Perineal pain following childbirth: Prevalence, effects on postnatal recovery and analgesia usage
Introduction
Perineal trauma is reported following 63% of vaginal births, resulting from an episiotomy (15%), naturally occurring tears (46%), or laceration+episiotomy (2%) (Laws and Sullivan, 2009). The combination of spontaneous tears and episiotomy therefore encompasses a large proportion of women who sustain perineal trauma after vaginal birth (Albers et al., 1999, Thompson et al., 2002, Dahlen et al., 2007b). Further sources of trauma include vaginal lacerations and injury to the external genitalia (labia, clitoris, periurethra) and the micro-trauma sustained with a so-called ‘intact’ perineum.
A range of practices may impact on the degree of perineal trauma sustained during childbirth. Antenatally, these may include perineal massage, use of perineal dilators and pelvic floor exercises (Beckmann and Garrett, 2006). During labour, the use of water immersion, techniques of pushing during second stage, application of warm packs during second stage and maternal position for birthing may also influence trauma (Dahlen et al., 2007a, Chou et al., 2009).
In the hours, days and months following childbirth, perineal trauma may be painful (Sleep et al., 1984, Glazener et al., 1995, Albers et al., 1999, East et al., 2009, Leeman et al., 2009). Perineal pain can result in decreased mobility, discomfort when passing urine or faeces (Sultan and Sultan and Thakar, 2002, Kapoor et al., 2005, Leeman et al., 2007), may negatively impact on the woman's ability to breast feed or to care for her new infant and may contribute to depression or mental exhaustion (Hedayati et al., 2003, Hedayati et al., 2005). Rajan (1994) reported improved breast-feeding rates following effective analgesia for perineal discomfort. Perineal trauma and pain that persists beyond the immediate postpartum period may also have longer-term effects, such as painful sexual intercourse for up to 18 months after giving birth (Buhling et al., 2006, Rogers et al., 2009). Pain requires attention whenever present, regardless of the trauma or underlying contributing factors.
Contemporary postnatal practice includes offering the woman numerous forms of pain relief, often used in combination (Hay-Smith, 1998, Hedayati et al., 2003, Mason et al., 2004, Hedayati et al., 2005, Chou et al., 2009). Evidence of the effectiveness of existing practices and newer treatments has been systematically appraised in several Cochrane reviews, including methods and materials for suturing perineal tears or episiotomies (Kettle et al., 2007, Kettle et al., 2010), topically applied anaesthetics (e.g. lignocaine) and a topical preparation of pramoxine/hydrocortisone (Hedayati et al., 2005), rectal analgesia (e.g. non-steroidal anti-inflammatory drugs) (Hay-Smith, 1998, Hedayati et al., 2003) and oral indomethacin (Mason et al., 2004) or paracetamol/acetaminophen (Chou et al., 2010). While these demonstrate varying levels of success in relieving perineal pain, they may also involve a degree of cost to the consumer, the health service, or both. Potentially harmful side effects also need to be considered. Consumer satisfaction is also an important consideration of any forms of analgesia used for reducing perineal pain (Corkill et al., 2001).
In preparation for a planned randomised controlled trial (RCT) of cooling treatments for pain management (Australian and New Zealand Clinical Trials Register, 2008), we undertook structured interviews with postnatal women to establish the prevalence of perineal pain following vaginal birth, the effects of such pain on women's recovery from childbirth, forms of analgesia used by the women and women's evaluations of the effectiveness of such analgesia.
Section snippets
Methods
Inclusion and exclusion criteria followed those for the proposed RCT, with inclusion being willing and able to give written, informed consent, singleton vaginal birth (including instrumental birth), English speaking, and one of the following: intact perineum, sutured or unsutured perineal tear(s) (to maximum of second degree, as recorded in the woman's clinical notes) or episiotomy. Third or fourth degree perineal tears or vulval haematoma were excluded, as they require specific clinical care
Findings
A non-consecutive sample of women who met the inclusion criteria and had given birth in the previous 72 hours were invited by research assistants to participate in the study between October 2008 and 2009. There was a response rate of 81% (215 of the 265 who were approached).
The majority of women were primiparous (53.5%) and sustained perineal trauma that required suturing (Table 1). Most women reported some degree of perineal pain (89.7%), which they classified as mild (53%), moderate (33%) or
Discussion
These structured interviews revealed that around 90% of women reported some perineal pain, noted to be moderate for 33% and severe for 3.7% of participants. Although the latter was less than the predicted 8%, post hoc analysis revealed a confidence interval of 2.5 based on the number of women included, suggesting that the sample was of adequate size. The degree of perineal trauma predicted women's ratings of perineal pain on a visual analogue scale, with more severe trauma related to higher
Conclusion
Pain from perineal trauma was commonly reported by women following vaginal birth. This pain affected women's ability to mobilise and was relieved by a variety of agents, including oral and rectal analgesia and the local application of ice packs. Side effects from these forms of analgesia were rare. Midwives are encouraged to ensure they are periodically aware of women's level of perineal pain by sensitive enquiring. Being aware that women are experiencing pain, midwives may be proactive in
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