|Year : 2021 | Volume
| Issue : 2 | Page : 101-105
Effect of implementation of perineal tear pain management programme on pain scores
Karunakaran Ramaswamy1, Nicolas Hooker2, Zofia Kotyra3, Saravanan Solai Dhanashekaran4, Sam Soltanifar5, Niamat Aldamluji6
1 Attending Physician, Adult Anesthesiology, Sidra Medicine, College of Medicine at Qatar University; Clinical Associate Professor in Anesthesiology, College of Medicine at Qatar University; Assistant Professor of Clinical Anesthesiology, Weill Cornell Medical College-Qatar, Doha, Qatar
2 Attending Physician, Adult Anesthesiology, Sidra Medicine, College of Medicine at Qatar University; Honorary Faculty, Clinical Department, College of Medicine, QU Health, Qatar University; Instructor in Clinical Anesthesiology, Weill Cornell Medicine-Qatar, Doha, Qatar
3 Attending Physician, Adult Anesthesiology, Sidra Medicine, College of Medicine at Qatar University; Senior Attending Physician, Adult Anesthesiology, Sidra Medicine; Assistant Professor, Weill Cornell Medical College, Doha, Qatar
4 Attending Physician, Adult Anesthesiology, Sidra Medicine, College of Medicine at Qatar University, Doha, Qatar
5 Division Chief (Acting),Adult Anesthesiology, Sidra Medicine; Assistant Professor of Clinical Anesthesiology,Weill Cornell Medicine-Qatar, Doha, Qatar
6 Attending Physician, Adult Anesthesiology, Sidra Medicine, College of Medicine at Qatar University; Assistant Professor of Clinical Anesthesiology, Weill Cornell Medical College-Qatar, Doha, Qatar; Honorary Senior Lecturer in Regional Anaesthesia, University of East Anglia, UK
|Date of Submission||14-Jun-2021|
|Date of Acceptance||15-Jul-2021|
|Date of Web Publication||01-Oct-2021|
Dr. Karunakaran Ramaswamy
Department of Anesthesiology, Sidra Medicine, Doha
Source of Support: None, Conflict of Interest: None
Background: Perineal tear (PT) occurs in more than 85% of the women undergoing vaginal birth and up to 11% of these can be third- and fourth-degree tears and the majority suffer from pain. Poorly managed pain can impact the mother and her capacity to look after the baby. The institution introduced a PT pain management programme (PPP) as part of a quality improvement programme. This paper is a retrospective analysis to determine the effect of this implementation on the pain scores and patient satisfaction. Objective: Does the PT pain management programme improve pain scores at rest 12 and 24 h post-repair? Does the programme improve maternal satisfaction? Methods: A pain management protocol had been implemented for women with PT from January 1, 2020. To assess the effectiveness of the protocol, data were retrieved from electronic medical records (Cerner Millennium) of 100 women who had a PT from January 1, 2019, to March 31, 2019 (pre-PPP), and 96 women who had a PT from April 1, 2020, to July 31, 2020 (post-PPP). We included consecutive women who had second-, third- and fourth-degree tears. Results: A significant difference in the pain scores at 12 h (mean ± SD [difference of means], 95% CI) (2.17 ± 1.11 vs. 4.5 ± 1.65 [2.33], 1.93–2.73, t (194) = 11.54, P < 0.0001) and 24 h (2.17 ± 1.11 vs. 4.32 ± 1.44 [2.15], 1.79–2.52, t (194) = 11.67, P < 0.0001) was found after the introduction of the PPP. The patient satisfaction scores after the programme were improved (8.13 ± 1.35 vs. 5.11 ± 1.72, t (194) = 13.6, P < 0.0001). Conclusions: The implementation of a pain programme for PT is associated with improvements in the pain scores and patient satisfaction. These improvements suggest that pain management protocols should be considered for women with a PT. Further prospective evaluations and work to confirm this finding would be useful in the other institutions.
Keywords: Pain, pain management programme, patient satisfaction, PT
|How to cite this article:|
Ramaswamy K, Hooker N, Kotyra Z, Dhanashekaran SS, Soltanifar S, Aldamluji N. Effect of implementation of perineal tear pain management programme on pain scores. J Obstet Anaesth Crit Care 2021;11:101-5
|How to cite this URL:|
Ramaswamy K, Hooker N, Kotyra Z, Dhanashekaran SS, Soltanifar S, Aldamluji N. Effect of implementation of perineal tear pain management programme on pain scores. J Obstet Anaesth Crit Care [serial online] 2021 [cited 2022 Jan 20];11:101-5. Available from: https://www.joacc.com/text.asp?2021/11/2/101/327410
| Introduction|| |
Perineal tear (PT) involves damage to the genitalia during labour, which can occur spontaneously or as a complication of episiotomy or instrumental delivery. During labour, the majority of the PT [Table 1] occurs along the posterior vaginal wall, extending towards the anus. More than 85% of the women who undergo a vaginal birth will suffer from some degree of PT. Of these, 0.6–11% are third- or fourth-degree PTs also referred to as OASIS (obstetric anal sphincter injuries).,
PTs can result in severe, immediate and long-term complications in a woman. Up to 90% of the women with PT suffer from pain and more than a third from moderate to severe pain, preventing them from mobilising and looking after the infant, difficulty in micturition, incontinence, constipation, decreased mobilisation and psychological impact in the short term. However, there are long-term implications, some of which may be experienced lifelong, including chronic pain, stress and urge incontinence, flatus, and faecal incontinence, chronic pelvic pain, dyspareunia.,
Various strategies have been tried to address the pain following PT, however, despite the above adverse outcomes, the management of pain following PT has been poor. Treating acute pain appropriately after PT may not only facilitate early recovery but has the potential to reduce long-term pain-related complications.
The institution introduced a PT pain management programme (PPP), an evidence-based quality improvement programme on January 1, 2020. We retrospectively analysed patient records to determine the effect of the introduction of the PPP on the pain scores and patient satisfaction following PT. The primary outcome was the effect on maternal pain scores at 12 and 24 h (at rest and post-repair). We hypothesised that this programme would decrease maternal pain scores.
| Materials and Methodology|| |
The project was reviewed by the institutional IRB (IRB number 1713224) and was exempted from full IRB review. All personal patient information was de-identified.
This work did not receive any specific grant from the funding agencies in the public, commercial or not-for-profit sectors.
The institution is a recently opened tertiary care women and children's hospital in Doha, Qatar. This paper is a retrospective analysis of the data to determine the effect of PPP implementation on pain scores and patient satisfaction. Data were retrieved from the electronic medical records (Cerner Millennium) of women who had PT from January 1, 2019, to March 31, 2019 (pre-PPP), and April 1, 2020, to July 31, 2020 (after-PPP). The pain scores are routinely measured in all our patients with vital signs.
The primary outcome was the pain scores at rest 12 and 24 h post-repair. We analysed data from the consecutive patients who had second-, third- and fourth-degree PTs. We analysed data that were collected routinely, comparing the periods before and after the introduction of the 'PPP protocol'. The key outcomes of interest included post-PT pain scores at 12 and 24 h.
Our sample size calculation was based on the institutional data on the pain scores following PT. The pre-PPP average pain score at rest 12 h post-repair was 4.6 ± 1.6 (mean ± SD). To power our analysis, we assumed that a 33% reduction in the pain score would be a clinically significant difference that is within the goals of the programme. A minimum sample size of 48 patients was calculated (24 per group) using a two-tailed t-test, an alpha error of 0.05 and a power of 90%.
We also analysed the satisfaction score. Women rated the information and management of PT with a satisfaction question rating from 0 (worst possible) to 10 (best care) before discharge. This was included as a part of a satisfaction survey that every patient routinely undertakes before discharge.
The treatment effect was assessed using t-tests. A P value ≤0.05 was considered statistically significant for the outcome. Values are presented as (mean ± SD [difference of means], 95% CI). All statistical analyses were performed with SPSS.
We also describe the steps of the introduction of the programme by our institution in detail, should any other institution wish to implement a similar programme.
Based on the patient feedback, objective assessment during pain rounds, and literature search results, a quality improvement project for PT was introduced in our institution from January 1, 2020. The protocols are intended to improve patient outcomes and accelerate return to normal pre-surgical function through standardisation of practice at all stages of the peri-operative period, guided by the best available evidence.
The PPP introduced for PT was based on the medications used routinely in our institution following a caesarean delivery, where appropriate modifications for this unique patient population have already been made. The establishment of PPP for our patients who developed PT adhered to a systematic and rigorous stepwise approach including the following:
Assembly of a multidisciplinary team and protocol construction: A multidisciplinary team comprising the representatives of midwifery, obstetrics, obstetric anaesthesia, physiotherapy, education, and nursing, to discuss better management of pain management of the patients having PT. After evaluating our practice, the multidisciplinary team focused on the standardisation of care, earlier ambulation and improved patient satisfaction.
A simple table and guidelines were developed with an emphasis on the high quality of care based on the best available evidence. The midwives and nurses were involved in development and education. Patient education was also included to ensure that the patients feel empowered to discuss their pain and any other issues freely with the nurses or midwives. A pain nurse and an anaesthesiologist would visit the women the next day during the pain rounds and check the compliance with PPP, empower the women and clarify any doubts.
Pre-PPP management: Before the programme, there was no systematic approach for women who suffered from PT, with a wide variation in care provision among the providers observed during our review process. No formal counselling or visit was performed other than the standard obstetric care.
Post-PPP protocol: The patients who have PT receive education with the midwife and later with a dedicated pain nurse explaining the protocol and the women are encouraged to ask any questions they might have about their PT care and overall hospital stay. The principal goal of this is to improve the patient understanding of PT care and alleviate anxiety, managing expectations and enhancing patient engagement in their care.
A simple PT checklist [Table 2] was designed to encourage the midwives and nurses as an aide memory. With an electronic medical record system, it is easy to build order sets (a fixed set of orders) for each category of the tear. We decided not to produce any patient education leaflets but rather let the midwives and pain nurses speak to the patients and address their questions.
| Results|| |
A total of 205 medical records (n = 103 before PPP and n = 102 after the PPP implementation) of the women who had PT during the study period were reviewed. Nine patients were excluded either due to missing relevant data or suspected errors in data entry. The incidence of second-, third- or fourth-degree tears in our institution is 16%; 4% of these were third-degree tears (OASIS). There were no fourth-degree tears. There was no difference in the degree of the tear type in the two groups and there was an equal number of OASIS in both groups. There was no significant difference in the demographics between the two groups.
We included (n = 100 before; n = 96 after) women who had second-, third- and fourth-degree PTs. A significant difference in the pain scores at 12 h (mean ± SD [difference of means], 95% CI) (2.17 ± 1.11 vs. 4.5 ± 1.65 [2.33], 1.93–2.73, t (194) = 11.54, P < 0.0001) and 24 h (2.17 ± 1.11 vs. 4.32 ± 1.44 [2.15], 1.79–2.52, t (194) = 11.67, P < 0.0001) was found after the introduction of the PPP [Figure 1].
The patient satisfaction scores after the program were improved (8.13 ± 1.35 vs. 5.11 ± 1.72, t (194) = 13.6, P < 0.0001).
| Discussion/Comment|| |
The implementation of a PPP protocol for PT at our institution resulted in a decrease in the pain scores at rest 12 and 24 h post-PT repair. It also improved patient satisfaction.
A variety of strategies have been tried to address the pain following PT. Single-dose aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) have been found to provide moderate pain relief compared to placebo and better analgesic effects compared with paracetamol. However, the studies were in the women who were not breastfeeding., Even a single dose of paracetamol with doses (500, 650 or 1000 mg) was found to be better than a placebo in providing analgesia to the women who had suffered a perineal injury. Single-dose rectal NSAID's suppository was found to provide better analgesia compared to placebo, up to 24 h following perineal injury. The effectiveness of topically applied local anaesthetics for treating perineal pain is not compelling.
Local cooling measures (ice packs, cold gel pads [with or without compression] or cold/iced baths) with gel pads with compression, hamamelis water (witch hazel), pulsed electromagnetic energy (PET), hydrocortisone/pramoxine foam (Epifoam), oral paracetamol or warm baths) provide temporary relief (gel pads, iced baths) but showed limited evidence in relieving perineal pain following an injury. Ice packs seem to be commonly used to provide immediate comfort. Some maternity gel pad cooling has been highly rated by mothers. Parenteral opioids have also been used but they cause constipation.
In our institution, standardisation is implemented from the time a woman has PT until they are discharged from the hospital. Pain following PT poses a burden on the women in the postpartum period.,, Postpartum pain may interfere with maternal-foetal bonding and impair maternal recovery. A key part of our PPP protocol is the institution of a standardised and effective multimodal analgesia protocol, based on the literature review, the use of approved medications in the postpartum period for pain management, and appropriate adjuncts.,
PPP is a multidisciplinary team-oriented approach to patient care that has the overarching goal of improving patient care. Standardization provides mothers with the consistency of care delivery by the healthcare providers if they suffer a PT.
Additional prospective research is required from other centres to confirm these findings. Other key data like analgesic use and length of hospital stay would be useful in future studies.
Strengths and limitations
Retrospective data review has several limitations including information bias and undetected confounders. As this was a single-centre data analysis, the generalizability of our results to the other centres is unclear, though the individual components of our PPP protocol are effective in the other populations. Other key data like analgesic use and length of hospital stay would have been useful. As this is a retrospective data analysis, we attempted to control for confounders as best possible, however, we could not consider all potential confounders including patients with a previous PT, chronic pain syndromes, anxiety, depression, and other medical conditions that may have affected the response to the pain following PT. Given that our cohort consisted of healthy patients, it is unlikely to significantly impact the outcome study results.
| Conclusions|| |
Our analgesia protocol was associated with a net decrease in the pain scores at rest at 12 and 24 h post-PT repair. Our results highlight the importance of a scheduled PPP for PT pain management. In addition to our multimodal pain management strategy, other factors may have contributed. Patient anxiety, anticipated pain, and the need for analgesics correlate with the pain intensity following PT. Addressing these concerns post-PT may reduce the overall patient pain perception and improve maternal satisfaction. Patient education covering the anticipated pain severity and plans regarding pain management strategies are likely to have reduced the anxiety and set realistic expectations, which may have led to lower peak pain scores.
PT pain is an important problem with a significant impact. Further work to confirm this finding would be useful in the other institutions and prospective evaluations.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lacross A, Groff M, Smaldone A. Obstetric anal sphincter injury and anal incontinence following vaginal birth: A systematic review and meta-analysis. J. Midwifery Women's Heal 2015;60:37-47
The Management of Third-and Fourth-Degree Perineal Tears Green-top Guideline No. 29, 2015.
East CE, Sherburn M, Nagle C, Said J, Forster D. Perineal pain following childbirth: Prevalence, effects on postnatal recovery and analgesia usage. Midwifery 2012;28:93-7.
Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev 2017;2:CD000081. doi: 10.1002/14651858.CD000081.pub3.
Turmo M, Echevarria M, Rubio P, Almeida C. Development of chronic pain after episiotomy. Rev Esp Anestesiol Reanim 2015;62:436-42.
Williams A, Herron-Marx S, Knibb R. The prevalence of enduring postnatal perineal morbidity and its relationship to type of birth and birth risk factors. J Clin Nurs 2007;16:549-61.
Peralta F, Bavaro JB. Severe perineal lacerations after vaginal delivery: Are they an anesthesiologist's problem? Curr Opin Anaesthesiol 2018;31:258-261.
Wuytack F, Smith V, Cleary BJ. Oral non-steroidal anti-inflammatory drugs (single dose) for perineal pain in the early postpartum period. Cochrane Database Syst Rev 2016;7:CD011352. doi: 10.1002/14651858.CD011352.pub2.
Mitchell J, Jones W, Winkley E, Kinsella SM. Guideline on anaesthesia and sedation in breastfeeding women 2020: Guideline from the Association of Anaesthetists. Anaesthesia 2020;75:1482-93.
Molakatalla S, Shepherd E, Grivell RM. Aspirin (single dose) for perineal pain in the early postpartum period. Cochrane Database Syst Rev 2017;2:CD012129. doi: 10.1002/14651858.CD012129.pub2.
Chou D, Abalos E, Gyte GM, Gülmezoglu AM. Paracetamol/acetaminophen (single administration) for perineal pain in the early postpartum period. In Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2010.
Hedayati H, Parsons J, Crowther CA. Rectal analgesia for pain from perineal trauma following childbirth. Cochrane Database Syst Rev 2003:CD003931. doi: 10.1002/14651858.CD003931.
Hedayati H, Parsons J, Crowther CA. Topically applied anaesthetics for treating perineal pain after childbirth. Cochrane Database Syst Rev 2005;:CD004223. doi: 10.1002/14651858.CD004223.pub2.
East CE, Begg L, Henshall NE, Marchant PR, Wallace K. Local cooling for relieving pain from perineal trauma sustained during childbirth. Cochrane Database Syst Rev 2012;CD006304. doi: 10.1002/14651858.CD006304.pub3.
Francisco AA, De Oliveira SMJV, Steen M, Nobre MRC, De Souza EV. Ice pack induced perineal analgesia after spontaneous vaginal birth: Randomised controlled trial. Women Birth 2018;31:e334-40.
Steen M, Cooper K, Marchant P, Griffiths-Jones M, Walker J. A randomised controlled trial to compare the effectiveness of ice-packs and Epifoam with cooling maternity gel pads at alleviating postnatal perineal trauma. Midwifery 2000;16:48-55.
Swain J, Dahlen HG. Putting evidence into practice: A quality activity of proactive pain relief for postpartum perineal pain. Women Birth 2013;26:65-70.
Petersen MR. Review of interventions to relieve postpartum pain from perineal trauma. MCN Am J Matern Child Nurs 2011;36:241-5.
Apfelbaum JL, Hawkins JL, Agarkar M, Bucklin BA, Connis RT, Gambling DR, et al
. Practice guidelines for obstetric anesthesia: An updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology*. Anesthesiology 2016;124:270-300.
Cattin A, De Baene A, Achon E, Bersot Y, Destoop Q, Pelissier A, et al
. Évaluation de la mise en place d'un protocole de réhabilitation précoce postcésarienne [Evaluation of enhanced recovery for elective cesarean section]. Gynecol Obstet Fertil Senol 2017;45:202-9.
Komatsu R, Carvalho B, Flood P. Prediction of outliers in pain, analgesia requirement, and recovery of function after childbirth: A prospective observational cohort study. Br J Anaesth 2018;121:417-26.
Lee A, Gin T. Educating patients about anaesthesia: Effect of various modes on patients' knowledge, anxiety and satisfaction. Curr Opin Anaesthesiol 2005;18:205-8.
[Table 1], [Table 2]