Hot and cold therapy for the treatment of perineal pain after vaginal delivery: Does Evidence support Traditional prac

1. Hot and cold therapy for the treatment of perineal pain after vaginal delivery:  Does Evidence support Traditional practice? Neddi Badgett Violet Kubwalo-Darrow Brenna Jones Keri Lyons Jessica Worrall

2. OUCH! Perineal injury continues to affect the majority of women. 85% will sustain some degree of trauma. Morbidity is a major health problem for women throughout the world. Women report perineal injury and stitches as the worst thing about giving birth. ��Pain and discomfort from perineal trauma can dominate the experience of early motherhood� (Walker, 1990). In the US, there are 2.8 million vaginal births per year. 85% of women will sustain some degree of perineal trauma. Pain relief is an important aspect of nursing care among women with perineal trauma. In the US, there are 2.8 million vaginal births per year. 85% of women will sustain some degree of perineal trauma. Pain relief is an important aspect of nursing care among women with perineal trauma.

3. Causes of Perineal trauma Tears are spontaneous Classified by the severity and what tissue layers are involved : First degree Second degree Third degree Fourth degree First degree tear involves perineal skin layer only Second degree tear involves posterior vaginal wall, Third degree tear involves the same structures as for second degree tears and, in addition; the anal sphincter. A fourth degree tear involves the anal sphincter complex (EAS and IAS) and anal epithelium. The most frequent occurring injury among the women studied is the second degree tear. First degree tear involves perineal skin layer only Second degree tear involves posterior vaginal wall, Third degree tear involves the same structures as for second degree tears and, in addition; the anal sphincter. A fourth degree tear involves the anal sphincter complex (EAS and IAS) and anal epithelium. The most frequent occurring injury among the women studied is the second degree tear.

4. Causes of perineal trauma, cont. Surgically induced by performing an episiotomy. Tissue layers involved are similar to a second degree tear. An episiotomy is performed when there is an indication to intervene, such as the fetus being in distress or when a forceps delivery is necessary. The picture demonstrates an episiotomy incision: The perineum is cut on an angle with scissors After delivery, the layers of muscle and skin are repaired  An episiotomy is performed when there is an indication to intervene, such as the fetus being in distress or when a forceps delivery is necessary. The picture demonstrates an episiotomy incision: The perineum is cut on an angle with scissors After delivery, the layers of muscle and skin are repaired

5. Consequences Short-term Outcomes Include: Pain and discomfort when sitting and voiding Inhibited mobility Impaired ability to care for baby Contributes to poor lactation Insomnia. Long-term Outcomes Include: Depression Maternal exhaustion Contributes to stress incontinence Dyspareunia Affects relationship with partner. Perineal trauma has short- and long-term negative consequences. The well-being of a newborn is so dependent on the health and functional abilities of their mother, therefore pain is a priority concern. ��Perineal pain and discomfort may disrupt breastfeeding, family life and sexual relationships�. In the first 3 months post delivery approximately 23% of women report dyspareunia 19% urinary incontinence Up to 10% fecal incontinence Perineal trauma affects the majority of women and there is limited evidence on how to prevent it. Severity of the injury, and uncontrolled pain lead to social and psychological consequences for these women. Perineal trauma has short- and long-term negative consequences. The well-being of a newborn is so dependent on the health and functional abilities of their mother, therefore pain is a priority concern. ��Perineal pain and discomfort may disrupt breastfeeding, family life and sexual relationships�. In the first 3 months post delivery approximately 23% of women report dyspareunia 19% urinary incontinence Up to 10% fecal incontinence Perineal trauma affects the majority of women and there is limited evidence on how to prevent it. Severity of the injury, and uncontrolled pain lead to social and psychological consequences for these women.

6. Existing treatments The following methods have been used to relieve the pain of perineal trauma: Oral analgesia Warm and cold sitz bath Medicated Suppository Lidocaine gel Localized cooling pad � Past and current practice include all of the above: Past and current practice include all of the above:

7. Guidelines The National Institute for Health and Clinical Excellence ACOG AWHONN The National Institute for Health and Clinical Excellence states :Topical cold therapy is an effective method of pain relief It�s important to note that this guideline neither mentions nor recommend warm sitz baths for perineal pain relief. *this guideline is utilizes by nurses overseas, at this time.* ACOG guidelines for the care of postpartum perineal pain include: Ice packs from 12 to 24 hours after delivery warm sitz baths after 24 hours and analgesics AWHONN patient handouts teach the use of continuous ice packs on the perineum to minimize swelling, and the use of warm or iced sitz baths to relieve pain and promote healing. The National Institute for Health and Clinical Excellence states :Topical cold therapy is an effective method of pain relief It�s important to note that this guideline neither mentions nor recommend warm sitz baths for perineal pain relief. *this guideline is utilizes by nurses overseas, at this time.* ACOG guidelines for the care of postpartum perineal pain include: Ice packs from 12 to 24 hours after delivery warm sitz baths after 24 hours and analgesics AWHONN patient handouts teach the use of continuous ice packs on the perineum to minimize swelling, and the use of warm or iced sitz baths to relieve pain and promote healing.

8. PICO question How does the administration of cold therapy compare to the use of warm sitz baths in decreasing women's perineal pain after a vaginal delivery? The question we investigated was:The question we investigated was:

9. Break it down Population Women after vaginal delivery Dependent variable Perineal Pain Contributing factors Severity of trauma Risk of trauma Type of trauma sustained

10. Break it down Variables Independent variables Cold therapy Warm sitz baths Cold therapy- Cooling of the perineum by various methods, such as iced sitz baths, gel pads, or ice packs with the intention of producing an analgesic effect by inducing numbness and decreasing inflammation. Warm sitz baths- A warm water soak for the perineum, it is now given with a small tub placed on the toilet, historically promoted to reduce the risk of infection from perineal trauma and promoting maternal comfort by decreasing perineal pain. Cold therapy- Cooling of the perineum by various methods, such as iced sitz baths, gel pads, or ice packs with the intention of producing an analgesic effect by inducing numbness and decreasing inflammation. Warm sitz baths- A warm water soak for the perineum, it is now given with a small tub placed on the toilet, historically promoted to reduce the risk of infection from perineal trauma and promoting maternal comfort by decreasing perineal pain.

11. Review of the literaturePerineal Pain Following Childbirth: Prevalence, Efforts on Postnatal Recovery and Analgesia Usage. A survey tertiary hospital in Australia 215 women who had delivered in the last 72 hours Focused on pain levels during specific activities, and relief after the different forms of analgesia. In our extensive search of the literature, we noted that recent studies on cold therapy were all done outside the U.S. and most were done by midwives. East & colleagues published an article in 2010, which compared the effects of different forms of analgesia: cold packs analgesia pills analgesia suppositories, and pain injections Among the women studies they had intact perineums sutured or unsutured perineal tears ( up to 2nd degree) and women who underwent episiotomy In our extensive search of the literature, we noted that recent studies on cold therapy were all done outside the U.S. and most were done by midwives. East & colleagues published an article in 2010, which compared the effects of different forms of analgesia: cold packs analgesia pills analgesia suppositories, and pain injections Among the women studies they had intact perineums sutured or unsutured perineal tears ( up to 2nd degree) and women who underwent episiotomy

12. Review of the literaturePerineal Pain Following Childbirth: Prevalence, Efforts on Postnatal Recovery and Analgesia Usage, cont. Findings: Pain was relieved by a variety, or combination of methods There were barriers to women using ice packs Conclusion Ice pack analgesia is effective. There is a need for more evidence regarding the effectiveness of cooling treatments in perineal pain. Findings: Pros: 59% of women surveyed felt that pain relief from the use of ice packs was effective with some reporting extremely effective. The highest usage of ice packs was among women who had sutured perineal tears and episiotomy. There were barriers to the use of ice packs, which included: providers recommendation to give only to women with sutured tears or episiotomy lack of comfort of ice packs r/t sharp edges women�s negative perception of chill factor to perineal area proximity of women�s room to an ice machine sensation of wetness as ice melted Conclusion: Ice pack analgesia is effective in relieving pain. A randomized controlled trial is needed to determine optimal forms of analgesia including the effectiveness of cooling agents on perineal pain. Findings: Pros: 59% of women surveyed felt that pain relief from the use of ice packs was effective with some reporting extremely effective. The highest usage of ice packs was among women who had sutured perineal tears and episiotomy. There were barriers to the use of ice packs, which included: providers recommendation to give only to women with sutured tears or episiotomy lack of comfort of ice packs r/t sharp edges women�s negative perception of chill factor to perineal area proximity of women�s room to an ice machine sensation of wetness as ice melted Conclusion: Ice pack analgesia is effective in relieving pain. A randomized controlled trial is needed to determine optimal forms of analgesia including the effectiveness of cooling agents on perineal pain.

13. Review of the literatureEffectiveness of cooling gel pads and ice packs on perineal pain 121 primiparous women randomized control trial investigated the effectiveness of localized cooling treatments on intensity of pain, wound healing , and overall satisfaction. Abedian & colleagues conducted a randomized control trial of 121 primaparous women These first time moms with episiotomies were divided into 3 groups: Those using cooling gel packs Those using ice packs Those using no localized treatment. The intensity of pain was measured on a 0-10 numerical scale and wound healing was evaluated by the REEDA scale which includes redness, edema, ecchymosis, discharge, and approximation of skin edges. The patient�s overall satisfaction with pain control was measured. **note* the gel pads were developed in 1999 by a midwifery team (Steen and Cooper) after consumer feedback, ie complaints about ice packs. This was done in the UK. Abedian & colleagues conducted a randomized control trial of 121 primaparous women These first time moms with episiotomies were divided into 3 groups: Those using cooling gel packs Those using ice packs Those using no localized treatment. The intensity of pain was measured on a 0-10 numerical scale and wound healing was evaluated by the REEDA scale which includes redness, edema, ecchymosis, discharge, and approximation of skin edges. The patient�s overall satisfaction with pain control was measured. **note* the gel pads were developed in 1999 by a midwifery team (Steen and Cooper) after consumer feedback, ie complaints about ice packs. This was done in the UK.

14. Review of the literatureEffectiveness of cooling gel pads and ice packs on perineal pain Findings: Localized cooling treatments are effective in alleviating perineal pain Ice packs were less effective than cooling gel pads in decreasing pain Conclusion Cooling gel pads are more effective in alleviating perineal pain and increasing wound healing rates then ice packs or no localized treatment Findings: the cooling gel pads proved to significantly reduce perineal pain, increase wound healing rates, and increase the patient�s satisfaction. The use of oral analgesia was also reduced in the women who used the cooling gel pads. Although the ice packs provided the cooling affect, patients were less satisfied overall with comfort and satisfaction, Also only women who had an episiotomy were allowed to participate in study. Other perineal traumas were excluded. Conclusion: Women�s views to treatment for perineal pain on wound healing are important. This study concludes that cooling gel pads were more effective in alleviating perineal pain without adverse affects. Traditional ice packs were less effective and less comfortable. Both cooling methods had better outcomes then no localized treatment.Findings: the cooling gel pads proved to significantly reduce perineal pain, increase wound healing rates, and increase the patient�s satisfaction. The use of oral analgesia was also reduced in the women who used the cooling gel pads. Although the ice packs provided the cooling affect, patients were less satisfied overall with comfort and satisfaction, Also only women who had an episiotomy were allowed to participate in study. Other perineal traumas were excluded. Conclusion: Women�s views to treatment for perineal pain on wound healing are important. This study concludes that cooling gel pads were more effective in alleviating perineal pain without adverse affects. Traditional ice packs were less effective and less comfortable. Both cooling methods had better outcomes then no localized treatment.

15. Review of the literatureAlleviating postnatal perineal trauma: to cool or not to cool? A systematic review of 8 studies. To identify cooling methods that were effective in cooling the perineum to promote pain relief and reduce inflammation, to assess use of analgesia, adverse outcomes in relation to healing, and maternal satisfaction. Steen & colleagues conducted a systematic review of 8 studies to compare two cooling methods: iced sitz baths cooling devices such as, ice packs or cold gel pads. Steen & colleagues conducted a systematic review of 8 studies to compare two cooling methods: iced sitz baths cooling devices such as, ice packs or cold gel pads.

16. Review of the literatureAlleviating postnatal perineal trauma: to cool or not to cool?,  Findings: Localized cooling of the perineum reduces perineal pain and inflammation. Women preferred cold gel pads or cold gel packs. There is a reduction in use of iced sitz baths due to women�s aversion to this cooling method. � Conclusion: The findings suggest localized cooling may reduce inflammation and perineal pain, but further research is needed to address specific interventions and varying amounts of time for each intervention, to determine most effective cooling treatments. Conclusion:Maternal preference was for ice packs or cold gel pads, and it was noted that there was a high refusal rate for iced sitz baths, suggesting why there has been a decline in it�s use. There is inadequate evidence to support which cooling method is most effective. Conclusion:Maternal preference was for ice packs or cold gel pads, and it was noted that there was a high refusal rate for iced sitz baths, suggesting why there has been a decline in it�s use. There is inadequate evidence to support which cooling method is most effective.

17. REVIEW OF the LiteratureSystematic Review: Local cooling for relieving pain from perineal trauma sustained during childbirth A Meta Analysis from Cochrane Seven randomized control trials were used, with 859 participants included. Compared the use of local cooling treatments, no treatment, witch hazel, pulsed electromagnetic energy, Epifoam, or warm baths for the treatment of perineal trauma following childbirth. East & colleagues conducted a meta-analysis in collaboration with Cochrane Library in which 7 randomized control studies were reviewed. This analysis was published in 2009. There were 859 participants and these variables were compared Local cooling treatments Witch hazel pulsed electromagnetic energy, otherwise known as ultrasound epifoam (hydrocortisone/pramoxine foam Warm baths The studies included in this analysis evaluated cooling treatments for 10 to 20 minutes , with no adverse effects noted. East & colleagues conducted a meta-analysis in collaboration with Cochrane Library in which 7 randomized control studies were reviewed. This analysis was published in 2009. There were 859 participants and these variables were compared Local cooling treatments Witch hazel pulsed electromagnetic energy, otherwise known as ultrasound epifoam (hydrocortisone/pramoxine foam Warm baths The studies included in this analysis evaluated cooling treatments for 10 to 20 minutes , with no adverse effects noted.

18. Review of the literatureSystematic Review: Local cooling for relieving pain from perineal trauma sustained during childbirth, Findings: Ice packs provided improved pain relief Women preferred the usability of gel pads as compared to ice packs, though no difference in pain relief was noted. There is limited evidence to support the effectiveness of the cooling treatment. � Conclusion The use of cooling treatments is common, but further research is indicated to find the most effective treatment to provide optimal relief. Conclusion: Multiple methods of cooling for pain relief were evaluated. These included: iced baths, cold gel pads, and ice packs to the perineum. Out of the seven studies, one study reported less perineal pain when ice packs were used compared to no treatment. It is probable that more than one treatment will be needed for pain relief, as oral analgesics to local anesthetics. Conclusion: Multiple methods of cooling for pain relief were evaluated. These included: iced baths, cold gel pads, and ice packs to the perineum. Out of the seven studies, one study reported less perineal pain when ice packs were used compared to no treatment. It is probable that more than one treatment will be needed for pain relief, as oral analgesics to local anesthetics.

19. Review of the literaturePerineal analgesia with an ice pack after spontaneous vaginal delivery Randomized control trial Sao Paulo, Brazil 114 nulliparous women Women were divided into three treatment groups, receiving cold therapy, a placebo of room temperature water, and no treatment. Conducted after Cochrane review to determine temperature needed for therapeutic effect of cold therapy. Oliveria & colleagues conducted a randomized control trial of 114 nulliparous women in Brazil. This study was conducted after the Cochrane review Women were divided into different treatment groups. Some were given cold therapy Room temperature water And no treatment This study was to determine temperature needed for therapeutic effects.Oliveria & colleagues conducted a randomized control trial of 114 nulliparous women in Brazil. This study was conducted after the Cochrane review Women were divided into different treatment groups. Some were given cold therapy Room temperature water And no treatment This study was to determine temperature needed for therapeutic effects.

20. Review of the literaturePerineal analgesia with an ice pack after spontaneous vaginal delivery Findings: A significant decrease in pain after cold pack application. Aversion to using an ice pack. A similar decrease in pain was noted in placebo group Conclusion An ice pack used for 20 minutes is useful in reducing perineal pain. The temperature recommended for therapeutic effect is 55F (12.6C) More research is necessary to validate findings of study. There was no significant difference in the decrease in pain between the experimental and control groups. Cold is effective by alleviating muscle spasm and reducing the activity of the muscle spindle and the speed of peripheral nerve conduction, thereby increasing the pain threshold. Conclusions are: --ice pack useage for 20 minutes helps reduce perineal pain. --therapeutic temperature of ice packs was 55.F --we need more research to validate study. There was no significant difference in the decrease in pain between the experimental and control groups. Cold is effective by alleviating muscle spasm and reducing the activity of the muscle spindle and the speed of peripheral nerve conduction, thereby increasing the pain threshold. Conclusions are: --ice pack useage for 20 minutes helps reduce perineal pain. --therapeutic temperature of ice packs was 55.F --we need more research to validate study.

21. Review of the literatureSitz Bath: Where is the evidence? Scientific Basis of a common practice 36 published articles Focused on determining the existence of evidence to justify use of sitz baths in management of anorectal disorder Recent studies on the effectiveness of sitz baths is severely limited, as most research was conducted in the 80�s. Only these 2 recent studies were found after extensive literature search and they do not directly address pain, but the variables of healing and infection. Tejirian & colleagues review of 36 published articles related to sitz bath usage. This study focused on finding evidence to justify use of sitz baths in treatment of anorectal disorders. Recent studies on the effectiveness of sitz baths is severely limited, as most research was conducted in the 80�s. Only these 2 recent studies were found after extensive literature search and they do not directly address pain, but the variables of healing and infection. Tejirian & colleagues review of 36 published articles related to sitz bath usage. This study focused on finding evidence to justify use of sitz baths in treatment of anorectal disorders.

22. Review of the literatureSitz Bath: Where is the evidence? Scientific Basis of a common practice Findings: Cold sitz bath reduce perineal hematoma Some respondents were reluctant to use ice cold baths. Some of the studies report complications with the use of sitz baths e.g.. skin burns, maternal neonatal streptococcus outbreaks, dissemination of herpes Conclusion: No scientific evidence to support the use of sitz baths in treatment of anorectal and perineal disorders. This study revealed: a reduction in anal pressure when hot sitz baths were used. Cold sitz did not show a reduction of pressure in either group. *There is No scientific data to encourage the use of this frequently recommended time consuming ritual. There is No ideal method in terms of additives and optimal duration that have been studied.This study revealed: a reduction in anal pressure when hot sitz baths were used. Cold sitz did not show a reduction of pressure in either group. *There is No scientific data to encourage the use of this frequently recommended time consuming ritual. There is No ideal method in terms of additives and optimal duration that have been studied.

23. Review of the literatureA sitz bath does not improve wound healing after elective episiotomy A Randomized Control Trial of 324 post partum women in Nigeria Study to see if warm sitz bath affects skin breakdown and infection rates, compared to no treatment Oladukun & colleagues conducted a randomized control trial of 324 Nigerian women. one group instructed to add 1-2 teaspoon of salt to a tub of warm water and sit in it for 20-30 minutes. Control group had no treatment Both group given NSAIDS for pain relief. The study was to determine if sitz bath would improve wound healing and reduce infection rates after episiotomy Oladukun & colleagues conducted a randomized control trial of 324 Nigerian women. one group instructed to add 1-2 teaspoon of salt to a tub of warm water and sit in it for 20-30 minutes. Control group had no treatment Both group given NSAIDS for pain relief. The study was to determine if sitz bath would improve wound healing and reduce infection rates after episiotomy

24. Review of the literatureA sitz bath does not improve wound healing after elective episiotomy, cont. Findings: 93% of women experienced greater healing to episiotomy wounds, compared to 89% of control group 5.7% of women experienced infection at incision site compared to 6% of the control group Authors � Conclusion; Sitz baths have little effect on wound healing after perineal injury There is little need for perineal care beyond routine cleansing NSAIDS offer better pain relief than warm sitz baths No statistical difference noted in infection and breakdown rates between the two groups.No statistical difference noted in infection and breakdown rates between the two groups.

25. Review of the literatureReduction of perineal trauma during and after childbirth: The Perineal Warm Pack Trial. Unpublished Thesis Thesis (unpublished) randomized controlled method 717 first time mothers Explored the effects of warm pack on perineal trauma and maternal comfort. Dahlan & Colleagues This was a randomized controlled study of 717 primiparous or 1st time mothers. 360 were randomly selected to receive warm packs and 357, who received standard care, or no warm packs. This study explored the effects of applying warm packs to the perineum during the 2nd stage of labor to prevent perineal trauma and provide maternal comfort by measuring outcomes for the need for suturing and maternal comfort. Dahlan & Colleagues This was a randomized controlled study of 717 primiparous or 1st time mothers. 360 were randomly selected to receive warm packs and 357, who received standard care, or no warm packs. This study explored the effects of applying warm packs to the perineum during the 2nd stage of labor to prevent perineal trauma and provide maternal comfort by measuring outcomes for the need for suturing and maternal comfort.

26. Review of the literatureReduction of perineal trauma during and after childbirth: The Perineal Warm Pack Trial,  Conclusions Warm packs provided perineal pain relief . Findings must be validated through further research. Findings: Warm pack to the perineum during the 2nd stage of labor, reduce perineal pain during the birth, and up to two days post delivery. Warm pack application does not decrease the need of perineal suturing. Warm Pack trial results showed: reduction in third and fourth degree tears, lower perineal pain scores during birth decreased perineal pain up to 2 days following birth. Warm packs did not decrease the probability of needing sutures among the two groups. Those receiving warm packs during 2nd stage of labor, reported less urinary incontinence twelve weeks postpartum. Nearly 80% of the mothers and midwives felt they would use warm packs again. Warm Pack trial results showed: reduction in third and fourth degree tears, lower perineal pain scores during birth decreased perineal pain up to 2 days following birth. Warm packs did not decrease the probability of needing sutures among the two groups. Those receiving warm packs during 2nd stage of labor, reported less urinary incontinence twelve weeks postpartum. Nearly 80% of the mothers and midwives felt they would use warm packs again.

27. Comparison of the literature Pro Cooling agents are effective in the treatment of perineal pain Con Literature on Sitz Baths is outdated. The most recent research was completed in the 1980�s. Research at this time is focused on cooling therapy.

28. Summary and comparison of research critiqued Comparison of the research revealed a common result. Cold therapy is effective in the reduction of perineal pain. Further research is needed to determine the most effective method. There is no scientific evidence to support the use of sitz baths for treatment of perineal trauma. In comparing the research we critiqued, a common theme emerged and that was that cold therapy is effective in the reduction of perineal pain. Further research is needed to determine which method is most effective. There is no scientific evidence to support the use of sitz baths for the treatment of perineal trauma.In comparing the research we critiqued, a common theme emerged and that was that cold therapy is effective in the reduction of perineal pain. Further research is needed to determine which method is most effective. There is no scientific evidence to support the use of sitz baths for the treatment of perineal trauma.

29. Recommendations for practice Offer cold therapy to women experiencing perineal pain, cooling gel pads seemed to be most preferred. Allow the use of sitz baths for comfort. Combination of pain relief methods may be needed to treat perineal pain.

30. Rationale for Practice change Cold therapy is easy to use Majority of hospitals already use cold therapy so no change is needed in education or providers� time. Research suggests women prefer the cooling gel pad design A change in education may be indicated for those providers promoting sitz baths for decreased pain or to promote healing. Limiting the use of warm sitz baths can save valuable healthcare resources. However, research suggests women prefer the cooling gel pad design, which may be worth adding to hospital inventory, if not already offered, still a lower cost treatment option than other pain relief methods. However, research suggests women prefer the cooling gel pad design, which may be worth adding to hospital inventory, if not already offered, still a lower cost treatment option than other pain relief methods.

31. Suggestions for further study Further research should focus on: Comparison of two independent variables: warm and cold therapy. Investigating the most effective cooling treatment. More research on the effects of warm packs to prevent or minimize perineal trauma during delivery. Possible new research question: Does the use of pain medication alleviate the need for sitz bath? Suggestions for more further research should: Compare the 2 independent variables of warm and cold therapy Investigate most effective cooling treatment Investigate the effects of warm packs in preventing or minimizing perineal trauma It brings up the question: does the use of pain medication eradicate the need for sitz bath? Suggestions for more further research should: Compare the 2 independent variables of warm and cold therapy Investigate most effective cooling treatment Investigate the effects of warm packs in preventing or minimizing perineal trauma It brings up the question: does the use of pain medication eradicate the need for sitz bath?

32. In closing, I want to share the abstract by Mary Rhodes Since the late nineteenth century, the average postpartum woman has been subjected to a great deal of swabbing, soaking, spraying, all in the name of perineal care. Many elaborate regimens have been devised to prevent infection, promote healing, and provide comfort to the mother, often based on little physiologic rationale or research data. All these regimens have taken away valuable time and energy that the new mother needs for more important tasks. A review of past and current perineal care practices and major research studies relative to perineal care can form a foundation from which to evaluate and update the management of perineal care. From the Abstract �Perineal care: then and now�. By Mary Rhodes, et al. in the Journal of Midwifery & Women�s Health, vol 35, Issue 4, p 220-229. In closing, I want to share the abstract by Mary Rhodes Since the late nineteenth century, the average postpartum woman has been subjected to a great deal of swabbing, soaking, spraying, all in the name of perineal care. Many elaborate regimens have been devised to prevent infection, promote healing, and provide comfort to the mother, often based on little physiologic rationale or research data. All these regimens have taken away valuable time and energy that the new mother needs for more important tasks. A review of past and current perineal care practices and major research studies relative to perineal care can form a foundation from which to evaluate and update the management of perineal care. From the Abstract �Perineal care: then and now�. By Mary Rhodes, et al. in the Journal of Midwifery & Women�s Health, vol 35, Issue 4, p 220-229.

33. References Abedian, Z., Greaves-Steen, M., Navvabi, S., (2009) Effectiveness of cooling gel pads and ice packs on perineal pain. British Journal of Midwifery, 17, 724-729. Albers, LL. (2005). Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth. Journal of Midwifery & Women's Health. 50(5), 365-372. American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. 2007. Guidelines for perinatal care (6th ed). Self care post partum discharge instructions. Retrieved from http://www .awh onn.org/awhonn/content.do?name=02_PracticeResources/2H_Patient handouts.htm. Christine E. East, et al. (2010). Perineal Pain Following Childbirth: Prevalence, Efforts on Postnatal Recovery and Analgesia Usage. Midwifery. Dahlen, H. (2007). Reduction of perineal trauma during and after childbirth the perineal warm pack trial. Unpublished Thesis, UTS, Australia.

34. References, cont. East, C. E. (2009). Systematic review: local cooling for relieving pain from perineal trauma sustained during childbirth East, C.E., Sherburn, M., Nagle C., Said, J., Forster, D., (2010). Perineal pain following childbirth: prevalence, effects on postnatal recovery and analgesia usage. Midwifery doi:10.1016/ j.midw.2010.11.009 The Cochrane Library. 2009, Issue 1.Excellence, N. I. (2006, July). Routine postnatal care of women and their babies. Retrieved March 11, 2011, from www.nice.org.uk/CG037: www.nice.org.uk Oladukun, A., Barbarisa, A., Adewole, L., Omnigudn, A., (2009) A sitz bath does not improve wound healing after elective episiotomy. Journal of Obstetrics and Gynecology.20(3),277-279

35. References, cont. Oliveira, S., Leventhal, C.L., Moacyr, R.C., Flora, M.B. (2011).Perineal analgesia with an ice pack after spontaneous vaginal birth: a randomized control trial. Journal of Midwifery & Women�s Health. 56(2), 141-146 Steen, M. (2010). Care and consequences of perineal trauma. British Journal of Midwifery. 18(11), 710-715. Steen, M., Briggs, M., King, D., (2006). Alleviating postnatal perineal trauma: to cool or not to cool? British Journal of Midwifery 14(5), 304-308. Tejirian, T., Maher A,. Abbas. M. (2005). Sitz bath: where is the evidence? Scientific basis of a common practice. Disease of the Colon and Rectum. 48. 2336-2340