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  We evaluated the effectiveness of high-frequency transcutaneous electrical nerve stimulation (TENS) as a pain relief resource for primiparous puerpere who had experienced natural childbirth with an episiotomy.   A controlled, randomized clinical study was conducted in a Brazilian maternity ward. Forty puerpere were randomly divided into two groups: TENS high frequency and a no treatment control group. Post-episiotomy pain was assessed in the resting and sitting positions and during ambulation. An 11-point numeric rating scale was performed in three separate evaluations (at the beginning of the study, after 60 min and after 120 min). The McGill pain questionnaire was employed at the beginning and 60 min later. TENS with 100 Hz frequency and 75 µs pulse for 60 min was employed without causing any pain. Four electrodes ware placed in parallel near the episiotomy site, in the area of the pudendal and genitofemoral nerves.   An 11-point numeric rating scale and McGill pain questionnaire showed a significant statistical difference in pain reduction in the TENS group, while the control group showed no alteration in the level of discomfort. Hence, high-frequency TENS treatment significantly reduced pain intensity immediately after its use and 60 min later.   TENS is a safe and viable non-pharmacological analgesic resource to be employed for pain relief post-episiotomy. The routine use of TENS post-episiotomy is recommended.
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High-frequency TENS in post-episiotomy pain relief in
primiparous puerpere: A randomized, controlled trialjog_1824 980..987
Ana Carolina Rodarti Pitangui1,3, Ligia de Sousa1, Flávia Azevedo Gomes1,
Cristine Homsi Jorge Ferreira2and Ana Márcia Spanó Nakano1
1College of Nursing and 2Department of Biomechanics, Medicine and Rehabilitation of the Locomotor Apparatus, Faculty of
Medicine, University of San Paulo, Ribeirão Preto, and 3Department of Physiotherapy, University of Pernambuco,
Petrolina, Brazil
Abstract
Aim: We evaluated the effectiveness of high-frequency transcutaneous electrical nerve stimulation (TENS) as
a pain relief resource for primiparous puerpere who had experienced natural childbirth with an episiotomy.
Methods: A controlled, randomized clinical study was conducted in a Brazilian maternity ward. Forty puer-
pere were randomly divided into two groups: TENS high frequency and a no treatment control group.
Post-episiotomy pain was assessed in the resting and sitting positions and during ambulation. An 11-point
numeric rating scale was performed in three separate evaluations (at the beginning of the study, after 60 min
and after 120 min). The McGill pain questionnaire was employed at the beginning and 60 min later. TENS with
100 Hz frequency and 75 ms pulse for 60 min was employed without causing any pain. Four electrodes ware
placed in parallel near the episiotomy site, in the area of the pudendal and genitofemoral nerves.
Results: An 11-point numeric rating scale and McGill pain questionnaire showed a significant statistical
difference in pain reduction in the TENS group, while the control group showed no alteration in the level of
discomfort. Hence, high-frequency TENS treatment significantly reduced pain intensity immediately after its
use and 60 min later.
Conclusion: TENS is a safe and viable non-pharmacological analgesic resource to be employed for pain relief
post-episiotomy. The routine use of TENS post-episiotomy is recommended.
Key words: episiotomy, non-pharmacological pain treatment, postoperative pain, postpartum period,
transcutaneous electrical nerve stimulation.
Introduction
Pain from perineal trauma has been reported to be one
of the most common causes of maternal morbidity in
the post-childbirth period.1,2 Women with an epi-
siotomy have experienced greater pain and may be
subjected to greater blood loss, hematomas, infections,
dehiscence, sexual dysfunction, vaginal prolapse and
rectovaginal fistula in comparison to other types of
perineal trauma.3In addition, these injuries can affect
many activities, such as walking, sitting, sleeping,
urinary and intestinal movements, self-care, care of the
newborn, the efficiency and ease of lactation, sleep and
appetite.1,4
Recently, some researchers have carried out studies
with the aim of investigating therapeutic measures that
Received: April 27 2011.
Accepted: October 29 2011.
Reprint request to: Dr Ana Carolina Rodarti Pitangui, Departamento de Fisioterapia, Universidade de Pernambuco, Br 203 Km 2 s/n,
Campus Universitário, Vila Eduardo, Petrolina, 56328-903 Pernambuco, Brasil. Email: carolpitangui@hotmail.com
Scientific address where project was executed: College of Nursing, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.
Place where the study originated: College of Nursing, University of São Paulo, Ribeirão Preto – EERP/USP, São Paulo, Brazil.
Registration number – ACTRN: ACTRN12610000471088.
bs_bs_banner
doi:10.1111/j.1447-0756.2011.01824.x J. Obstet. Gynaecol. Res. Vol. 38, No. 7: 980–987, July 2012
980 © 2012 The Authors
Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology
are capable of mitigating the pain associated with an
episiotomy; however, this subject is incipiently and
infrequently approached in the literature. Both phar-
macological and non-pharmacological methods have
been employed as treatment for this discomfort.2
Medication therapy consists of the use of non-
hormonal oral analgesics and anti-inflammatory
agents that are applied to the injured area;1,5 non-
pharmacological resources commonly include the use
of hot and cold compresses and vaginal washes.1,5
However, there are few studies capable of supporting
the effectiveness of non-pharmacological techniques,
and the observations that follow them are frequently
supported by opinions.1,5,6
Transcutaneous electrical nerve stimulation (TENS)
consists of an easily handled, low-cost, non-
pharmacological, non-invasive resource that is associ-
ated with minimal side effects and sends electrical
impulses through the skin to control the pain.7,8
Although studies have demonstrated the effective-
ness of TENS in countless surgical procedures,9,10 no
previous study has attempted to investigate the effect of
TENS on post-episiotomy pain using local application
in the perineal area. Hence, the objective of this study
was to evaluate the effectiveness of high-frequency
TENS as a pain relief resource employed in primiparous
puerpere who had experienced natural childbirth with
an episiotomy.
Patients and Methods
Participants
This was a controlled, randomized clinical study. Forty
primiparous puerpere in a Brazilian maternity ward
who had experienced a spontaneous vaginal delivery
with an episiotomy were randomly selected into two
groups: high-frequency TENS (n=20) versus no treat-
ment control (n=20). All participants voluntarily
signed a Free and Informed Consent Form. The study
was approved by the Research Ethics Committee of the
Nursing School of Ribeirão Preto in the University of
San Paulo, Brazil.
The volunteers were randomly placed in the active
(TENS) group or the no treatment control group using
a computer-generated randomization sequence. Ran-
domization occurred in the order in which participants
were enrolled in the study according to the computer-
generated randomization list prepared prior to the start
of the study. A blocking randomization was pro-
grammed to generate a sequence of allocation to ensure
that there was a close balance of the number of subjects
in each group throughout the study. The women were
randomized into the active and the no treatment
groups with a 1:1 ratio. The trial design is presented in
Figure 1.
Sample size calculations were previously deter-
mined in a pilot study with 15 puerpere. Reductions in
Figure 1 Trial design. TAF, high
frequency transcutaneous elec-
trical nerve stimulation.
Assessed for eligibility
(
n = 51
)
Excluded (n = 11)
Not meeting the inclusion criteria
(n = 9)
Refused to participate in the study
(n = 2)
Randomized
(
n = 40
)
Allocated to TAF group
(
n = 20
)
Allocated to control group
(
n = 20
)
Lost to follow up or
discontinued the protocol
(n = 0)
Lost to follow up or
discontinued the protocol
(n = 0)
Analyzed (n = 20)
Excluded from analysis
(n = 0)
Analyzed (n = 20)
Excluded from analysis
(n = 0)
High-frequency TENS in post-episiotomy
© 2012 The Authors 981
Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology
pain scores following the intervention were used as the
measurement parameter. A reduction of 1.3 points11,12
in the 11-point numeric rating scale was considered to
be clinically relevant with a standard deviation of 1.47
and 1.25 for the TENS group and control group, respec-
tively. An a=0.01 and power =90% (b=0.1) required a
sample size of 20 individuals in each group.
Inclusion and exclusion criteria
Inclusion criteria were: (i) low risk primiparous preg-
nancy; (ii) older than 18 years of age; (iii) literate,
understanding the Portuguese language; (iv) aware of
time and space; (v) post-vaginal spontaneous delivery;
(vi) experienced an episiotomy with stitches; (vii) pre-
senting pain in the episiotomy area; and (viii) absence
of any genitourinary pathology. Exclusion criteria
were: (i) contraindications to TENS, such as open
wounds; (ii) puerperal complications (increased bleed-
ing requiring intervention, physiological signs sug-
gesting infection, fever, anesthesia complications,
hypertension or breast conditions); (iii) previous expo-
sure to TENS or electrical stimulation; (iv) morbid
obesity; and (v) instrumental delivery (i.e. use of
forceps).
Apparatus and TENS treatment
TENS treatment was performed using a portable appli-
ance model (Tens KW Compact; KW Indústria Nacio-
nal de Tecnologia e Eletrônica, San Paulo, Brazil),
which generates a balanced pulse of biphasic, asym-
metric waves with control switches for frequency varia-
tion and amplitude. Four silicone-carbon electrodes
(5.5 cm ¥3 cm) were placed on the skin parallel to the
episiotomy site (Fig. 2). The region corresponds to
the pudendal and genitofemoral nerves that supply
the perineal area. TENS was applied with 100 Hz
frequency and 75 ms pulse for 60 min.13 The increase
in the electrical impulse intensity was guided by the
participants. They were instructed that the intensity
should result in a strong numbing sensation, but with
no muscle contraction. The TENS appliance was cali-
brated at the beginning of data collection by a digital
oscilloscope.
Procedures
The institution’s routine protocols include limited
episiotomy use. When required, episiotomies are per-
formed using a mediolateral incision with local anes-
thesia. During labor, the patients can receive epidural
analgesia and in the postpartum period they can receive
medications and ice packs. The medications used are
dipyrone (metamizole) taken orally or intravenously
and diclofenac (a non-steroidal anti-inflammatory
drug) taken orally or by intramuscular injection. The
medication is ordered on a prn (as needed) basis, upon
patient request.
Prior to beginning data collection, the records of
the study participants were examined to determine
if they had received epidural analgesia during
labor or if they had used other medications or non-
pharmacological resources to relieve their pain. Partici-
pants should have been standing within at least 6 h
and no more than 24 h after labor. This time period
encompasses the period of time in which the women
could be expected to leave their bed and cease taking
medication for pain, if pain medications were used; the
24-h period refers to the acute phase of the injury (epi-
siotomy), inflammatory process and predominance of
pain. If the study participants had taken any pain
medications or used other pain-relieving methods, the
period in which it was used was controlled based on
the medical orders, thus controlling any possible inter-
ferences in pain assessment. Afterwards, a data form
was completed which included the puerpere profiles,
obstetric procedures performed, and records and data
from the labor period and the newborn for both
groups.
Two investigators were involved in data collection
for this study. They were trained to standardize the
treatment and assessments. Investigator 1 was respon-
sible for patient evaluation and assessing the pain in
all subjects. Investigator 2 applied the treatment in the
high-frequency TENS group.
Figure 2 Schematic representation of the positioning of
the electrodes on the puerpere.
A. C. R. Pitangui et al.
982 © 2012 The Authors
Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology
Functional capacity check
In order to check functional capacity, at the beginning
of the study the participants were asked about their
daily activities and whether there were any limitations
present. These activities were: sitting, ambulating, uri-
nating, bowel movements, personal hygiene, eating,
sleeping and breast-feeding.
Pain measurement
Post-episiotomy pain was assessed using an 11-point
numeric rating scale (NRS). The volunteers were
required to give a number between 0 and 10 that indi-
cated their pain intensity, where 0 indicated no pain
and 10 was the most intense pain imaginable. This tool
presents validity and reliability to measure acute and
post-surgery pain.14–16 This assessment was performed
in both groups at the following times: (i) beginning of
the study – first evaluation; (ii) after 60 min – second
evaluation; and (iii) after 120 min – third evaluation.
The NRS was employed for all three assessments. The
pain during resting and movement was measured by
the NRS; the participants were asked to both sit and
ambulate and report their level of pain during those
activities.
Since pain is a multidimensional experience, the Bra-
zilian version of the McGill Pain Questionnaire (MPQ)
was selected to measure the effect of TENS on multiple
domains of pain. The MPQ has four dimensions
(sensory, affective, evaluative and miscellaneous) rep-
resented by 20 subcategories. This study also assessed
the Pain Rating Index (PRI) and the Number of Words
Chosen (NWC) aspects of the MPQ. These pain mea-
surement tools were applied at the beginning of the
study and after 60 min.
Patients in the no treatment control group and the
TENS group were excluded from analysis of the pain
outcome if they were given any other treatment (anal-
gesic medication or other non-pharmacological
methods) during the data collection period. For ethical
reasons, the patients in the control group received con-
ventional pharmacological treatment or TENS treat-
ment at the end of study.
TENS–related questions
After the conclusion of the study, puerpere from the
TENS group were asked the following questions about
the therapeutic application: (i) What did you think
about TENS therapy? (ii) Would you use TENS again in
the future? (iii) Are you satisfied with TENS? and (iv)
Would you like to make any comments or suggestions
regarding TENS?
Data analysis
Data for the TENS high frequency and control groups
by the NRS were compared using the unpaired t-test,
and intragroup differences were analyzed using the
repeated measures anova with post-hoc Tukey. Basic,
obstetric and neonatal characteristics were compared
using the Mann–Whitney test for analyzing continuous
variables, and Pearson’s c2-test or Fisher’s exact test for
analyzing categorical variables. Data are represented as
mean SD.
In the MPQ category analysis, as a criterion to char-
acterize the pain of the experience of episiotomy in
natural childbirth, descriptors chosen by at least 33% of
study participants were established, since values equal
or higher to this percentage would be sufficient to iden-
tify the characteristics of a particular type of pain.17,18 To
analyze the PRI of the MPQ, the Wilcoxon test was used
for the intragroup analysis and the Mann–Whitney
test for the intergroup analysis. In the intergroup analy-
sis for the NWC the unpaired t-test was used and the
intragroup differences were calculated using the
paired t-test. Results for all tests were considered sig-
nificant at P<0.05. All data analyses were performed
using the Statistical Package for Social Sciences soft-
ware versiom 16.0 (SPSS, Chicago, IL, USA).
Results
Participant characteristics
Puerpere ages varied between 18 and 31 years (median
of 20.5 years). In both groups, there were no significant
statistical differences in age (P=0.369), education
(P=0.749) or color (P=0.386).
Obstetric variables
As for the gestational age, all 40 puerpere had full-term
pregnancies (median of 39 weeks’ gestation). The
median of prenatal care appointments was eight
appointments. Regarding epidural analgesia, 71.1% of
women from both groups were given an epidural. In
the TENS group, 68.4% had an epidural, while the
figure was 73.7% for the control group. No significant
difference was observed in the use of epidural analge-
sia (P=0.721), spontaneous delivery of the placenta
(P=0.547) or the presence of a companion during labor
(P=0.311).
Neonatal variables
Concerning the newborn infants, 55% were male and
the median weight was 3070 g. No significant statistical
difference was found in weight (P=0.820) or height
(P=0.799).
High-frequency TENS in post-episiotomy
© 2012 The Authors 983
Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology
Resources used postpartum
The pain relief resources used by the study participants
in the TENS group before the beginning of the study
were: diclofenac (14.3%), dipyrone (9.5%) and ice packs
(4.8%). The control group used diclofenac (10%) and
ice packs (15%). No significant difference was obser-
ved in these variables between the groups (P=0.675,
P=0.157, P=0.269, respectively).
Functional limitations
The activities that were reported by the puerpere
as causing functional limitation due to episiotomy
pain were: sitting (87.5%), walking (77.5%), personal
hygiene (55%) and sleeping (45%), followed by less
affected functions: breastfeeding (22.5%), urinating
(22.5%) and eating (5%). Regarding bowel movements,
82.5% mentioned that they had not had a bowel
movement within the studied time frame.
Pain outcomes
Numeric rating scale
The groups presented similar pain scores in the basal
level while resting (P=0.068), sitting (P=0.054) and
ambulating (P=0.334). Treatment with TENS at high
frequency significantly reduced pain intensity as mea-
sured by the NRS in resting, sitting and ambulating
activities (P<0.001), immediately after TENS and
60 min later when compared with the control group. In
intragroup analyses, when comparing the first evalua-
tion with the second evaluation, and the first evaluation
with the third evaluation, there was a significant statis-
tical difference only in the TENS group (Table 1).
McGill Pain Questionnaire
The descriptors that were chosen by at least 33% of
puerpere (and thus better describe perineal pain due to
the episiotomy) were: (i) sore, sensorial (67.5%); (ii)
hurting, sensorial (60%); (iii) discomfort, evaluation
(57.5%); (iv) annoying, affective (55%); (v) burning,
sensorial (47.5%); (vi) stinging like a needle, senso-
rial (45%); (vii) throbbing, sensorial (42.5%); and (viii)
pressure, sensorial (37.5%).
There was no significant difference in the basal
analysis for the PRI (P=0.182) or NWC (P=0.389)
scores between the TENS group and the control group.
After TENS treatment, a decrease in NWC (P<0.001)
was shown in the TENS group, as well as PRI for
the sensory, affective, evaluative, miscellaneous and
total categories (P<0.001) (Fig. 3). The control group
showed no alteration in NWC (P=0.235) and PRI for
the sensory (P=0.262), affective (P=0.834), evaluative
(P=0.750), miscellaneous (P=0.500) and total catego-
ries (P=0.429). The highest number of patients chose
words from the sensory category, and there was a
similar tendency in both groups in this selection of
words (P=0.784).
TENS–related questions
One-hundred percent of puerpere reported that they
found TENS comfortable and would use it again.
Table 1 Post-episiotomy pain intensity measured using the numeric rating scale
Evaluation activities TENS
(mean SD)
Control
(mean SD)
P-value
First evaluation
Resting 4.47 1.54 3.89 1.96 0.068
Sitting 6.21 1.84 5.00 1.91 0.054
Ambulating 5.47 2.50 4.68 2.47 0.334
Second evaluation
Resting 0.89 1.15†‡ 3.94 1.98 <0.001*
Sitting 1.78 1.61†‡ 4.73 1.96 <0.001*
Ambulating 1.68 1.70†‡ 5.05 2.36 <0.001*
Third evaluation
Resting 1.36 1.53†§ 4.10 2.18 <0.001*
Sitting 2.42 1.80†§ 5.21 2.01 <0.001*
Ambulating 2.36 2.06†§ 5.21 2.39 <0.001*
*P<0.05. Data are reported as mean SD. †Intergroup difference. ‡Intragroup difference
between the first and second evaluations. §Intragroup difference between the first and third
evaluations. Rows: analysis intergroup. Columns: analysis intragroup. Analysis intragroup –
P-value: TENS <0.001*. Control >0.05. Analysis intergroup: Unpaired t-test. Analysis intra-
group: Repeated measures anova with post-hoc Tukey. TENS, transcutaneous electrical
nerve stimulation.
A. C. R. Pitangui et al.
984 © 2012 The Authors
Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology
Regarding the use of TENS therapy for the treatment of
their pain, 50% professed to be ‘very satisfied’ and 50%
were ‘satisfied’. None of the participants chose the
items ‘little satisfied’ or ‘not satisfied’. No discomfort
or irritation was reported by the women.
Discussion
The objective of this study was to evaluate the effec-
tiveness of TENS as a perineal pain relief resource
employed in primiparous puerpere who had under-
gone an episiotomy. The data in this research suggest
that high-frequency TENS use significantly reduces
pain intensity in post-episiotomy puerpere. TENS
decreased the scores of initial pain classified as mod-
erate to weak in resting, sitting and ambulation activi-
ties, therefore producing a relevant clinical difference.
Since pain is considered to be a multidimensional
and subjective phenomenon,19,20 the implementation of
a measuring instrument to take into account of all its
varied aspects is suggested.9The NRS is considered to
be an easily understood application tool,21,22 having a
good correlation with the visual analogical scale fre-
quently used during the post-surgical period.15 Th e
MPQ is an important instrument to measure the com-
plexity of painful experiences.23
Results achieved in this study using the MPQ dem-
onstrated that the TENS group showed a reduction in
the NWC and PRI, confirming the results found in the
NRS that demonstrate the effectiveness of TENS for
post-episiotomy perineal pain.
Regarding the MPQ, both groups showed a higher
tendency towards choosing descriptors within the
sensory category, a fact that was expected by the
researchers and has also been found by other authors, as
this category has typically gathered the majority of
descriptors in previous studies.9,24
As in this study where we demonstrated the efficacy
of the use of TENS, other authors found similar results,
demonstrating the indication of its employment for
post-surgical pain.9,10,25,26 High-frequency TENS reduces
pain by interfering with transmission of the nociceptive
input at the level of the spinal cord through activation
of d-opioid and gamma-aminobutyric acid (GABA)A
receptors, subsequently reducing input through the
ascending spinothalamic tract.25,27
In order to obtain better results in the employment of
high-frequency TENS, it is fundamental to standardize
the location and positioning of electrodes, time, pulse
duration, intensity and electrical stimuli frequency8,28,29
TENS ideal intensity should be the highest intensity
capable of generating a strong paresthesia,8without
causing pain30 These recommendations were followed
in this study.
Regarding puerpere opinions, 100% of the partici-
pants who used TENS found the TENS therapy com-
fortable and reported that they would use it again. No
reports of side effects or dissatisfaction were made,
supporting the results of other studies.25
Concerning functional limitation, many authors have
found that perineal pain can cause decreased mobil-
ity2,31 and discomfort when passing feces or urine,31
have a negative impact on the woman’s ability to care
for her infant or to breastfeed,1,4,32 and may add to
mental exhaustion or depression.33 Agreeing with the
literature, in this study women also reported functional
limitations in daily activities.
Unfortunately, for ethical reasons it was not possible
to have a control group who received no treatment of
pain, as it was necessary to offer the use of a pain
resource to this group at the end of study. Hence it
was not possible to verify analgesia consumption
after TENS treatment. Furthermore, for clinical and
Figure 3 Post-episiotomy pain measured by the Pain
Rating Index (PRI) of the McGill Pain Questionnaire
(MPQ). Bars represent the average value; error bars
represent the standard deviation. Intergroup analysis
was done using the Mann–Whitney test and intragroup
analysis was done using the Wilcoxon test. †Intergroup
difference; P<0.05. *Intragroup difference between the
first and second evaluations; P<0.05. All categories of
PRI were significantly lower in the transcutaneous
electrical nerve stimulation (TENS) group after TENS
treatment when compared with the control group
(Control). 1, first evaluation; 2, second evaluation; A,
affective; E, evaluation; M, miscellaneous; S, sensory; T,
total; TAF, high frequency transcutaneous electrical
nerve stimulation.
High-frequency TENS in post-episiotomy
© 2012 The Authors 985
Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology
logistical reasons, it was impossible to know if analge-
sia was requested by the women or given under phy-
sician orders.
A limitation of the study is that, while investigators
were blinded, patients were not, for obvious reasons.A
placebo group was not included because its inclusion is
not possible in the case of TENS, as there is no placebo
equivalent for sensory stimulation.34 However, a no
treatment control group was included because its
presence is believed to be fundamental in providing
a comparison parameter to the TENS group. Possible
limitations to our study include not only the lack of a
placebo TENS group, but also the duration of the study
(a one-hour follow-up to capture the potential benefits
of intervention). Despite the results found in this study,
future research is needed to elucidate the effects and
influences of TENS on relieving post-episiotomy pain.
Inclusion of a placebo group, different parameters of
electrical waves and a longer follow-up period will
provide more information regarding the use of TENS
as a method of pain relief for women who have expe-
rienced an episiotomy in natural childbirth.
This randomized and controlled clinical study dem-
onstrated that high-frequency TENS is an effective
modality that is easily applied, low cost and is safe to use
in the control of pain in primiparous puerpere having
undergone an episiotomy, resulting in a decrease
in pain scores during resting, sitting and walking
activities right after its use and 60 min later. Therefore,
TENS is a safe and viable non-pharmacological
analgesic resource to be employed for pain relief
post-episiotomy.
Acknowledgments
The authors thank the Conselho Nacional de Desenvolvi-
mento Científico e Tecnológico (CNPq, Brazil).
Disclosure
No potential conflicts of interest have been declared.
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... Physical inactivity and excessive weight gain in pregnancy, have been documented as independent risk factors for maternal obesity and related pregnancy complications, including gestational diabetes mellitus [3]. Numerous bene ts can be obtained through the physical therapy interventions used in this phase of the female life cycle [4][5][6][7][8][9][10][11][12][13][14][15]. ...
... In the immediate postpartum period, physiotherapy assistance can improve women's global functionality, posture, facilitating breastfeeding, preventing circulatory, respiratory, and complications. There is evidence for the use of physiotherapeutic interventions to provide pain relief related to cesarean section [12], perineal trauma [13][14][15] and, assist in the process and demands related to breastfeeding [20,21]. Additionally, in the postpartum period, the musculoskeletal rehabilitation process should also be started early in the maternity hospital environments. ...
... The role of the physiotherapist encompasses the immediate postpartum period, seeking to prevent deep vein thrombosis, to improve the respiratory, cardiac, gastrointestinal, locomotor, postural, urinary functions, among others, encouraging the bond between mother and the newborn. Also, it seeks to relieve pain related to perineal trauma and cesarean section favoring the healing processes [12][13][14][15]. ...
Preprint
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Background Many recommendations contained in the guidelines available to date are specifically related to clinical practice in obstetrics. Although many physiotherapists are facing similar issues to gynecologists and obstetricians about the care and well-being of pregnant women with confirmed or suspected COVID-19, no specific guidelines were found regarding the physiotherapist's practice in this area. This article aimed to offer guidance regarding physiotherapy in obstetrics during the COVID-19 pandemic. Methods A group of experts in physiotherapy in women's health performed a literature search and proposed a clinical guideline for the physiotherapy management of assistance during pregnancy, labour, and the postpartum period in times of COVID-19. This document was reviewed by other physiotherapists, which analyzed the suggested topics and reached a consensus. Results The recommendation addresses in general terms concerning pregnancy and the postpartum period during the COVID-19 pandemic, summarize the physiotherapy care in obstetrics, the practice of the physiotherapist at the outpatient level, physiotherapy clinics, and at pregnant women’s home. Recommendations on the safety of the care environment; general aspects of care to pregnant women without symptoms of COVID-19; specific aspects of care for pregnant women without symptoms of COVID-19; care to pregnant women with COVID-19; the practice of activity and physical exercises monitored in pregnant women and the postpartum in times of pandemic and about the physiotherapist's assistance in the maternity hospital with parturients and puerperal women are still presented. Conclusion This study provides some guidance for continuity of the physiotherapist's work in obstetrics during the COVID-19 pandemic. Telephysiotherapy is a possibility for the permanence of care during the pandemic, opening new perspectives for the expansion of practice and research in women’s health, especially in obstetrics.
... 17 Sistematik inceleme kapsamındaki kadınların yaş ortalaması en düşük 20,5, en yüksek 29 ± 5,4 olarak saptanmıştır. 14, 18 Kartal ve arkadaşlarının çalışmasında epizyotomi yapılan kadınların ortalama yaşı 24,05 ± 2,4, Kalis ve arkadaşlarının çalışmasında 27,25 ± 3,91 Keramat ve Khosravi'nin çalışmasında 25,79, Karbanova'nın çalışmasında ortalama yaş 28,1 olarak saptanmış, bu sonuçlar derlemedeki sonuçlarla benzerlik göstermekle birlikte yaş ortalamalarının düşük olduğu görülmüştür. [19][20][21][22][23] Bu sonuçlar, epizyotomi uygulamasının genç annelerde daha sıklıkla yapıldığını göstermektedir. ...
... Çalışmaların on altısında, 0-10 arası puanlama yapılmış, en düşük ağrı skorları buz baketi uygulaması 1. ve 4. saatte 1,5, yüksek frekanslı TENS uygulaması 1. saatte 1,45 yüksek frekanslı TENS ve düşük frekanslı TENS uygulaması 0,27, lavanta yağı uygulaması 4. saatte 2,70, lavanta-timol yağı uygulaması 7. günde 3,5, tarçın merhemi uygulaması 10. günde 1,2, at kuyruğu merhemi uygulaması 10. günde 0,8 olarak saptanmıştır (Tablo 2). 18,[32][33][34][35][36][37][38] Nonfarmakolojik Yöntemler, Uygulama Özellikleri ve Ağrıyı Azaltmada Etkisi ...
... Düşük frekanslı TENS ve yüksek frekanslı TENS uygulamasının perineal ağrıyı rahatlatmada farklılık oluşturmadığı, fakat Yüksek Frekanslı TENS kullanımının hemen ardından ve 60 dk. sonrasında perineal ağrı şiddetinin önemli ölçüde azaldığı saptanmıştır 18,34 Benzer çalışmalarda, TENS uygulamasının primer dismenorenin tedavisinde kullanıldığı ve doğum ağrısında azalma sağladığı saptanmıştır. 51,52 TENS'in diz ağrıları ve osteoartriti olan bireylerin ağrıları için güvenli ve uygulanabilir bir yöntem olduğu belirtilmiştir. ...
... TENS has low risks of harm, including toxicity or other side effects. The postoperative analgesic benefits of TENS, along with secondary beneficial effects, is supported by previous studies following various surgeries: thoracotomies 17,18,36 , major and minor visceral surgery 4,5,15,31,37 , liposuction 13 , gynecological 16,24,28 and urological 19 , as well as orthopedic 29 and spine surgery 40 . ...
... Our trial revealed that the role of TENS in the absolute and relative reduction of pain when standing up from bed and walking was greater than that at rest. It supports previous findings that TENS reduces movement, but not resting postoperative pain and the hypothesis that TENS works through reducing hyperalgesia 29 . Some studies suggest that TENS is effective in inducing antihyperalgesia even when the electrodes were placed on the opposite side to the pain irritant 1,35,38 , because the inhibitory descending system are bilateral, diffuse, and connect both sides of the spinal cord 34 . ...
Article
Full-text available
In this randomized, double-blind, placebo-controlled trial, we evaluated the role of transcutaneous electrical nerve stimulation (TENS) in the multimodal treatment (non-opioid analgesics and kinesiotherapy) of postoperative pain following open inguinal hernia repair. In total, 80 males participants with elective primary unilateral hernia Lichtenstein repair were randomly allocated to receive TENS or a placebo-TENS procedure. The TENS group received local and segmental conventional TENS on the first and second postoperative days. In the placebo-TENS group, intensity was set at 0-0.5mA. Change of pain level at rest, when walking, when standing up from bed, pressure algometry parameters and additional analgesic use were the main outcomes. Reduction of VAS pain score and absolute and relative pain relief were observed in the TENS group following the procedures compared to the placebo-TENS group (p<0.001). The pressure pain threshold and maximal tolerable pressure in the hernia side were equal before the TENS procedure in both groups (p=0.84), but after the procedure, these were higher in TENS group (p<0.001). Additional non-opioid analgesics requirements were lower in the TENS group on the first and second postoperative days (p<0.001). TENS is a safe procedure that can reduce postoperative pain and analgesic use after open inguinal hernia repair. The study was registered in the database of clinicaltrials.gov (register number NCT03739060) Perspective This article presents TENS as a safe and effective non-pharmacologic intervention to reduce post-operative pain after open inguinal hernia repair. TENS could be used in daily practice as part of a multimodal postoperative pain treatment, especially for patients suffering from hyperalgesia.
... Enquanto para as cesarianas, nas primeiras 24 horas, é administrado dipirona sódica por via intravenosa e, após este tempo, passa a usar os mesmos medicamentos prescritos para as puérperas de parto vaginal. Outros autores observaram que mesmo as puérperas que receberam medicamentos para o alívio da dor, apresentaram dor moderada, o que sugere que eles não foram suficientes para a analgesia 2,14,20 . ...
Article
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Introdução: O parto vaginal e a cesariana podem gerar desconfortos comprometendo as atividades funcionais no puerpério. Objetivos: Comparar a dor, a amplitude de movimento (ADM), o desempenho e a limitação funcional de primíparas após o parto vaginal e cesariana. Métodos: Utilizou-se a versão curta do questionário de dor McGill (VC-QDM), a escala visual analógica (EVA), a intensidade de dor presente (IDP), o flexímetro, o teste timed up and go (TUG) e o questionário de limitação funcional. Resultados: Após o parto vaginal, houve relatos de dor “dolorida à palpação” e “cortante” com intensidade severa e IDP desconfortante. Após a cesariana, a ADM de flexão e rotações do tronco foram menores, maior intensidade de dor e necessidade de mais tempo para realização das atividades do TUG, mostrando pior desempenho funcional. Algumas limitações funcionais estiveram presente independente da via de parto. Conclusão: O grupo cesariana apresentou menor ADM, maior intensidade de dor e pior desempenho funcional. Contudo, a maioria das puérperas apresentou alguma limitação funcional.
Article
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Background and Objectives: Characterising the features of methodologies, clinical attributes and intervention protocols, of studies is valuable to advise directions for research and practice. This article reports the findings of a secondary analysis of the features from studies screened as part of a large systematic review of TENS (the meta-TENS study). Materials and Methods: A descriptive analysis was performed on information associated with methodology, sample populations and intervention protocols from 381 randomised controlled trials (24,532 participants) evaluating TENS delivered at a strong comfortable intensity at the painful site in adults with pain, irrespective of diagnosis. Results: Studies were conducted in 43 countries commonly using parallel group design (n = 334) and one comparator group (n = 231). Mean ± standard deviation (SD) study sample size (64.05 ± 58.29 participants) and TENS group size (27.67 ± 21.90 participants) were small, with only 13 of 381 studies having 100 participants or more in the TENS group. Most TENS interventions were ‘high frequency’ (>10 pps, n = 276) and using 100 Hz (109/353 reports that stated a pulse frequency value). Of 476 comparator groups, 54.2% were active treatments (i.e., analgesic medication(s), exercise, manual therapies and electrophysical agents). Of 202 placebo comparator groups, 155 used a TENS device that did not deliver currents. At least 216 of 383 study groups were able to access other treatments whilst receiving TENS. Only 136 out of 381 reports included a statement about adverse events. Conclusions: Clinical studies on TENS are dominated by small parallel group evaluations of high frequency TENS that are often contaminated by concurrent treatment(s). Study reports tended focus on physiological and clinical implications rather than the veracity of methodology and findings. Previously published criteria for designing and reporting TENS studies were neglected and this should be corrected in future research using insights gleaned from this analysis.
Article
Although many women's health physiotherapists are facing similar issues as obstetricians pertaining to the care of pregnant women with confirmed or suspected COVID‐19 infection, no specific guidelines were found regarding best practice for physiotherapists in this area. Therefore, the present study sought to offer guidance around obstetrical physiotherapy care during the COVID‐19 pandemic.
Article
Background We performed a systematic review using Consensus Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines to identify the best available patient-reported outcome measure (PROM) of postpartum pain. Methods This review follows COSMIN guidelines. We searched four databases with no date limiters, for previously identified validated PROMs used to assess postpartum pain. PROMs evaluating more than one author-defined domain of postpartum pain were assessed. We sought studies evaluating psychometric properties. An overall rating was then assigned based upon COSMIN analysis, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the level of evidence for psychometric properties of included PROMs. These assessments were used to make recommendations and identify the best PROM to assess postpartum pain. Results We identified 19 studies using seven PROMs (involving 3511 women), which evaluated postpartum pain. All included studies evaluated ≥1 psychometric property of the included PROMs. An adequate number of pain domains was assessed by the Brief Pain Inventory (BPI), Short Form-BPI (SF-BPI), and McGill Pain Questionnaire (MPQ). The SF-BPI was the only PROM to demonstrate adequate content validity and at least a low-level of evidence for sufficient internal consistency, resulting in a Class A recommendation (the best performing instrument, recommended for use). Conclusion SF-BPI is the best currently available PROM to assess postpartum pain. However, it fails to assess several important domains and only just met the criteria for a Class A recommendation. Future studies are warranted to develop, evaluate, and implement a new PROM designed to specifically assess postpartum pain.
Article
Background Physical therapists provide treatment for pain and other common complaints for women in the postpartum period, thereby contributing to the improvement of their functioning. However, before applying any interventions, physical therapists should assess their patients to identify the desired therapeutic goals. In this context, the International Classification of Functioning, Disability and Health (ICF) may be a useful tool for documenting functioning data and operationalizing collaborative goal setting. Objective To identify ICF categories and the respective domains that should be considered in the evaluation of women postpartum. Methods A consensus-building, three-round e-mail survey was conducted using the Delphi method. The sample included Brazilian physical therapists with expertise in women’s health. Meaningful content was analyzed in accordance to the ICF linking rules. The kappa coefficient and content validity index (CVI) were calculated. Results The panel consisted of 45 participants with a median age of 33 years and more than 10 years of experience in women’s health. A total of 1261 meaningful contents were identified from the responses in the first round. After consensus was achieved, a final list of 62 items was prepared, including 53 categories (11 were on structures; 15 on body functions; 12 on activities and participation; 15 on environmental factors) and nine personal factors (CVI = 0.89). Conclusion From the perception of physical therapists, an ICF-based postpartum assessment to describe functioning and disability must comprise 53 ICF categories and nine personal factors.
Chapter
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The experience of childbirth is subjective and has multidimensional components through which every woman passes in different ways. It is one of the most beautiful episodes in mother’s life, related to happiness and celebration. However, childbirth is also associated with negative emotions such as anxiety, low sense of safety, and expectation of pain. Strong and persistent pain that is associated with labor may negatively affect both mother and fetus. During labor, a woman is dealing not only with the contractions but also with the belief that the culture has made for her. Although childbirth is viewed as a normal physiological process, it can produce significant pain that requires effective pain management. The non-pharmacological approach includes a wide variety of methods to address labor pain, which prevent suffering by enhancing the psychological and spiritual components. The non-pharmacological methods of labor pain relief require patient’s preparation and antenatal education. The non-pharmacological methods that used to relief labor pain are massage, acupuncture, continuous support, positioning, breathing techniques, water immersion, music therapy, and biofeedback are some of the techniques used to achieve an effective coping level for women. The aim of this chapter is to explore women’s perception toward non-pharmacological methods during labor.
Article
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OBJECTIVE: The objective of this study was to characterize and measure perineal pain in puerperal primiparous undergoing episiotomy. METHODS: A descriptive design was conducted in 40 puerperal primiparous who underwent normal childbirth with episiotomy. Pain was measured with the Brazilian version of the McGill questionnaire (Br-MPQ). RESULTS: Participants had a mean pain level of 4.2, and the words that better characterized perineal pain were: sore; hurting, discomfort, annoying, burning, stinging, throbbing, and pressing. CONCLUSION: The intensity of perineal pain was reported to be moderate. The pain characteristics most reported consisted of the sensorial dimension. The findings of this study suggest the need for identification of both the qualitative and quantitative aspects of pain in obstetric services.
Article
Objective: To determine the psychometric properties and applicability of four pain scales in Chinese postoperative adults. Design: A prospective clinical study. Setting: A university-affiliated hospital. Patients: In total, 173 Chinese patients (age range 18-78 years) undergoing scheduled surgery. Interventions: Recalled pain and anticipated postoperative pain intensity were rated preoperatively with a visual analog scale (VAS), a numeric rating scale (NRS), a verbal descriptor scale (VDS), and the Faces Pain Scale Revised (FPS-R). From the day of surgery to the sixth postoperative day, patients were interviewed for the scores of current operative pain intensity and the worst, least, and average pain on that day. On the sixth postoperative day, retrospective ratings over the 7 days were also obtained and tool preferences were investigated. Outcome measures: Scale reliability was evaluated using intraclass correlation coefficients (ICCs). Scale validity was assessed by correlations between scales, analysis of variance with repeated measures, and the sensitivity of the scales to interventions. Chi-square tests were used to investigate if error rate and preference rate were related to gender, age, and educational level. Results: All four pain intensity scales had good reliability and validity when used with Chinese adults. The ICCs of the four scales across current, worst, least, and average pain on each postoperative day were consistently high (0.673-0.825), and all scales at each rating were strongly correlated (r = 0.71-0.99). Analysis of variance with repeated measures revealed significant decreases in scores associated with postoperative days, and all four scales were sensitive in evaluating analgesic efficacy. Both the VDS and the FPS-R had low error rates. Nearly half of the participants (48.1%) preferred the FPS-R, followed by the NRS (24.4%), the VDS (23.1%), and the VAS (4.4%); however, no significant differences were noted in terms of gender, age, and educational level. Conclusions: These findings demonstrate that although all four scales can be options for Chinese adults to report pain intensity, the FPS-R appears to be the best one. Providing tool options to address individual needs or preferences is suggested.
Article
To establish the prevalence of perineal pain, the effects of pain on postnatal recovery, analgesia used to relieve pain and the perceived effectiveness of such analgesia at the Royal Women's Hospital, Victoria, Australia. We conducted structured interviews of 215 women in the postnatal ward of a tertiary hospital, within 72 hours of a vaginal birth. The structured interviews revealed that 90% of women reported some perineal pain, with 37% reporting moderate or severe pain. The degree of perineal trauma predicted women's ratings of perineal pain on a visual analogue scale, with more severe trauma related to higher pain scores. Over a third of women experienced moderate or severe perineal pain, particularly when walking (33%) or sitting (39%), while 45% noted that pain interfered with their ability to sleep. Women reported moderate or severe perineal pain when they undertook activities involving feeding their infant (12%) or caring for their infant (12%). Women used a range of analgesia, including a combination of ice packs (69%), oral analgesia (75%), narcotic analgesia (4%) and anti-inflammatory suppositories (25%). The majority of women rated these forms of analgesia as effective and identified very few side effects. Following vaginal birth, women commonly reported pain from perineal trauma. This pain affected women's ability to mobilise and was relieved by a variety of agents. Side effects from analgesia were rare. The prevalence of perineal pain and the associated impact on women's recovery from childbirth warrants midwives' proactive care in offering a range of effective pain relief options to women.
Article
The aim of the study was to compare the pain-relieving effect and the time spent in the recovery ward after treatment with high-frequency, high-intensity transcutaneous electrical nerve stimulation (TENS) or intravenous (IV) conventional pharmacological treatment after surgical abortion. Two-hundred women who underwent surgical abortion and postoperatively reported a visual analogue scale (VAS) pain score3 were included. The patients were randomised to TENS or conventional pharmacological treatment for their postoperative pain. The TENS treatment was given with a stimulus intensity between 20 and 60 mA during 1 min and repeated once if insufficient pain relief (VAS3). In the conventional pharmacological treatment group, a maximum dose of 100 microg fentanyl was given IV. There was no difference between the groups with regard to pain relief according to the VAS pain score (TENS=VAS 1.3 vs. IV opioids=VAS 1.6; p=0.09) upon discharge from the recovery ward. However, the patients in the TENS group spent shorter time (44 min) in the recovery ward than the conventional pharmacological treatment group (62 min; p<0.0001). The number of patients who needed additional analgesics in the recovery ward was comparable in both groups, as was the reported VAS pain score upon leaving the hospital (TENS=2.0 vs. conventional pharmacological treatment=1.8, NS). These results suggest that the pain-relieving effect of TENS seems to be comparable to conventional pharmacological treatment with IV opioids. Hence, TENS may be a suitable alternative to conventional pain management with IV opioids after surgical abortion.
Article
This article is not available through ChesterRep This article describes the design, development and evaluation of a new cooling maternity gel pad for the alleviation of perineal pain. Specific details of laboratory investigations of cooling and warm curves for different gel compositions, microbiological challenge tests and MDSA data are discussed. A risk assessment for the designed established that the new device has a low hazard rating and negligible exposure potential. Women’s opinions of treatment effect are highly significant.
Article
Objective: To evaluate the effectiveness of standard regimes (ice packs and Epifoam) at relieving perineal trauma and compare these with a new cooling device (maternity gel pad). Design: A randomised controlled trial involving three treatment groups. The women were free to choose the time of initial application (within four hours after delivery) in all treatment groups and the number of subsequent treatments up to 48 hours after suturing. Setting: A midwifery unit in the north of England and then continued in the women's own homes. Participants: 120 women who had undergone an instrumental delivery and had a 48 hours post-delivery stay in a postnatal ward. Measurements and findings: The ordinal scale of none, mild, moderate and severe was used to determine the levels of perineal oedema and bruising at initial assessment (less than 4 hours), 24 hours and at 48 hours, by use of a newly developed visual evaluating tool. Self-assessed pain was recorded using a 10-point visual analogue scale within four hours, at 24 hours, 48 hours, and finally at five days after suturing. Women's opinions as to the effectiveness of their treatment was rated by use of a 5-point scale describing the categories; poor, fair, good, very good and excellent. A high proportion of women had some perineal oedema at initial assessment. A statistically significant difference in the proportion of women with oedema was found between treatment groups at 48 hours (p = 0.01), which was in favour of the maternity gel pad group. This was particularly noticeable for women with initial levels of mild oedema (p = 0.017). Localised treatment with the gel pad caused a significant decrease in reported pain at 48 hours in women who initially demonstrated moderate or severe pain (p = 0.048). A significant increase in the proportion of women with some bruising was seen across all treatment groups from initial assessment, through 24 hours to 48 hours (p < 0.0005). The bruising was significantly less in the gel-pad group in women who initially had no bruising (p = 0.021). There was no statistically significant effect of treatment at other initial levels of severity for oedema, bruising or pain at 24 hours, 48 hours and five days (for pain). Women in the gel-pad group rated the effectiveness of their localised treatment to be significantly higher than women in the other two treatment groups (p < 0.0005). Key conclusions: This trial demonstrated that a high proportion of women experience perineal oedema, bruising and pain following an instrumental delivery, which continues for at least five days for perineal pain, despite oral analgesia. Maternity gel pads, which were specially designed to cool the perineal region, were more effective in alleviating perineal trauma when compared with hospital standard regimens and were more highly rated by women.
Article
Transcutaneous Electrical Nerve Stimulation (TENS) is a non-pharmacological agent, based on delivering low voltage electrical currents to the skin. TENS is used for the treatment of a variety of pain conditions. To assess the analgesic effectiveness of TENS for acute pain in adults to see if it had any clear analgesic effect in its own right. The following databases were searched: Cochrane Pain, Palliative and Supportive Care Group Specialised Register; the Cochrane Central Register of Controlled Trials, CENTRAL (in The Cochrane Library); MEDLINE; EMBASE; CINAHL; AMED; PEDro; OTseeker; OpenSIGLE; and, reference lists of included studies. The most recent search was undertaken in August 2008. Randomised controlled trials (RCTs) of adults with acute pain (less than 12 weeks) were included if they examined TENS given as a sole treatment and assessed pain with subjective pain scales. Studies were eligible if they compared TENS to placebo TENS, no treatment controls, pharmacological interventions or non-pharmacological interventions. Studies on experimental pain, case reports, clinical observations, letters, abstracts or reviews were excluded. Studies on TENS and labour pain, pain due to dental procedures and primary dysmenorrhoea were excluded. Studies where TENS was given with another treatment as part of the formal study design were also excluded. No restrictions were made regarding language. Two authors independently assessed trial eligibility and extracted data. Data were extracted on the following: types of participants and pain condition, study design and methods, treatment parameters, adverse effects, and outcome measures. Study authors were contacted for additional information if necessary. Of 1479 studies identified in the search, 132 were identified as relevant. Of these, 116 were excluded; the vast majority of these were excluded due to TENS being given with another treatment. Four studies were categorised as awaiting classification as the information provided in the full text failed to clarify their eligibility. Twelve RCTs involving 919 participants at entry were included. The types of acute pain conditions included procedural pain, e.g. cervical laser treatment, venipuncture, screening flexible sigmoidoscopy and non-procedural pain, e.g. postpartum uterine contractions, rib fractures. It was not possible to perform a meta-analysis due to insufficient data. Due to insufficient extractable data in the studies included in this review, we are unable to make any definitive conclusions about the effectiveness of TENS as an isolated treatment for acute pain in adults.