoperative complications between groups.

CONCLUSION

Our results demonstrate that the water spray method could provide a safe and reliable alternative to the sitz bath for post-hemorrhoidectomy care. Furthermore, the water spray method could be used instead of the sitz bath as a more convenient and satisfactory form of treatment.

Local cooling for relieving pain from perineal trauma sustained during childbirth

BACKGROUND

Perineal trauma is common during childbirth and may be painful. Contemporary maternity practice includes offering women numerous forms of pain relief, including the local application of cooling treatments.

OBJECTIVES

To evaluate the effectiveness and side effects of localised cooling treatments compared with no treatment, other forms of cooling treatments and non-cooling treatments.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2007), CINAHL (1982 to January 2007) and contacted experts in the field.

SELECTION CRITERIA

Published and unpublished randomised and quasi-randomised trials (RCTs) that compared localised cooling treatment applied to the perineum with no treatment or other treatments applied to relieve pain related to perineal trauma sustained during childbirth.

DATA COLLECTION AND ANALYSIS

At least two independent authors performed data extraction for each study. Analyses were performed on an intention-to-treat basis where data allowed. We sought additional information from the authors of three trials.

MAIN RESULTS

Seven published RCTs were included, comparing local cooling treatments (ice packs, cold gel pads or cold/iced baths) with no treatment, hamamelis water (witch hazel), pulsed electromagnetic energy (PET), hydrocortisone/pramoxine foam [Epifoam] or warm baths. The RCTs reported on a total of 859 women. Ice packs provided improved pain relief 24 to 72 hours after birth compared with no treatment (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.41 to 0.91). Women preferred the utility of the gel pads compared with ice packs or no treatment, although no differences in pain relief were detected between the treatments. None of our comparisons of treatments resulted in differences detected in perineal oedema or bruising. Women reported more pain (RR 5.60, 95% CI 2.35 to 13.33) and used more additional analgesia (RR 4.00, 95% CI 1.44 to 11.13) following the application of ice packs compared with PET.

AUTHORS' CONCLUSIONS

There is only limited evidence to support the effectiveness of local cooling treatments (ice packs, cold gel pads, cold/iced baths) applied to the perineum following childbirth to relieve pain.

Effects of Warm Water Sitz Bath on Symptoms in Post-anal Sphincterotomy in Chronic Anal Fissure—A Randomized and Controlled Study

BACKGROUND

Sitz bath is frequently recommended by physicians for a variety of anal disorders including anal fissure. The aim of the present study was to determine whether sitz bath does have any therapeutic properties improving upon a patient's postoperative symptoms after a closed lateral sphincterotomy.

MATERIALS AND METHODS

Forty-six patients were randomly assigned to receive analgesics and fiber supplement alone (control patients) or a twice-daily sitz bath along with identical fiber and analgesics (sitz bath group). A 24-h pain score--post-defecation anal burning and symptom improvement--was evaluated on a visual analog scale (VAS).

RESULTS

The groups were equally matched for age, gender distribution, and duration of disease. No significant difference in mean pain score between groups (p = 0.284) was noticed after one week. However, the patients from the control group experienced significant anal burning compared with patients from sitz bath group (p < 0.0001). The improvement score was higher in the sitz bath group when compared with the control group; however, it did not reached a statistically significant level.

CONCLUSIONS

Patients after sphincterotomy for anal fissure receiving sitz bath experienced similar levels of pain when compared with those not receiving sitz bath. However, they reported a significant relief in anal burning and a marginally better satisfaction score and no reported adverse side effects.

RANDOMIZED, CONTROLLED STUDY COMPARING SITZ-BATH AND NO-SITZ-BATH TREATMENTS IN PATIENTS WITH ACUTE ANAL FISSURES

AIM

To determine the efficacy and safety of sitz baths in the management of acute anal fissures.

METHOD

Individual patients were randomized to either receive sitz baths or no sitz baths for 4 weeks in addition to oral psyllium husk. Patients were asked to soak their hips and buttocks in a tub containing plain lukewarm water for 10 min, once after defecation in the morning and again at bedtime. Each week, the patients were called to assess pain scores and healing of fissures, whereas the level of satisfaction was recorded at the end of 4 weeks. Main outcome measures were validated pain scores and levels of satisfaction.

RESULTS

Fifty-eight subjects were recruited for this study. In all, 52 of them completed the trial (27 in the sitz bath group and 25 in the control group). Although the pain score was lesser in the sitz bath group than in the control group, it failed to reach statistical significance. There were no significant differences in fissure healing between the two groups over the 4-week study period. However, patients in the sitz bath group reported better satisfaction levels than the control group (P < 0.01). Although no serious adverse effects were observed, two patients from sitz bath group developed perianal skin rash.

CONCLUSION

This study suggests that sitz baths improve patient satisfaction in acute anal fissures. However, the healing and overall pain relief was not significant enough to attract attention. It was also found to be associated with adverse effects in few patients.

Sitz bath: where is the evidence? Scientific basis of a common practice

PURPOSE

This study was designed to determine if evidence exists to justify and support the recommendation of sitz bath in the management of anorectal disorders.

METHODS

A Medline search was conducted using the key words "sitz bath" and "hot bath."

RESULTS

Thirty-six articles were found which highlighted the physiology, benefits, risks, complications, and techniques of sitz bath. Most of the studies were published in gynecologic or nursing journals. One randomized study comparing sitz bath to placebo was found. Two articles speculated that sitz bath induces relaxation of the internal sphincter muscle. Cold sitz bath was reported to decrease perineal edema more than warm sitz bath, although patients tended to prefer the latter. Five articles reported complications of sitz bath, including dissemination of herpes, maternal-neonatal Streptococcus outbreak, and skin burns.

CONCLUSION

A review of the literature demonstrated a lack of scientific data to support the use of sitz bath in the treatment of anorectal disorders. Additional randomized and controlled clinical studies are needed to investigate whether this time consuming recommendation is beneficial to patients.

Effect of cutaneous stimulation on pain reduction in emergency department patients

CONTEXT

The problem of unrelieved pain in Emergency Department (ED) patients as well as contraindications to analgesics and narcotics due to masking of symptoms during the diagnostic period, presents itself as a unique opportunity for ED nurses to utilize non-pharmacological and non-invasive interventions such as cutaneous stimulation (CS) to relieve pain.

OBJECTIVE

To evaluate the effectiveness of a specific protocol of CS, developed by the researchers, in reducing pain levels in ED patients. Another objective was to determine the effect of CS on blood pressure and heart rate. Potential factors that could influence the dependent variables such as age, gender, educational level, location of pain, and site of CS were tested.

DESIGN

A one group pre-test post-test experimental design measured variables before and after intervention in all subjects.

SAMPLE

After being screened for inclusion, 50 patients (38 adults, 12 children) were admitted to the study and were treated with CS to relieve pain.

RESULTS

Following CS, subjects reported significantly reduced pain, and demonstrated reduced heart rate, and blood pressure readings. The location of pain significantly influenced heart rate and diastolic blood pressure but not pain level. The most effective site of CS was contralateral to the pain. Age, gender and educational level had no significant affect.

CONCLUSIONS

The results of this study provide empirical evidence that CS effectively reduces pain, heart rate, and blood pressure in ED patients. The intervention of CS has solid utilization potential and could be easily incorporated into standard ED procedure. Further research is needed to identify threats to internal validity especially that of the caring presence of the nurse.

Effect of cutaneous stimulation on pain reduction in emergency department patients

CONTEXT

The problem of unrelieved pain in Emergency Department (ED) patients as well as contraindications to analgesics and narcotics due to masking of symptoms during the diagnostic period, presents itself as a unique opportunity for ED nurses to utilize non-pharmacological and non-invasive interventions such as cutaneous stimulation (CS) to relieve pain.

OBJECTIVE

To evaluate the effectiveness of a specific protocol of CS, developed by the researchers, in reducing pain levels in ED patients. Another objective was to determine the effect of CS on blood pressure and heart rate. Potential factors that could influence the dependent variables such as age, gender, educational level, location of pain, and site of CS were tested.

DESIGN

A one group pre-test post-test experimental design measured variables before and after intervention in all subjects.

SAMPLE

After being screened for inclusion, 50 patients (38 adults, 12 children) were admitted to the study and were treated with CS to relieve pain.

RESULTS

Following CS, subjects reported significantly reduced pain, and demonstrated reduced heart rate, and blood pressure readings. The location of pain significancy influenced heart rate and diastolic blood pressure but not pain level. The most effective site of CS was contralateral to the pain. Age, gender and educational level had no significant affect.

CONCLUSIONS

The results of this study provide empirical evidence that CS effectively reduces pain, heart rate, and blood pressure in ED patients. The intervention of CS has solid utilization potential and could be easily incorporated into standard ED procedure. Further research is needed to identify threats to internal validity especially that of the caring presence of the nurse.

A new device for the treatment of perineal wounds

The development and evaluation of a maternity gel pad for the alleviation of perineal pain

The effects of cold therapy on postoperative pain in gynecologic patients: a prospective, randomized study

OBJECTIVE

The purpose of the study was to determine the effect of cold therapy on the subjective assessment of pain, analgesic requirements, and wound complications in female patients undergoing major abdominal surgery.

STUDY DESIGN

Twenty-seven patients were entered in the study in a prospective, randomized fashion. The Hot/Ice Thermal Blanket was applied to 13 patients, and 12 patients were in the control group. All patients underwent exploratory laparotomy and received postoperative pain relief with intravenously self-administered morphine sulfate through a patient-controlled analgesic pump.

RESULTS

Compared with the control group (0.363 +/- 0.118 mg/kg/day), the cold pack group used more morphine sulfate on the first postoperative day (0.529 +/- 0.236 mg/kg/day, p < 0.05). The mean amount of morphine sulfate used by both groups was similar on postoperative day 2.

CONCLUSION

We conclude that the cold pack does not improve postoperative pain control in gynecologic patients undergoing exploratory laparotomy.

The impact of research findings on current practice in relieving postpartum perineal pain in a large district general hospital

In order to study the impact of research findings on current clinical practice 100 members of midwifery and medical staff of a large district general hospital were surveyed regarding their treatment of postpartum perineal pain. Of the 76 who responded only 20 (26%) referred to research findings to support their clinical practice and in only one case was the research appropriate to the population in question. Important research findings were not applied, while the majority of the reported practice was not research-based. Research-based practice is not only the responsibility of the individual clinician but also of those at educational and management levels. Local strategies should be developed and resources made available to facilitate research utilisation and implementation.

Pain relief using cutaneous modalities, positioning, and movement

Positioning, movement, and certain cutaneous modalities may be easily used by all caregivers, including the family, to bring comfort and pain relief to terminally ill patients with pain. For such patients, these techniques are most appropriately used in addition to pharmacologic control of pain. Patients themselves may use some of the cutaneous modalities with minimal assistance from others, thereby promoting a sense of independence. Other techniques may be performed by family and friends, providing them with the assurance that they are assisting a loved one. The techniques presented here can be readily used in the home or hospital setting and are relatively low risk, simple, and inexpensive. This paper presents specific guidelines for patients and caregivers in relation to the use of superficial massage, superficial heat and cold, menthol application to skin, transcutaneous electrical nerve stimulation (TENS), positioning, and movement. Because of their simplicity and ease of use, these techniques tend to be overlooked. However, taking the time to introduce these techniques to patients and families often results in a significant contribution to the comfort of the dying patient.

Nursing approaches to nonpharmacological pain control

A combination of pharmacological and nonpharmacological methods of pain control probably yield the most effective pain relief for the patient. The nurse may make a significant contribution to pain control by being able to offer a variety of nonpharmacological methods of pain relief that the patient may use in combination with the more traditional methods of analgesia or local anesthesia. Recent research supports some of the older methods of nonpharmacological pain control such as distraction, especially humor; relaxation using the patient's own memory of peaceful events; and cutaneous stimulation, especially use of cold. Cutaneous stimulation may even be effectively used at sites other than the site of pain. Specific examples of these techniques are presented.

Effects of heat and cold on the perineum after episiotomy/laceration

The Redness Edema Ecchymosis Discharge Approximation (REEDA) tool, devised to evaluate postpartum healing of the perineum following an episiotomy/laceration, was used to evaluate the effects of heat and cold on the perineum during the first 24 hours after delivery. Ninety patients were randomly assigned to one of three treatment groups. Treatment consisted of 30 subjects applying a warm perineal pack, 30 applying a cold perineal pack, and 30 taking a warm sitz bath. Analysis of variance indicated no difference in the REEDA score before or two hours after treatment. A Pearson r correlation indicated the REEDA score was associated with a laceration and not with infant weight. Although these findings do not support assumptions from the literature, this study provides baseline data and trends for future study.