How to alleviate perineal pain following an episiotomy

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Rationale and key points

An episiotomy increases maternal morbidity in the postnatal period. This How to module aims to help nurses to advise women on how to alleviate perineal pain associated with an episiotomy. Alleviating perineal pain is an important aspect of maternal health care.
  • A combination of pain relief methods, systemic and localised, may be required to alleviate perineal pain associated with an episiotomy.
  • It is important that nurses, midwives and doctors advise women on how to alleviate perineal pain, prevent infection and promote healing following an episiotomy.

Useful resources

References

Abedzadeh Kalahroudi M, Sadat Z, Saberi F (2011) The efficacy of 2% lidocaine gel in pain relieving of episiotomy: a double-blind randomized trial. Pakistan Journal of Medical Sciences. 27, 2, 375-378.
Achariyapota V, Titapant V (2008) Relieving perineal pain after perineorrhaphy by diclofenac rectal suppositories: a randomized double-blinded placebo controlled trial. Journal of the Medical Association of Thailand. 91, 6, 799-804. MEDLINE
American Academy of Family Physicians (2012) Advanced Life Support in Obstetrics (ALSO). Provider Syllabus. AAFP, Leawood KS.
de Souza Bosco Paiva C, Junqueira Vasconcellos de Oliveira SM, Amorim Francisco A, da Silva RL, de Paula Batista Mendes E, Steen M (2015) Length of perineal pain relief after ice pack application: a quasi-experimental study. Women and Birth. CROSSREF
East CE, Sherburn M, Nagle C, Said J, Forster D (2012) Perineal pain following childbirth: prevalence, effects on postnatal recovery and analgesia usage. Midwifery. 28, 1, 93-97. MEDLINE •CROSSREF
Hedayati H, Parsons J, Crowther CA (2003) Rectal analgesia for pain from perineal trauma following childbirth. Cochrane Database of Systematic Reviews. Issue 3, CD003931. MEDLINE
Kamondetdecha R, Tannirandorn Y (2008) Ibuprofen versus acetaminophen for the relief of perineal pain after childbirth: a randomized controlled trial. Journal of the Medical Association of Thailand. 91, 3, 282-286. MEDLINE
clinical procedures, clinical skills, episiotomy, pain assessment, pain management, pain relief, perineal pain, postnatal care.

Learning objectives

After reading this module you should be able to:
  • Name the two types of episiotomy commonly performed.
  • Assess the severity of perineal pain and associated inflammation following an episiotomy.
  • Understand what pain relief will help to alleviate perineal pain associated with an episiotomy.
  • Advise women on how to alleviate perineal pain, prevent infection and promote healing following an episiotomy.
  • Understand the evidence to support management of postpartum perineal pain.

Preparation and equipment

  • The practitioner should offer pain relief immediately following repair of an episiotomy.
  • The practitioner should explain to the woman that she will experience some pain and discomfort associated with the incision and repair for the next few days, but this will gradually ease during the first week and be less severe the following week.
  • The severity of perineal pain and associated oedema and bruising should be monitored during the early postnatal period, and systemic and localised forms of pain relief should be offered.
  • The practitioner should discuss with the woman how to seek help and advice if she experiences any ongoing pain or associated problems.
  • The practitioner should ensure the necessary equipment is available, including:
    • Gloves.
    • Lubricating gel.
    • Gauze.
    • Suppository containing 100mg diclofenac.
    • A cool gel pad or ice pack with a gauze sleeve.
    • Analgesia, for example paracetamol.
  • Procedure
    1. Immediately following repair of an episiotomy, assess the severity of perineal pain and associated inflammation. Ask the woman to rate the severity of pain (use a validated pain assessment tool, as per trust policy) and describe any pain sensation. Some women may not have full sensation if they have had an epidural. The rating of the woman’s pain severity and pain description assist in the assessment and management of pain.
    1. Following the repair of an episiotomy and with the woman’s informed verbal consent, administer 100mg diclofenac rectally, as prescribed, if there are no contraindications.
    1. Offer localised cooling, for example a cool gel pad or ice pack, to help alleviate swelling and perineal pain. Do not apply the cool gel pad or ice pack directly to the skin layer; use a gauze sleeve to prevent an ice burn.
    1. Show the woman how to apply a cool gel pad or ice pack, so she can apply one herself when required to alleviate pain.
    Early postnatal period:
    1. Assess the severity of perineal pain by asking the woman to rate the severity of pain and describe any pain sensation. Offer systemic and localised pain relief to meet her needs.
    1. Recommend paracetamol, bathing and localised cooling for mild to moderate pain.
    1. For severe pain, tramadol or oxycodone may be prescribed in some cases, but these drugs are contraindicated in women who are breastfeeding. An alternative method of pain relief is a non-steroidal anti-inflammatory drug (NSAID) and localised cooling.
    1. With the woman’s informed verbal consent, screen the bed or close the door to ensure privacy. Ask the woman to adopt a semi-recumbent position with her legs apart, to allow observation of the perineum and episiotomy for signs of healing and infection.
    1. Wash your hands and put on sterile gloves to cut or snip the tie-off suture or knot near the fourchette to ease any discomfort caused by sutures, if required.
    1. Recommend bathing to the woman since this may be soothing and the water can help with the breakdown and absorption of suture material.
    1. Advise the woman on perineal hygiene, pelvic floor exercises, and adoption of sitting and lying positions that alleviate direct pressure on the perineum.
    1. Explain how diet and nutrition can aid healing and the need to drink plenty of fluids.
    1. Discuss the need for self-care and sufficient rest, since tiredness and lack of sleep can influence the experience of pain.
    1. Document the pain assessment and what measures have been taken to alleviate perineal pain and its effectiveness.

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