Investigate the Utilization of Natural Measures on relieving Post Cesarean Incision Pain
Hanan A.*, Kamilia R. **, Ahmed R. ***, Amina M. ****
* Assist. Lecturer, Faculty of Nursing Mansoura University.
**Prof. of Maternity and Neonatal Nursing, Faculty of Nursing Ain Shams University.
***Prof. of Obstetric and Gynecology, Faculty of Medicine Ain Shams University.
****Assist. Prof. of Maternity and Gynecology Nursing, Faculty of Nursing Mansoura University.
Abstract:
Post cesarean section pain is a significant problem so this study aimed to investigate the utilization of natural measures on relieving post cesarean incision pain. The study design is an intervention study design. The study sample involved 150 mother divided into 75 mother as control group who received post cesarean section hospital routine analgesics for pain relief and 75 as intervention group who received foot and hand massage for 20 minutes. They were randomly selected from Ain Shams Maternity University hospital. Tools used for data collection were a structured interviewing questionnaire sheet, a numerical rating scale and short form McGill pain questionnaire. The results showed that, a statistically significant difference in mean of pain level among study groups at 6, 12, 18 hours after delivery, (p˂0.00). Also there was a statistical significant difference between mean of pain score before and after massage immediately and one hour after massage. In the light of these results the study supports the effectiveness of foot and hand massage on relieving post cesarean section pain. So this study recommended that the intervention used in this study to be a booklet or brochure about pain management post cesarean section and distributed among maternity health services in Ministry of health Egypt.
Key words: natural management, pain, cesarean incision
Introduction
Cesarean section is the birth of fetus through a trans-abdominal incision in the uterus. It is one of most common surgical procedure world wide (1).Cesarean section women had a particular condition after the operation when compared to the patients who went through other surgical procedures. As she needs to perform more activities in order to take care of the newborn and herself, therefore, she is subjected to more pains in the surgical section location (2).
Although patients tended to have the available multimodal analgesic management this was not always used to its maximum effectiveness. It was evident that analgesic administration practices did not consistently reflect management that was responsive to pain intensity nor did it always reflect a multimodal approach to treatment(3). Sousa et al. (2009) found high pain scores among cesarean section women which rated from moderate 51.7% to sever 20% in spite of using analgesics (2). In addition, the persistent pain is more common one year after cesarean section and the women with persistent pain recalled significantly more pain on the day after cesarean section (4).
It is necessary that pain relief be safe and effective, that it is not interfere with the mother's ability to move around and care for her infant, and that it is resulted in no adverse neonatal effects in breast-feeding women (5).
Recently, many complementary therapies such as music, TENS, relaxation, reflexology were effective in managing post cesarean section pain (6-8). Also massage has been shown beneficial to reduce stress, enhance blood circulation, decrease pain, promote sleep, reduce swelling, enhance relaxation, and increase oxygen capacity of the blood. It has also been recognized as a non-pharmaceutical treatment for cancer and postoperative pain (9).
Foot and hand massage has the potential to aid in pain relief. The Massage stimulates cutaneous mechanoreceptors that activate large primary afferents. They release GABA and endorphins, which inhibit neurotransmitters discharged from the primary nociceptive neurons and evoke depressive reactions within the receptive field in the pain pathway. As a result, receptor activation of second transmission neurons is blocked preventing nociceptive information from reaching consciousness (10).
According to the gate control theory painful impulses are transmitted by large diameter and small diameter nerve fibers. Stimulation of large diameter fibers prevents the small diameter fibers from transmitting signals. Tactile stimulation produced by massage travels through the large diameter fibers. These fibers also carry a faster signal. In essence, massage sensations win the race to the brain, and the pain sensations are blocked because the gate is closed (11).
Significance of the study:
Effective postoperative pain control can be achieved through non-pharmacological therapies. Massage is one of the most widely used as complimentary therapies in nursing practice. Foot and hand massage have the potential to aid pain relief (10). So this study was conducted to investigate the utilization of foot and hand massage as Natural Measures on relieving post cesarean incision pain.
Aim of the study
The aim of this study was to investigate the utilization of natural measures on relieving post cesarean incision pain.
Research Hypotheses
Foot and hand massage has positive effect on relieving post cesarean section incision pain.
Study design
This study is an intervention study design.
Setting
It was conducted on postnatal cesarean section room at Ain Shams Maternity University Hospital from January 2011 to September 2011.
Sampling
The desired sample size was calculated to be 150 women using type I error =0.05 and power of 0.80 and assuming the standard deviation of the NRS =2 a sample size of 70-75 per group is satisfactory to detect a difference of 1 between control and exposed groups. Sample size calculation is done with PS program Version 3.0.43 (12). The sample was a systematic random sample. It is divided into two groups, 75 control and 75 intervention groups.
Sample Criteria:
Post cesarean section women were selected according to the following criteria:
· Conscious women.
· women with intact hand and foot skin and free from arthritis, phlebitis, burn wound, injury, inflammation, eczema, cardiovascular and respiratory disease.
Ethical consideration:
Before conducting the study, the researcher obtained an approval form the ethical committee at Faculty of Nursing Ain Shams University. Also the researcher was obtained written consent from director of Ain Shams University Maternity Hospital to carry out the study.
Tools of the study
Three tools were used for data collection,
1. A structured interviewing questionnaire sheet containing general characteristics.
2. A numerical rating scale, it is an assessment scale with fixed scale steps, a linear line with marks spaced 1 cm apart ranging from 0 (no pain) to 10 (worst pain imaginable). It is widely preferred by national and international investigators for its applicability and clarity in determining the pain intensity of patient.
3. Modified McGill pain questionnaire short form: this scale was used by the researcher to assess pain characteristic.
Data collection
The control group received post cesarean section hospital routine care (analgesic) for pain relief measure and their pain measured at 6, 12 and 18 hours after the surgery. While the intervention group received foot and hand massage for 20 minutes, 5 minutes for each hand then 5 minutes for each foot. Foot and hand massage was applied at three times at 5:40, 11:40, 17:40 hour after delivery the researcher measure the level of pain before the massage session and immediately after massage and one hour after massage.
Technique:
The researcher applied the massage without using no special equipment, which includes petrissage, kneading, and friction applied to the patient's hands and feet using classical massage techniques. The researcher held the mother’s hand gently in one of her hands. The researcher used thumb and fingers to make circles over the mother’s entire palm, all fingers, and the outer surface of the hand. The palm was spread by the researcher’s fingers. Hand massage applied to each hand for 5 minutes avoiding an intravenous catheter inserted area if any. Following hand massage, the mother's foot was elevated by supporting it with a pillow. The sole was spread and rubbed by the researcher's fingers. The thumb was used to make circles over the entire sole of the foot. The knuckles of one hand stroked the sole with an up-and-down motion. The heel and ankle was kneaded between the researcher's thumb and forefinger. The pillow support was removed to finish the massage (10).
Table (1): Comparison between mean score of pain level among control and intervention groups at 6, 12 & 18 hours post Cesarean.
Variables / Groups / SignificanceControl / Intervention / T / P- value
Pain level score 6 hours after delivery
Mean & S.D / 6.44±1.90 / 4.09±1.55 / 8.23 / 0.00**
Pain level score 12 hours after delivery
Mean & S.D / 5.37±1.84 / 3.05±1.17 / 9.22 / 0.00**
Pain level score 18 hours after delivery
Mean & S.D / 3.52±1.40 / 1.84±1.10 / 8.17 / 0.00**
* Statistically significant (p <0.05) ** Statistically highly significant (p <0.001 )
Table (2): Pair wise comparison of pain scores before and after foot and hand massage in intervention group
Variables / Mean / SD / 95% Confidence Interval of the Difference / SignificantLower / Upper / T / P- value
Pain score before 1st massage and immediately after 1st massage / 2.813 / ±0.485 / 2.702 / 2.925 / 50.26 / 0.00**
Pain score before 1st massage and one hour after 1st massage / 2.107 / ±0.669 / 1.953 / 2.261 / 27.26 / 0.00**
Pain score before 1st massage and one and half hour after 1st massage / 1.360 / ±0.799 / 1.176 / 1.544 / 14.74 / 0.00**
Pain score before 2nd massage and immediately after 2nd massage / 2.880 / ±0.434 / 2.780 / 2.980 / 57.51 / 0.00**
Pain score before 2nd massage and one hour after 2nd massage / 2.227 / ±0.628 / 2.082 / 2.371 / 30.73 / 0.00**
Pain score before 2nd massage and one and half hour after 2nd massage / 1.560 / ±0.740 / 1.390 / 1.730 / 18.27 / 0.00**
Pain score± before 3rd massage and immediately after 3rd massage / 2.493 / ±0.529 / 2.372 / 2.615 / 40.78 / 0.00**
* Statistically significant (p <0.05) ** Statistically highly significant (p <0.001)
Table (3): Comparison of Mother's pain description between study groups.
Variables / Groups / SignificanceControl / Intervention / X2 / P- value
No / % / No / %
Stabbing / 1 / 1.3 / 10 / 13.3 / 7.946 / 0.05*
Spasmodic (cramping) / 39 / 52.0 / 27 / 36.0 / 3.896 / 0.048*
Hot burning / 12 / 16.0 / 12 / 16.0 / 0 / 1.0
Aching / 16 / 21.3 / 22 / 29.3 / 1.269 / 0.260
Heavy / 1 / 1.3 / 7 / 9.3 / 4.754 / 0.029*
Tender / 2 / 2.7 / 9 / 12.0 / 4.807 / 0.028*
Cutting / 18 / 24.0 / 29 / 38.7 / 3.749 / 0.053
Fearful / 0 / 0.0 / 9 / 12.0 / 9.574 / 0.002*
Punishing / 0 / 0.0 / 1 / 1.3 / 1.007 / 0.316
Pulling / 16 / 21.3 / 18 / 24.0 / 0.152 / 0.697
spreading / 3 / 4.0 / 6 / 8.0 / 1.064 / 0.302
Throbbing / 25 / 33.3 / 27 / 36 / 0.118 / 0.731
* Statistically significant (p <0.05)
Table (4): Frequency distribution of observed mother's behavior immediately post cesarean birth among control compared to intervention group.
Variables / Groups / SignificantControl / Intervention / X2 / P- value
No / % / No / %
Moaning / 24 / 32.0 / 34 / 45.3 / 2.811 / 0.094
Crying / 19 / 25.3 / 22 / 29.3 / 0.302 / 0.583
Grimace / 27 / 36.0 / 34 / 45.3 / 1.354 / 0.245
Clenched teeth / 17 / 22.7 / 25 / 33.3 / 2.116 / 0.146
Lip pitting / 13 / 17.3 / 23 / 30.7 / 3.655 / 0.056
Wrinkled fore head / 14 / 18.7 / 14 / 18.7 / 0.000 / 1.0
Restlessness / 6 / 8.0 / 10 / 13.3 / 1.119 / 0.290
Immobilization / 34 / 45.3 / 22 / 29.3 / 4.103 / 0.043*
Changing position in bed / 4 / 5.3 / 6 / 8.0 / 0.429 / 0.513
* Statistically significant (p <0.05)
Table (5): Frequency distribution regarding mother's first mobility post cesarean section among intervention compared to control group.
Mobility after delivery / Groups / SignificantControl / Intervention / T / P- value
Mean / 9.37 / 9.08 / 0.366 / 0.72*
Median / 9 / 8
Std. Deviation / 3.039 / 3.467
* Not statistically significant (p >0.05)
Table (6): Frequency distribution of intervention and control groups regarding conditions aggravating pain.
Conditions aggravating pain / Groups / SignificantControl / Intervention / X2 / P- value
No / % / No / %
Sitting / 35 / 46.7 / 33 / 44.0 / 0.108 / 0.743
Standing / 24 / 32.0 / 26 / 34.7 / 0.120 / 0.729
Walking / 21 / 28.0 / 31 / 41.3 / 2.943 / 0.086
Defecation / 2 / 2.7 / 2 / 2.7 / 0 / 1.0
Carrying the newborn / 40 / 53.3 / 21 / 28.0 / 9.974 / 0.002*
Breast feeding / 40 / 53.3 / 24 / 32.0 / 6.977 / 0.008*
Cough/sneezing / 15 / 20.0 / 16 / 21.3 / 0.041 / 0.840
Movement (turning in bed) / 44 / 58.7 / 53 / 70.7 / 2.363 / 0.124
Urination / 4 / 5.3 / 7 / 9.3 / 0.883 / 0.347
* Statistically significant (p <0.05)
Analysis of the Results
Table (1) highlights a value shows that a statistically significant difference in mean of pain level among study groups at 6, 12, 18 hours after delivery, (P-value˂0.000). As mean of pain level was (6.44±1.9, 5.37±1.84, 3.52±1.4) in control group versus (4.09±1.55, 3.05±1.17, 1.84±1.1) in intervention group after foot and hand massage.