doi 10.15296/ijwhr.2017.49 doi 10.15296/ijwhr.2015.27
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Original ReviewArticle International Journal of Women’s Health and Reproduction Sciences International Journal of Women’s Health and Reproduction Sciences Vol.Vol. 3, No. 3, July 2015, 126–131 5, No. 4, October 2017, 290–294 ISSN 2330- 4456 ISSN 2330- 4456
Women on the Other Side of War and Its Effect Nitrous Oxide Versus Lidocaine for Poverty: Pain Relief During on the Health of Reproduction Episiotomy Repair: A Randomized Trial Ayse Cevirme1, Yasemin Hamlaci2*, Kevser Ozdemir2
Nahid Javadifar1, Azam Honarmandpour2*, Zahra Abbaspoor1, Amal Saki Malehi3 Abstract
War and poverty are ‘extraordinary conditions created by human intervention’ and ‘preventable public health problems.’ War and Abstract
poverty haveSince many negative effects onishuman health, especially health. this Health problems arising due war and the poverty are of nitrous Objectives: pain reduction an important concern women’s in childbirth, study was designed totoevaluate effects being observed as sexualwith abuse and rape,on all kinds of violence andepisiotomy subsequent gynecologic and obstetricswomen. problems with physiological oxide in comparison lidocaine pain relief, during repair in primiparous and psychological courses, A and pregnanciesrandomized as the resultcontrolled of undesired butmethod forced or obliged andand even120 rapes. Certainly, Materials and Methods: prospective trial was used marriages in this study term pregnant women unjustrecruited. treatment The suchintervention as being unable to gain footingnitrous on the land lived (asylum seeker, refugee, etc.) andrepair, being deprived were group received oxideit 2is minutes before starting episiotomy until theofend of the social security, rights received and human rights about the deprivation of access to health services and of provision of procedure. Thecitizenship control group 5 mL of brings lidocaine (2%) before starting the episiotomy. The results of the 2 groups were service intended for gynecology and obstetrics. purpose of this scale article(VAS). is to address effects of war and poverty thechi-square health of test were compared with regard to pain intensity usingThe a visual analogue Mann-Whitney, student’s t teston and reproduction of women and to offer scientific contribution and solutions. used to analyze the data. Keywords: Poverty, Reproductive health, Results: Sixty women were studied in War each group. Nine participants (15%) in nitrous oxide group, as opposed to 23 participants (38.4%) in lidocaine group had moderate, severe or extremely severe pain intensity (P value = 0.005). In terms of satisfaction level, there was no significant difference between 2 groups (P value = 0.713). Conclusion: The results of this study showed that pain intensity in thethat nitrous oxide group conflicts was significantly than that in thought severe military in Africalower shorten Introduction the lidocainethe infiltration Application of nitrous oxide atthe leastexpected 2 minutes beforefor repair may be an effective method for pain lifetime more than 2 years. In general, Throughout history ofgroup. the world, the ones who had management episiotomy WHO had calculated that 269 thousand people had died confronted theinbitterest face repair. of poverty and war had alKeywords: Nitrous oxide, Episiotomy, Lidocaine, in 1999 due to the effect of wars and that loss of 8.44 milways been the women. As known poverty and warPain affects
lion healthy years of life had occurred (2,3). Wars negatively affect the provision of health services. 5 minutes after inhalation (10).laboratories Nitrous oxide Health institutions such as hospitals, and induces health centers are of direct targets of war. wars the release endorphins andMoreover, at higherthe concentrations, causethey the migration of qualified andmuscular provide analgesia, as health well asemployees, skeletal and thus relaxation the health services hitches. Assessments indi(6). Unfortunately, despitemade recommendation cate that the effect of destruction in the infrastructure of against the routine use of episiotomy, this procedure is health continues for 5-10 years even after the finalization performed for tothe majority of primiparous women in of conflicts (3). Due resource requirements in the re(Taiwan) (2,3). Episiotomy repair requires anesthesia, and structuring developing countries are a considerable investments after (3,11). war, theThere share allocated to lidocaine is usuallyHealth used for this purpose (4). Infiltration healthnumber of investigations about post perineal repair pain has decreased (1). War and Women’s Famine, synonymous with war and poverty, is clearer for of lidocaine can cause accidental intravascular injection relief after episiotomy (12,13) but there are few reports women; war means disadvantages suchedema as full due de- to Mortalities Morbiditiesof analgesia during perineal suturing and sensation of deep burning pain, and on theand effectiveness struction, loss of future(5). andToday, uncertainty for women. Wars are most from wars are womenin andchildbirth insertion of needle non-injectable methods The ones (14).who Since pain affected is an important concern are conflicts that destroy families, societies and cultures children. While deaths depending on direct violence afhave a new place in medicine to reduce pain. Nitrous and using episiotomy is inevitable in some cases, this fect the male population, the indirect deaths kill children, that negatively affect the health of community and cause oxide (combination of N and O with the equal ratio of randomized clinical trial study was conducted to evaluate 2 2 to the data of World women and elders more. In Iraq between 1990-1994, inviolation of human rights. According 50%) strong analgesic (equivalent 15 mg fant deaths the effectiveness of reality nitrous oxide to had shown this in its more in barecomparison form Healthhas Organization (WHO)effects and World Bank, into2002 of subcutaneous morphine) is frequently used in with lidocaine during episiotomy an increaseonof pain 600%intensity (4). The war taking five years repair in wars had been among the first and ten reasons which killed childbirth and emergencies by Civil medical professionals primiparous women. the child deaths under age of 5 by 13%. Also 47% the most and caused disabilities. losses are at the rate(6). increases ofStudies 90% within losses (1). haveallshown that nitrous oxide or entonox can of all the refugees in the world and 50% of asylum seekers and displaced are women and girls and 44% refWarutilized has many effects agent on human health. Onecancers of be as negative an analgesic in obstetrics, Materialspeople and Methods ugees and asylum seekers are children under the age of these is its effect of shortening the average human life. intraarticular injections, sigmoidoscopy, colonoscopy, Study Design and Participants 18 (5). According to the data of WHO, the average human life is and biopsy, (7) and it appears to provide effective This prospective randomized controlled clinical trial As the result of wars and armed conflicts, women are 68.1 years for males and 72.7 years for females. It is being human health either directly or indirectly, the effects of this condition on health and status of women in the soIntroduction ciety should not be ignored. This study intends to cast light nearly on the effects of war and poverty onhas the reproductive For 80 years, episiotomy been routinely health of women. this is purpose, the face evidence of war affectperformed but For there no strong of its ing the women, the problem of immigration, inequalities effectiveness, hence it has remained controversial (1). The in distribution of income based on gender and the effects prevalence of episiotomy varies from 10% in developed of all these on the reproductive health of women will be countries addressed. (Sweden) to 100% in developing countries
analgesia for many parturient women (7,8). However, in was conducted on primiparous women who attended a study, it was not effective in reducing pain in shoulder a referring academic hospital in the southwest of Iran Received 12 December 2014, Accepted 25 April 2015, Available online 1 July 2015 joint dislocation repair (9). The peak effect of nitrous (Shushtar). Inclusion criteria were: Primipara women 1 2 Department of Nursing, Sakarya University, Sakarya,after Turkey.inhalation Department ofand Midwifery, Sakarya University, Turkey. oxide occurred within 30 seconds between 39 Sakarya, to 42 weeks of gestation according to *Corresponding author: Yasemin Hamlaci, Department of Midwifery, Sakarya University, Sakarya, Turkey. Tel: +905556080628, persisted for about 1 minute and gradually decreased in sonographic findings or last menstrual period date, Email:
[email protected] Received 3 February 2017, Accepted 19 April 2017, Available online 20 May 2017 Reproductive Health Promotion Research Centre, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. 2Department of Midwifery, Shoushtar Faculty of Medical Sciences, Shoushtar, Iran. 3Department of Biostatistics and Epidemiology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. *Corresponding Author: Azam Honarmandpour, Tel: +989166224524, Fax: +9806136222323, Email:
[email protected] 1
Javadifar et al
mother’s age in 18 to 35 years, singleton gestation, uncomplicated pregnancy, cephalic presentation and first trimester body mass index (BMI) in range of 18.5 to 30 kg/ m2. Women were excluded if they had operative delivery, perineal laceration or large episiotomy, intact perineum and previous sensitivity to local anesthesia or nitrous oxide. Using of opioids, inhalation or pudendal block for labor pain relief is not common in our institutions.
Groups were compared with regard to pain intensity using a visual analogue scale (VAS) (Figure 1). According to this scale, zero indicates no pain, 1 to 3 mild, 4 to 6 moderate, 7 to 9 severe and 10 expresses extremely severe pain (15). Participants received explanation and were fully informed about the procedures. Confounding variables were matched for 2 groups which included incision length, type of incision, type of incision repair, and number of vaginal examinations. The procedure of episiotomy and Setting and Sampling repair was performed by one of the midwives of the institute The primary outcome measure of the present study was (A.H). She was there 6 hours per day, 4 days per week in pain intensity during episiotomy repair and secondary different working time from July to September 2015. All outcomes were satisfaction with the anesthesia and side episiotomies were performed as mediolateral episiotomy effects of N2O. The power of the study was calculated after fetal head crowning at the top of the contraction. based on a previous study in which mean pain intensity Data gathering was done by another staff, unaware of during perineal repair was 4.24 ± 2.78 (14). Based on the type of analgesia. In the delivery room after placental a study potency of 80%, an alpha of 0.05, parameters delivery, the control group received routine care and 5 ml of previous studies and attrition of 30%, the sample of lidocaine (2%) along the edges of the episiotomy with size was determined as 120 women (60 women in each frequent aspirations before starting the episiotomy repair. group). Women were allocated to each group by block Women in the intervention group received routine care randomization method in a 1:1 ratio using a randomized and inhaled nitrous oxide deeply and slowly 2 minutes computer-generated list. The allocation arm was written before starting the episiotomy repair until the end of the on cards that were sealed in sequentially numbered procedure as they were trained. Entonox mask was worn on opaque envelopes. The envelopes were opened after the the mother’s face for repeated inhalation, according to the 2010 Flow Diagram model of “deep inhale- pausing- slow exhaleenrolled women had completed the basicCONSORT evaluations. respiration
Enrollment
Assessed for eligibility (n= 192)
Excluded (n= 52 ) Not meeting inclusion criteria (n=48) Declined to participate (n=4)
Randomized (n= 140)
Allocated to intervention (n = 70) Received allocated intervention (n = 60 ) Did not receive allocated intervention (give reasons) (n = 10)
Allocation Allocated to intervention (n = 70) Received allocated intervention (n = 60 ) Did not receive allocated intervention (give reasons) (n = 10)
Follow-Up Lost to follow-up (give reasons) (n= 0)
Lost to follow-up (give reasons) (n= 0)
Discontinued intervention (give reasons) (n = 0)
Discontinued intervention (give reasons) (n = 0)
Analysis Analysed (n = 60)
Analysed (n= 60)
Figure 1. Flow Diagram of Recruitment and Retention of Participants in the Study. International Journal of Women’s Health and Reproduction Sciences, Vol. 5, No. 4, October 2017
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rest”. The women were free to use nitrous oxide whenever they liked. In all cases, episiotomies were repaired with routine technique. In Iran, mediolateral episiotomy is a common procedure especially in primipara women and the absorbable catgut used for episiotomy repair. The duration of nitrous oxide use, respiratory rate, pulse rate, blood pressure and O2 saturation were recorded by a staff before, during and after episiotomy repair. Pain intensity was measured using VAS after repair in postpartum care unit. In VAS measurement scale, number 5 was deemed as acceptable pain intensity. The questionnaire and checklist were designed based on scientific resources and 10 faculty members confirmed the content validity of the tools. Mother’s satisfaction in 2 groups was evaluated using the scale of completely satisfied, satisfied, unsatisfied, and completely unsatisfied and adverse effects of N2O were assessed in the intervention group. Statistical Analysis Data analysis was performed using SPSS version 16.0. Normality of the quantitative variables in the groups was not confirmed using Kolmogorov-Smirnov test. The Mann-Whitney U test was used to compare nonparametric variables and the t test was performed for continuous parametric variables (neonatal birth weight and head circumference). The chi-square test was performed for categorical data and the differences were considered statistically significant if P value was less than 0.05. Results Both groups showed no statistical significant difference in maternal age, education, BMI, neonatal birth weight, head circumference, duration of second and third stages of labor and gestational age (LMP and sonography). The duration of episiotomy repair was significantly lower in N2O group (Table 1). There was no significant difference between
the 2 groups in terms of clinical properties (pulse rate, respiratory rate, blood pressure and O2 saturation) and other conditions such as, rupture of amniotic membrane, requiring labor induction, participation in childbirth preparation classes, exercises and perineal massage during pregnancy (P value>0.05). None of the women in the intervention group needed lidocaine in addition to N2O to relief the pain, all participants in the intervention group tended to use N2O until the end of perineal repair. The rate of the adverse effects in the N2O group showed that 20 patients (33.3%) had no special side effects, 26 patients (43.3%) had dizziness, 7 patients (11.7%) had dry mouth (xerostomia), and 7 cases (11.7%) showed drowsiness. The adverse effects were temporary and they disappeared after termination of the inhalation. Pain intensity in the N2O group using VAS was significantly lower compared with the lidocaine group (P value
