Original Article              Pharmacological and non pharmacological treatment                 for relief of perineal pai...
Pharmacological and non pharmacological treatment for relief of perineal pain after vaginal delivery   195    In an Americ...
196     Hasegawa J, Leventhal LC    Data were analyzed using descriptive statistics                              Table 2. ...
Pharmacological and non pharmacological treatment for relief of perineal pain after vaginal delivery   197Table 5. Distrib...
198     Hasegawa J, Leventhal LCperineal pain showed no significant differences in pain        The study was composed of p...
Pharmacological and non pharmacological treatment for relief of perineal pain after vaginal delivery   199than 3,500 g. Th...
200     Hasegawa J, Leventhal LC26.	Casella C. Calor tem efeito analgésico por até uma hora, dizem pesquisadores      29.	...
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  1. 1. Original Article Pharmacological and non pharmacological treatment for relief of perineal pain after vaginal delivery Tratamento farmacológico e não farmacológico no alívio da dor perineal pós-parto normal Joyce Hasegawa1, Lucila Coca Leventhal2ABSTRACT Descritores: Dor; Períneo; Período pós-parto; Analgesia obstétrica;Objective: To identify the types of pharmacological and non- Partopharmacological treatments used during hospitalization, in the reliefof perineal pain after vaginal deliveries. Methods: Data were obtainedfrom medical files of patients who had vaginal deliveries during 2007. INTRODUCTIONResults: The mean age of mothers was 32.4 years, and 97.7% of Perineal trauma is a significant problem that affectsthem suffered perineal trauma. As to treatment for relief of perineal women worldwide who had vaginal deliveries, as it maypain after a vaginal delivery, 98.5% used drugs, the most frequent of cause pain and discomfort during the postpartum period.which were non-steroidal anti-inflammatory drugs, and 62.3% of them Several factors are responsible for perineal trauma, e.g.,also used non-drug treatments, especially ice packs. Conclusion:It is important that healthcare professionals, who attend to new size of fetus, poor adaptation of the fetal presentationpuerperas, know how to assess and treat perineal pain. Considering to the pubic symphysis, anomalous fetal positions, andthe high rates of perineal trauma following vaginal deliveries, we need episiotomies(1-2).to offer patients treatment alternatives for perineal pain, based on Perineal loss of integrity may cause the womanscientific evidence. postpartum discomfort and may negatively influence psychological and physical function, especially pain(3).Keywords: Pain; Perineum; Postpartum period; Analgesia, obstetrical; In breastfeeding, pain inhibits the release ofDelivery oxytocin, the hormone responsible for the ejection reflex (let-down reflex) and production of breast milk. Even when there is a normal production ofRESUMO maternal milk, pain, fatigue and anxiety may impedeObjetivo: Identificar os tipos de tratamentos farmacológicos e the delivery of milk to the newborn, increasingnão farmacológicos utilizados no alívio da dor perineal após oparto normal, utilizados pela puérpera no período de internação. maternal anxiety even more and blocking the releaseMétodos: Os dados foram obtidos por meio dos prontuários of oxytocin(4).médicos de puérperas que tiveram parto normal no ano de 2007. It is important to point out that there is no reliableResultados: A média de idade das puérperas foi de 32,4 anos e evidence that the routine use of the episiotomy has a97,7% sofreram trauma perineal. Quanto ao tratamento para o alívio beneficial effect. Episiotomies provoke a greater lossda dor perineal, após o parto normal 98,5% utilizaram fármacos, of blood and increase the incidence of dyspareuniasendo o anti-inflamatório não esteroidal o mais frequente, e 62,3% and perineal pain after birth. They are indicated inutilizaram também o tratamento não farmacológico, o fármaco situations of fetal distress, large fetuses, prematurity,mais utilizado foi bolsa de gelo. Conclusão: É importante que os if the perineum has little elasticity, or there is vulvarprofissionais que atendem à puérpera, saibam avaliar e tratar a dorperineal. Considerando as elevadas taxas de traumatismo perineal edema, and the threat of perineal laceration(5-6).após o parto normal ainda presentes em nossa população, precisa- Among the practices employed to avoid trauma,se oferecer às puérperas alternativas de tratamento para a dor we mention protection of the perineum and perinealperineal, com base em evidências científicas. massage during the final expulsion period(7).Final paper presented at Faculdade de Enfermagem do Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil. Nurse from Faculdade de Enfermagem do Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brasil.1 Obstetric nurse; PhD in Obstetric Nursing from Escola de Enfermagem da Universidade de São Paulo – USP; Lecturer at the Child-maternal Nursing Department of Faculdade de Enfermagem of Hospital2 Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil. Corresponding author: Lucila Coca Leventhal – Avenida Professor Francisco Morato, 4.293 – Butantã – CEP 05521-200 – São Paulo (SP), Brasil – Tel.: 11 3746-1001 – e-mail: lucila0308@hotmail.com Received on Jan 17, 2009 – Accepted on Mar 12, 2009einstein. 2009;7(2 Pt 1):194-200
  2. 2. Pharmacological and non pharmacological treatment for relief of perineal pain after vaginal delivery 195 In an American research study carried out with physical therapy equipment, such as ultrasound and1,573 women in the postpartum period, 67% of transcutaneous electrical nerve stimulation (TENS)(2).primiparas without episiotomies and 82.3% of those Ultrasound is a device that emits sound waves (16 towith episiotomies reported perineal pain two weeks 18 kHz) with a frequency of 3 MHz, which is not audibleafter birth(8). to the human ear. It requires continual assistance of the The physical factors associated with perineal pain operator during treatment and; therefore, has a highinterfere in various activities of puerparas, such as cost relative to the physical therapist’s time. TENS is awalking, sitting, sleeping, self-care, caring for the low frequency device (varying from 1 to 250 HZ) thatnewborn, appetite, sexual dysfunction, which can lead sends electrical impulses through the skin. It possessesto maternal exhaustion and hinder the experience significant advantages such as low cost, few side effects,of maternity, in some cases even leading to marital and it is effective in decreasing pain and consumptionproblems(1). of analgesics(15-16). In a study conducted with puerperas who had vaginaldeliveries in the city of São Paulo, the prevalence of painwas 96% higher during the first 24 hours, and perineal OBJECTIVEpain was the most frequently cited. The women referred To identify which types of drugs and non-drugsinterference of pain in breastfeeding, sleeping, caring treatments are used during hospitalization in relief offor the baby, locomotion, and elimination (voiding and maternal perineal pain after a vaginal delivery.evacuating)(9). Despite the use of measures to prevent pain, thereare several treatments for relief of perineal pain. METHODSPharmacological and non-pharmacological methods This is a quantitative, descriptive, exploratory, andare used to treat this discomfort(2,10). retrospective study. This study was developed at According to the Dictionary of Drug Administration the maternity of Hospital Israelita Albert Einsteinin Nursing, 2007/2008(11), pharmacological pain relief (HIAE). The maternity has 45 puerperium beds, fourmethods include non-steroidal anti-inflammatory drugs, delivery rooms, four prepartum/delivery/puerperiumoral analgesics, local anesthetics and opioids. rooms, three prepartum rooms, and one screening Several factors should be considered in oral room. During the year 2007, at this hospital thereanalgesic preparations, such as intensity of pain, were 2,931 births; 2,283 (77.9%) of them were byprobability of the medication causing constipation, caesarian section, 569 were normal (19.3%), and 83gastric irritation, passage of the drug to maternal milk, by forceps (2.8%).and more serious adverse effects, such as prolonged From July 3rd to July 11th, 2008, the period duringbleeding time(10). which the authors were available, data were collected According to these criteria, paracetamol and in medical files. All files of women who had vaginalibuprofen are considered the safest ones for use during deliveries during the period of February 1st to April 29th,lactation, due to their short time of action and of reports 2007, were analyzed, totaling 130 patient files.of adverse effects on the newborn(12). For this study, an instrument that had been For non-pharmacological methods, we have observed developed by the authors themselves was used,in practice the use of ice packs, hot compresses, and with open-ended and closed questions, containingsitz-baths. three parts. The first part has identification data of Ice packs during the first 24 hours postpartum is a the women, such as age, level of schooling, maritaltraditional method used for the immediate symptomatic status, among others. The second part was composedrelief of pain since it anesthetizes the perineum, but of data on gestation and delivery, such as type ofthis relief is generally short-lived, and there is no laceration and newborn birthweight. The third partevidence of any long-term benefit. After 24 hours, heat consisted of information on pharmacological and non-is recommended because it increases circulation to pharmacological methods of relieving pain used by thethe region. Forms of heat used are hot compresses or puerpera during hospitalization.sitz-baths. It helps to reduce perineal edema, to avoid According to resolution 196/1996 of the Nationalthe formation of hematomas, to relieve discomfort, Council of Health, the project was approved by theto promote recovery of the wound by cleaning the Ethics in Research Committee of HIAE (Ethics inperineum and anus, and reduces inflammation(13-14). Research Committee approval protocol # 842), and Recently, new non-drug methods have been authorization was requested from this Committee toinvestigated for relief of pain. They are composed of not use the informed consent form. einstein. 2009;7(2 Pt 1):194-200
  3. 3. 196 Hasegawa J, Leventhal LC Data were analyzed using descriptive statistics Table 2. Data on pregnancy and deliveryand, presented in the form of tables using descriptive Data on pregnancy and delivery n %statistics. Gestational age 37 - 41 weeks 123 94.6 32 - 36 weeks 7 5.4RESULTS Parity Nullipara 61 46.9In July 2008, 130 patient medical files of puerperas who Primipara 52 40.0had vaginal deliveries were identified during the period Multipara 17 13.1from February to April 2007. Anesthesia Maternal age varied from 20 to 44 years, and most Yes 128 98.5 No 2 1.5of them were between 20 and 34 years old (90/130; Perineal trauma69.2%); the mean was 32.4, the median was 32, and the Yes 127 97.7standard deviation, 3.9. Most of them had remunerated No 3 2.3occupations (92.3%), had more than 12 years of NB sexschooling (98.4%), were married (93.8%), and white Female 67 51.5(96.9%), as can be observed on Table 1. Male 63 48.5 Birth weightTable 1. Distribution of sociodemographic characteristics of puerperas studied < 2,500 g 5 3.9 2,500 – 3,500 g 103 79.2 Sociodemographic characteristics n % ≥ 3,500 g 22 16.9 Age group (years) NB: newborn. 20 – 34 years 90 69.2 ≥ 35 years 40 30.8 Occupation Table 3 shows that the most widely used drugs Remunerated job 120 92.3 were non-steroidal anti-inflammatory drugs (91.5%), Housewife 10 7.7 followed by oral analgesics (88.5%). Several patients Schooling had more than one type of drug prescribed. 8 - 11 years 1 0.8 12 and more years 128 98.4 No record 1 0.8 Table 3. Distribution of pharmacological groups treatment Marital status Pharmacological treatment n % Married 122 93.8 Non-steroidal anti-inflammatory drugs 119 91.5 Single 5 3.9 Oral analgesics 115 88.5 Separated 3 2.3 Local anesthetic 71 54.6 Skin color Opioids 21 16.1 White 126 96.9 Did not use 2 1.6 Yellow 4 3.1 According to gestation and delivery data presented As to the non-pharmacological treatment (Table 4)on Table 2, we note that all women of this study had used by 81 (62.3%) patients during hospitalization, iceprenatal accompaniment, with seven or more clinical packs were the most frequently used (61.5%), and theyvisits (100.0%); most mothers delivered at a gestational were prescribed up to six times a day for 20 minutesage of 37 to 41 weeks (94.6%). As to parity, 46.9% were each time. The second most common treatment usednulliparas, 40.0% primiparas, and 13.1% multiparas; was the warm sitz-baths (2.3%), and for some women80.8% of them had not had abortions/miscarriages in more than one non-drug treatment was prescribed.their other gestations. Most women were anesthetized(98.5%). In 128 patients anesthetized, the most Table 4. Distribution of non-pharmacological groups treatmentfrequent type of anesthesia used was double anesthetic Non-pharmacological treatment n %block (79.7%), followed by rachianesthesia (10.9%) Ice packs 80 61.5and epidural block (9.4%). It was also noted that 127 Warm sitz-bath 3 2.3(97.7%) puerperas had perineal trauma. Hot compresses 1 0.8 Did not use 49 37.7 As to data on newborns, most were female (51.5%),with predominant weight between 2,500 to 3,500 g(79.2%), as presented on Table 2. Table 5 shows a high percentage of use of non- Of the 130 medical files selected, 98.5% women steroidal anti-inflammatory drugs, especially in womenused pharmacological treatment and 62.3% used non- with newborns weighing more than 3,500 g. The use ofpharmacological treatment. opioids was also greater (27.3%) among these patients.einstein. 2009;7(2 Pt 1):194-200
  4. 4. Pharmacological and non pharmacological treatment for relief of perineal pain after vaginal delivery 197Table 5. Distribution of women who used pharmacological and non-pharmacological Table 7. Distribution of women who used pharmacological and non-pharmacologicaltreatment per newborn birth weight treatment per parity NB weight NB < 2,500 g NB 2,500 – 3,500 g NB > 3,500 g Parity Nulliparas Primiparas Multiparas Pharmacological Pharmacological treatment n (%) n (%) n (%) n (%) n (%) n (%) treatment Non-steroidal anti-inflammatory drugs 56 (91.8) 48 (92.3) 15 (88.2) Non-steroidal anti- 4 (80.0) 94 (91.3) 21 (95.4) Oral analgesics 54 (88.5) 45 (86.5) 16 (94.1) inflammatory drugs Local anesthetics 42 (68.8) 23 (44.2) 6 (35.3) Oral analgesics 4 (80.0) 90 (87.4) 21 (95.4) Opioids 8 (13.1) 11 (21.5) 2 (11.7) Local anesthetics 3 (60.0) 59 (57.3) 9 (40.9) Did not use 1 (1.6) 1 (1.9) - Opioids - 15 (14.5) 6 (27.3) Non-pharmacological treatment Did not use 1 (20.0) 1 (0.9) - Ice pack 42 (68.8) 31 (59.6) 7 (41.2) Non-pharmacological treatment Warm sitz-bath - 3 (5.7) - Ice pack 4 (80.0) 62 (47.7) 14 (63.6) Hot compresses 1 (1.6) - - Warm sitz-bath - 2 (1.94) 1 (4.5) Did not use 17 (27.8) 20 (38.5) 12 (70.6) Hot compresses - - 1 (4.5) Total 61 (100.0) 52 (100.0) 17 (100.0) Did not use 1 (20.0) 41 (31.5) 7 (31.8) Total 5 (100.0) 103 (100.0) 22 (100.0) medical files from which we collected data, there wereNB: newborn nursing notes about perineal pain, but these annotations referred only to the presence or absence of the algesicAs to the non-drug treatment, ice-packs were the most complaint. No record was found as to the application offrequently used in the three groups. a pain scale, report of improvement or worsening of the According to the type of trauma, as shown on pain and/or of any interference of pain in breastfeeding,Table 6, women with episiotomies were those who most in caring for the newborn, in sleeping, or in walking,used a non-steroidal anti-inflammatory drug (94.6%); among others.patients with lacerations usually used ice packs. In a study carried out in maternities in the city of Belo Horizonte, the prescription of analgesics was notedTable 6. Distribution of women who used pharmacological and non-pharmacological in 75.5%, and of non-steroidal anti-inflammatories intreatment per type of trauma 77.8%, in the immediate postpartum period, and more Type of trauma Episiotomy Laceration Intact perineum than one medication was prescribed simultaneously(17). Pharmacological treatment n (%) n (%) n (%) This shows the high rate of drugs prescribed for relief Non-steroidal anti-inflammatory 106 (94.6) 11 (73.3) 2 (66.7) drugs of pain. Oral analgesics 99 (88.4) 14 (93.3) 2 (66.7) In the present study, among pharmacological Local anesthetics 66 (59.2) 3 (20.0) 2 (66.7) treatments used, we noted that non-steroidal anti- Opioids 19 (17.0) 1 (6.7) 1 (33.3) inflammatories were the most frequently used drugs Did not use 1 (0.9) - 1 (33.3) in most cases. They make up the largest group of Non-pharmacological treatment analgesics, have moderate potency, and are widely used Ice pack 65 (58.8) 14 (93.3) 1 (33.3) in prevention and treatment of postoperative pain(18). Warm sitz-bath 1 (0.9) 2 (14.3) - The non-steroidal anti-inflammatory drugs are Hot compresses 1 (0.9) - - among the drugs most often used by patients. However, Did not use 46 (41.1) 1 (6.7) 2 (66.7) among the 27 non-steroidal anti-inflammatories Total 112 (100.0) 15 (100.0) 3 (100.0) marketed in Brazil, only 14 contained references to safety for use during breastfeeding(12,17). Regarding parity, as per Table 7, high indices were Oral analgesics were the second most frequentlynoted of the use of drugs in all three categories. However, used drug in this study. A bibliographic review with thenulliparas (68.8%) utilized more local anesthetics than objective of assessing analgesic efficacy and adversedid primiparas (44.2%) and multiparas (35.3%). The effects of a single dose of dipyrone for acute postoperativeuse of ice was also more frequently present among the pain, showed that dipyrone has efficacy similar to that ofnulliparas. ibuprofen (400 mg) and other analgesics often used to treat moderate to intense postoperative pain. The most common adverse effects were somnolence, stomachDISCUSSION upsets, and nausea(19).In the present study, we noted that a large number The third most commonly used drug in this studyof puerperas used pharmacological and non- was local anesthetic. A bibliographic review composedpharmacological treatments for the relief of pain during of 976 women, with the objective of evaluating thethe postpartum period of hospitalization. In many effects of topically applied anesthetics in postpartum einstein. 2009;7(2 Pt 1):194-200
  5. 5. 198 Hasegawa J, Leventhal LCperineal pain showed no significant differences in pain The study was composed of patients who underwentrelief when the topic anesthetic was compared to the instrumentation during vaginal delivery. After 48topical use of a placebo(1). hours postpartum, a statistically significant difference When pain passes the most intense level, codeine was found in reduction of edema, hematomas andderivatives are used, but they should be employed for pain. This was greater in the group that used the newshort durations, since prolonged use predisposes toward treatment. The authors point out that it is likely thatconstipation, which is particularly important to avoid in the results of the new treatment were significant, sincetreatment of perineal pain(10,20). it is a new type of therapy developed specifically for the Lidocaine is a local anesthetic with good absorption, perineal region. The application is made in the form ofeasy administration, and the patient herself may apply a sanitary pad that extends from the labia major to theit. Nevertheless, a study conducted in Texas, USA, with anal region(25).200 women divided into two groups, one receiving Despite hot compresses being one of the least usedplacebo and the other, lidocaine, showed no significant methods, scientists confirm that the application of heatdifference between the two groups. Therefore, lidocaine interrupts pain and offers comfort to the patients. Somewas not effective in the relief of perineal pain(21). studies showed that temperatures over 40 °C (104o F) Rectal analgesia includes the use of a local anesthetic block the chemical messengers of the cells responsiblethat can relieve pain of any intensity, caused by perineal for alerting the body about pain, with an effect that maytrauma within the first 24 hours after the birth, and leads last for up to one hour. Nonetheless, relief is temporary,to less use of other types of analgesia during the first 48 but in spite of the restricted duration of the effect ofhours when used as a rectal suppository. There is no heat, these discoveries may be useful for making the useinformation available on the relief of pain with the use of artifices such as hot water bottles more common inof rectal suppository for three days after delivery(22). the relief of pain(26). As to non-drug treatment, the use of ice packs was The primary purposes in application of heat are tothe most common. Cold applications are therapeutically reduce inflammation and alleviate the pain. The time ofprescribed in order to provoke vasoconstriction. This application should be 20 minutes at most(23).constriction reduces blood circulation in the area of A study was conducted with the objective of assessingapplication, affording relief of pain caused by decreasing the effect of cold and hot treatment on the perineumpressure on nerve endings. It is also used to decrease of women who suffered lacerations and episiotomies.hemorrhage, deter inflammation, prevent suppuration, It comprised 90 women in three groups: 30 in the hotand alleviate congestion(23). water bottle group, 30 in the ice pack group, and 30 in With the objective of evaluating the effect of the warm sitz-bath group. The duration of treatmentcryotherapy in relief of perineal region pain in was established as 20 minutes. Perineal discomfort wasnulliparas, who had vaginal deliveries, a randomized and evaluated before, immediately after, and at half ancontrolled clinical trial was carried out, with a sample hour, one hour, and two hours post-treatment. Thereof 114 women, comparing the use of ice packs for 20 was no significant difference among the groups before,minutes (Experimental) with the same time of use of a immediately after, and after treatment(27).water bottle (Placebo) and one group without treatment Avoidance of perineal trauma is the best method(Control) in a maternity located in the city of São Paulo. for prevention of pain(7), as was observed in the presentThe mean initial temperature of the perineum in all study in which patients with episiotomies used morethree groups was 32.7 °C (90.86 °F). In the group with non-steroidal anti-inflammatory drugs.ice packs, the perineal temperature dropped to 12.6 °C In an American study carried out with 23,244(54.68 °F), in the water bottle group it increased to 30.9 women using multiple analysis logistic regression, it°C (87.62 °F), and in the Control, to 34.2 °C (93.56 °F). was determined that the main risk factors for third andThere was a significant improvement of pain in all three fourth degree lacerations were: primiparity, newborngroups, reducing from 4.6 to 3.3 in a 0 to 10 scale in the weighing more than 4 kg, use of forceps, and medianControl Group, to 2.1 in the Placebo Group, and to 1.6 episiotomy(28-29).in the Experimental Group. In the comparison of pain In this study, we chose not to include forcepsamong the groups, the Experimental Group had the deliveries due to the small number of cases.lowest mean relatively to the Control Group(24). In the present research study, nulliparas used more Another study was performed with the objective of local anesthetic than primiparas and multiparas. Theassessing the effectiveness and comparing the use of use of ice was also predominantly present among thean ice pack and a local anti-inflammatory (Epifoam™), nulliparas. As to weight of the newborn, there was a highwith a new randomized and controlled-type treatment, percentage of non-steroidal anti-inflammatory drug usein a maternity in the Northern region of England. among women who gave birth to babies weighing moreeinstein. 2009;7(2 Pt 1):194-200
  6. 6. Pharmacological and non pharmacological treatment for relief of perineal pain after vaginal delivery 199than 3,500 g. The use of opioids was also greater for 7. Enkin M, Keirse MJNC, Neilson J, Crowther C, Duley L, Hodnett E, et al. Athese patients. guide to effective care pregnancy and childbirth. Oxford: Oxford University Press; 2000. An adequate treatment of pain is not only a 8. Declercq E, Cunningham DK, Johnson C, Sakala C. Mother’s reports ofpathophysiological issue, it is also an ethical and postpartum pain associated with vaginal and cesarean deliveries: results of aeconomic issue. The best control of pain avoids national survey. Birth. 2008;35(1):16-24.unnecessary suffering, which negatively interferes, for 9. Alexandre CW, Kimura AF, Tsunechiro MA, Oliveira SMJV. A interferência daexample, in breastfeeding as the pain causes stress and dor nas atividades e necessidades da puérpera. Nursing. 2006;93(9):664-8.discomfort. Treatment affords greater satisfaction and 10. 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