Perineal Pain Management with Cryotherapy after Vaginal Delivery: A Randomized Clinical Trial

Abstract

Introduction Systematic reviews that evaluate the perineal cryotherapy to reduce pain in the vaginal postpartum are inconclusive.

Purpose To evaluate clinical effectiveness of cryotherapy in the management of humanized postpartum perineal pain and vaginal edema.

Methods A double-bind randomized controlled clinical trial (UTN number: U1111–1131–8433) was conducted in a hospital in Northeastern, Brazil. Women were included following humanized childbirth. All had vaginal deliveries of a single, full-term pregnancy with cephalic presentation. Exclusion criteria included previous perineal lesion, episiotomy during the current delivery, instrumental delivery, uterine curettage and postpartum hemorrhage. In the experimental group, an ice pack was applied six times on the perineum for 20 minutes, reducing the temperature between 10 and 15 ° C, then 60 minutes without exposure to cold. In the non-cryotherapy, a water bag unable to reduce the temperature to this extent was used, compliance with the same application protocol of the first group. Perineal temperature was monitored at zero, 10 and 20 minutes for application in both groups. Evaluations were made immediately before and after the applications and 24 hours after delivery spontaneous, to determine the association between variables.

Results A total of 80 women were included in the study, 40 in each group. There was no significant difference in scores of perineal pain and edema between the groups with or without cryotherapy until 24 hours after childbirth. There was no difference between groups when accomplished repeated measures analysis over the 24 hours after delivery, considering the median perineal pain (p = 0.3) and edema (p = 0.9). Perineal cryotherapy did not influence the amount of analgesics used (p = 0.07) and no adverse effect was registered.

Conclusion The use of cryotherapy following normal vaginal delivery within the concept of humanized minimally interventionist childbirth had no effect on perineal pain and edema, since it was already substantially lower, nor the need for pain medicaments.

Resumo

Introdução Revisões sistemáticas que avaliam a crioterapia perineal para redução da dor no pós-parto por via vaginal são inconclusivas.

Objetivo Avaliar a efetividade clínica da crioterapia para controlar a dor e o edema perineais após parto vaginal humanizado.

Métodos Ensaio clínico (n° UTN: U1111–1131–8433) randomizado controlado duplo-cego, realizado em uma maternidade no Nordeste do Brasil. Incluíram-se mulheres após parto vaginal humanizado, de gestação única, cefálica, a termo, e foram excluídas aquelas com lesão perineal prévia, episiotomia no parto atual, parto instrumental e hemorragia perineal ativa. O grupo experimental foi submetido a seis aplicações de bolsa de gelo triturado na região do períneo, por 20 minutos, reduzindo a temperatura entre 10 e 15°C, com 60 minutos entre as aplicações. O grupo sem crioterapia recebeu uma bolsa de água, que não reduzia a temperatura a esse nível, respeitando o mesmo protocolo de aplicação do primeiro grupo. A monitorização da temperatura perineal foi realizada nos minutos zero, 10 e 20 de aplicação, em ambos os grupos. Para determinar a associação entre as variáveis, foram realizadas avaliações imediatamente antes e após as aplicações e 24 horas após o parto.

Resultados Foram incluídas 80 puérperas no estudo, sendo 40 em cada grupo. Não houve diferença significativa para os escores de dor e edema perineais entre os grupos com ou sem crioterapia até 24 horas após o parto. Não houve diferença entre os grupos quando realizada análise de medidas repetidas em todas as avaliações, considerando a mediana dos escores de dor (p = 0,3) e edema (p = 0,9) perineais. A crioterapia perineal não influenciou na quantidade de analgésicos utilizados (p = 0,07) e nenhum efeito adverso foi registrado.

Conclusões A utilização da crioterapia após parto vaginal humanizado, minimamente intervencionista, não modifica escores de dor e edema perineais, por já serem, substancialmente, baixos, tampouco altera a necessidade de medicamentos analgésicos.

Keywords

cryotherapy - pain management - perineum - postpartum period - natural childbirth

Palavras-chave

crioterapia - manejo da dor - períneo - período pós-parto - parto normal

• References

• 1 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 (1) 93-97
• 2 Persico G, Vergani P, Cestaro C, Grandolfo M, Nespoli A. Assessment of postpartum perineal pain after vaginal delivery: prevalence, severity and determinants. A prospective observational study. Minerva Ginecol 2013; 65 (6) 669-678
• 3 Li WY, Liabsuetrakul T, Stray-Pedersen B. Effect of mode of delivery on perceived risks of maternal health outcomes among expectant parents: a cohort study in Beijing, China. BMC Pregnancy Childbirth 2014; 14: 12
• 4 Hasegawa J, Leventhal LC. Pharmacological and non pharmacological treatment for relief of perineal pain after vaginal delivery. Einstein (São Paulo) 2009; 7 (2) 194-200
• 5 Pitangui ACR, Sousa L, Ferreira CHJ, Araujo RC, Nakano AMS. Análise da prescrição de medidas terapêuticas para o alívio da dor em puérperas pós-episiotomia. Rev Bras Fisioter. 2007; 11 (Suppl): 80
• 6 Lu YY, Su ML, Gau ML, Lin KC, Au HK. The efficacy of cold-gel packing for relieving episiotomy pain - a quasi-randomised control trial. Contemp Nurse 2015; 50 (1) 26-35
• 7 Cameron H. Midwives benefit from good postnatal care, too. Pract Midwife 2014; 17 (7) 14-16
• 8 Byrom A. Perineal pain in focus: reviewing topical anaesthetic treatments. Pract Midwife 2015; 18 (7) 24 , 26–27
• 9 Chiarelli P, Cockburn J. Postpartum perineal management and best practice. Aust Coll Midwives Inc J 1999; 12 (1) 14-18
• 10 Bavaresco GZ, Souza RSO, Almeica B, Sabatino JH, Dias M. The physiotherapist as a professional to assist pregnant women. Cien Saude Colet 2011; 16 (7) 3259-3266
• 11 Francisco AA, de Oliveira SM, Leventhal LC, de Bosco CS. Cryotherapy after childbirth: the length of application and changes in perineal temperature. Rev Esc Enferm USP 2013; 47 (3) 555-561
• 12 Carvalho GA, Chierichetti HSL. Avaliação da sensibilidade cutânea palmar nas aplicações de crioterapia por bolsa de gelo e bolsa de gel. Rev Bras Ciênc Mov. 2006; 14 (1) 23-30
• 13 Chesterton LS, Foster NE, Ross L. Skin temperature response to cryotherapy. Arch Phys Med Rehabil 2002; 83 (4) 543-549
• 14 Brancaccio N, Klein AA, Böettche GA , et al. Análise de lesão muscular em ratos treinados e sedentários submetidos a crioterapia. Fisioter Mov 2005; 18 (1) 59-65
• 15 Pestre CM, Bastos FN, Netto Júnior J, Vanderlei LCM, Hoshi RA. Métodos de recuperação pós-exercício: uma revisão sistemática. Rev Bras Med Esporte. 2009; 15 (2) 138-144
• 16 Swenson C, Swärd L, Karlsson J. Cryotherapy in sports medicine. Scand J Med Sci Sports 1996; 6 (4) 193-200
• 17 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 (1) 48-55
• 18 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; 5 (5) CD006304
• 19 Mac Auley DC. Ice therapy: how good is the evidence?. Int J Sports Med 2001; 22 (5) 379-384
• 20 Chapman CR, Syrjala KL. Measurement of pain. In: Bonica JJ, editor. The management of pain. 2nd ed. Philadelphia: Lea & Febiger; 1990. . p. 580–94
• 21 Riesco MLG, de Oliveira SM. Postnatal perineal edema assessment: agreement among observers. Rev Gaucha Enferm 2007; 28 (4) 465-472
• 22 Marston L, Sedgwick P. Randomised controlled trials: missing data. BMJ 2014; 349: g4656
• 23 Steen M. A randomised controlled trial to evaluate the effectiveness of localised cooling treatments in alleviating perineal trauma: the APT study. Midwifery Dig. 2002; 12 (3) 373-376
• 24 de Souza Bosco Paiva C, Junqueira Vasconcellos de Oliveira SM, Amorim Francisco A, da Silva RL, de Paula Batista Mendes E, Steen M. Length of perineal pain relief after ice pack application: A quasi-experimental study. Women Birth 2016; 29 (2) 117-122
• 25 Petrocnik P, Marshall J. Hands-on or hands-poised: what does the evidence say?. Pract Midwife 2015; 18 (7) 10-12
• 26 Dresang LT, Yonke N. Management of spontaneous vaginal delivery. Am Fam Physician 2015; 92 (3) 202-208
• 27 Macarthur AJ, Macarthur C. Incidence, severity, and determinants of perineal pain after vaginal delivery: a prospective cohort study. Am J Obstet Gynecol 2004; 191 (4) 1199-1204
• 28 Pitangui ACR, Araújo RC, Bezerra MJS, Ribeiro CO, Nakano AMS. Low and high-frequency TENS in post-episiotomy pain relief: a randomized, double-blind clinical trial. Braz J Phys Ther 2014; 18 (1) 72-78
• 29 Amorim Francisco A, Junqueira Vasconcellos de Oliveira SM, Barbosa da Silva FM, Bick D, Gonzalez Riesco ML. Women's experiences of perineal pain during the immediate postnatal period: a cross-sectional study in Brazil. Midwifery 2011; 27 (6) e254-e259
• 30 Turmo M, Echevarria M, Rubio P, Almeida C. Development of chronic pain after episiotomy. Rev Esp Anestesiol Reanim 2015; 62 (8) 436-442
• 31 Imarengiaye CO, Andet ABA. Postpartum perineal pain among Nigerian women. West Afr J Med 2008; 27 (3) 148-151
• 32 Carroli G, Belizan J. Episiotomy for vaginal birth. Cochrane Database Syst Rev 2000; (2) CD000081
• 33 Chang SR, Chen KH, Lin HH, Chao YMY, Lai YH. Comparison of the effects of episiotomy and no episiotomy on pain, urinary incontinence, and sexual function 3 months postpartum: a prospective follow-up study. Int J Nurs Stud 2011; 48 (4) 409-418
• 34 Hubb AJ, Orr KL, Stockdale CK. Puerperal vulvar edema and hematoma complicated by overuse of cold therapy—a report of two cases. J Low Genit Tract Dis 2015; 19 (2) e28-e30
• 35 World Health Organization. Care in normal birth: a practical guide. Geneva: WHO; 1996