Post-Episiotomy Self-Care Practice among Primiparous Women attending Maternity Teaching Hospital in Sulaimani/ Iraq

Muhammad, kharman Ahmad; Atiya Kareem Mohammed, Atiya Kareem Mohammed Atiya Kareem Mohammed

doi:10.33899/mjn.2023.176966

Post-Episiotomy Self-Care Practice among Primiparous Women attending Maternity Teaching Hospital in Sulaimani/ Iraq

kharman Ahmad Muhammad

Atiya Kareem Mohammed Atiya Kareem Mohammed Atiya Kareem Mohammed

Mosul Journal of Nursing, 2023, Volume 11, Issue 1, Pages 123-132
10.33899/mjn.2023.176966

Abstract

Background and Objectives: Episiotomy care is very essential, if neglected it can lead to serious complications such as infections, open wounds, etc. Therefore, it is very important to pay special attention to maintaining perineal hygiene and caring for episiotomy. The present study aimed to determine the effect of perineal self-care instructions on pain and healing of episiotomy in women after childbirth. Method: descriptive-analytic (Cross-sectional) study of 260 Primiparous Womenin Maternity Teaching Hospital/Sulaimani City. Data have been collected using a questionnaire by direct interview lasted 4 consecutive months from June 2021 to October 2021. The questionnaire consists of: Maternal Demographic Characteristics, Episiotomy History, Post episiotomy Self-care practice. Results there is a statistically significant association between age and level of education with Post episiotomy Self-care practice, moreover, primiparous women in the current study reported a poor level of Self-Care Practice with Perineal Hygiene, Reducing Perianal discomfort and pain, Positioning and movement, and Pelvic floor muscle exercises, but thankfully, they have a good level of self-care practice concerning dealing with episiotomy complications or risks and eat healthy nutrition. Conclusion According to the study's findings, only a tenth percent of the puerperal women has good practice regarding post-episiotomy Self-care, while the rest of the participant have fair practice and poor practice. Recommendation Women must be informed and guided during their prenatal care concerning the episiotomy procedure.

Keywords:

Post-Episiotomy Self-Care Practice among Primiparous Women attending Maternity Teaching Hospital in Sulaimani/ Iraq

¹kharman Ahmad Muhammad & ²Atiya K. Mohammed *

Department of adult nursing, College of Nursing, University of Sulaimani, City of Sulaimani, Iraq;
MaternityTeachingHospita,l Halabja City, Iraq

²Correspondence to: Dr. Atiya Kareem Mohammed, Maternal Neonate Nursing Department, College of Nursing, University of Sulaimani, Iraq.

Email: atiya.mohammed@univsul.edu.iq. https://orcid.org/ 0000-0002-4954-0986

ORCID

ABSTRACT

Background and Objectives: Episiotomy care is very essential, if neglected it can lead to serious complications such as infections, open wounds, etc. Therefore, it is very important to pay special attention to maintaining perineal hygiene and caring for episiotomy. The present study aimed to determine the effect of perineal self-care instructions on pain and healing of episiotomy in women after childbirth. Method: descriptive-analytic (Cross-sectional) study of 260 Primiparous Womenin Maternity Teaching Hospital/Sulaimani City. Data have been collected using a questionnaire by direct interview lasted 4 consecutive months from June 2021 to October 2021. The questionnaire consists of: Maternal Demographic Characteristics, Episiotomy History, Post episiotomy Self-care practice. Results there is a statistically significant association between age and level of education with Post episiotomy Self-care practice, moreover, primiparous women in the current study reported a poor level of Self-Care Practice with Perineal Hygiene, Reducing Perianal discomfort and pain, Positioning and movement, and Pelvic floor muscle exercises, but thankfully, they have a good level of self-care practice concerning dealing with episiotomy complications or risks and eat healthy nutrition. Conclusion According to the study's findings, only a tenth percent of the puerperal women has good practice regarding post-episiotomy Self-care, while the rest of the participant have fair practice and poor practice. Recommendation Women must be informed and guided during their prenatal care concerning the episiotomy procedure.

Keywords: postpartum women, Self-care, perineal self-care, episiotomy pain, and healing.

Received: 31August 2022, Accepted: 7 October 2022, Available online: 28 January 2023

INTRODUCTION

Episiotomy is one of the most common surgical procedures performed on women worldwide (Ibrahim, M. S. et al; 2018).

Episiotomy was first introduced in 1742 to reduce fetal distress. However, this goal has expanded towards the reduction of perineal damage, and traumas, and speeding up the childbirth process (Jahlan, I., et al, 2020), (Saeid, M. S., et al. 2014).

Episiotomy Care to speed healing by hygiene, Diet, and Pelvic floor muscle exercises, Visually assess the repair and healing process at each postpartum check and share the findings with the woman In hygiene Advise the woman to Support the perineal wound when coughing or defecating, Avoid constipation, Use the correct sitting position on the toilet, elbows on knees, leaning forward with feet supported on a foot-stool to aid defecation, Wash and pat dry perineal area after toileting, Change perineal pads frequently, wash hands before and after changing and shower at least daily to keep the perineum clean, Check the wound daily with a hand mirror provide education about the signs of infection and wound breakdown and Report any concerns to the midwife or General Practitioner times (Tabetha, 2019).

Furthermore, self-care involves a comprehensive approach to issues and strategies used by individuals to overcome situations that are detrimental to their health or well-being. In this view, Orem self-care practices would be considered as care practices formed by mothers to carry out their care during the puerperal stage and with important procedures such as episiotomy, as discussed in this study (WHO, 2009).

Unfortunately, in the Kurdistan Region, episiotomy is still routinely performed regardless of the indication and there has been a lack of awareness of the consequences of episiotomy. May return to lack of access to protocol or policy of episiotomy practice in their units; In addition to a context of bed shortages in overcrowded hospitals, interventions like this speed up labor and delivery. Lack of time is a major reason for both midwives and doctors to cut the perineum to deliver women faster.

METHOD

Study design: A descriptive-analytic (Cross-sectional) study design, was conducted in Sulaimani Maternity Teaching Hospital which is the only governmental and biggest maternity hospital in Sulaimani city.

Sample of the study:

A non-probability purposive sampling was used for selecting the 260 postpartum women. The study was carried out from Jun 2021 to October 2021.

Eligibility criteria:

women were recurred to participate in the study by specific inclusion criteria such as Maternal taking at any age, Primigravida, Vaginal delivery with episiotomy, Mothers who had a full term baby or preterm baby, Having knowledge or no about episiotomy, Accept to participate in the study and exclusion criteria included Mothers with cesarean section, and who do not know to speak Kurdish.

Sample size:

The calculation of the number of samples was based on a previous study conducted by FATAH, S. S. (2019).

350 case

350

Maternity Teaching Hospital

260 case

included

90 case

excluded

260 Case

Figure1: Flowchart of the distribution of the sample according to the setting of the study.

Tools were used for data collection:

A questionnaire was constructed by the researcher which consists of four parts:

Maternal Demographic characteristics,History of Episiotomy, and Post episiotomy Self-care practice consisted of (Perineal Hygiene, Nutrition, Reducing Perianal discomfort and perineal pain, Positioning and movement, Pelvic floor muscle exercises, Complications or risks).

Nott// Sample (260), Total score (260), No (0), Yes (1)

The scale of practice of patients was classified as good practice (≥ 75%) with a score (195-260), Fair practice: (50% - < 75%) with a score (130 – 194), and poor practice (<50%) with score (0 – 129).

Methods of data collection:

Data were collected based on a structured questionnaire. When the client met the study criteria, obtained verbal consent, and assured the mother that privacy would be maintained, the latter was given a brief introduction, the researcher explained the purpose of the study to the mother, and the record was kept as follows. was used as the Primary data collection source. The time spent collecting the data was 4 months from Jun 2021 to October 2021. Researchers collected data through face-to-face interviews and recorded them on prepared questionnaires. Each form was coded and each interview lasted approximately 10-15 minutes.

Data analysis:

The data were managed and analyzed using descriptive and inferential statistics by using the SPSS program version 22.

P-value: there were criteria of probability levels to determine the significance of

the test:

· Highly significant (p≤0.001)
· Significant (p≤0.05)
· Nonsignificant (p>0.05)

RESULTS

Table (1): Distribution of the study sample according to their socio-demographic characteristics

	Groups	Frequency	Percent
Age (Years)	< 18	13	5.0
	18 – 25	167	64.2
	> 25	80	30.8
	Mean ± S.D	23.13± 3.47
Level Education	Illiterate	5	1.9
	Able to Read &Write	5	1.9
	Primary School Graduated	29	11.2
	Secondary School Graduated	115	44.2
	Institution and College Graduated	106	40.8
	Post Graduated	0	0.0
Occupation	Governmental employed	5	1.9

	Housewife	255	98.1
Residence	Urban	195	75.0
	Suburban	59	22.7
	Rural	6	2.3
Total		260	100.0

It can be seen in the table (1) that the majority of the samples were (64.2%) aged between 18 to 25 years old; 30.8% of total samples were aged 25 years old and more and the minorities of the samples were (5%) age less than 18 years old. Moreover, 44.2% of the total samples had Secondary School Graduated; 40.8% of them had Institution and College Graduated; 11.2% had Primary School Graduated and 1.9% of samples had Illiterate or Able to Read &Write. Occupation parts 98.1% of the total samples were Housewife and 1.9% of the samples were Governmental employed. Finally, of the total participants: 75.0% were living in Urban; 22.7% were living in Suburban and 2.3% were living Rural.

Table (2): Distribution of the study sample according to Episiotomy History

		Group		Frequency	Percent
Type of episiotomy	Midline (median) incision	Yes		0	0.0
		No		260	100.0
	Mediolateral incision (most common)	Yes		260	100.0
		No		0	0.0
	Lateral incision	Yes		0	0.0
		No		260	100.0
	(J) shaped incision	Yes		0	0.0
		No		260	100.0
Have tear with episiotomy	Yes			59	22.7
	No			201	77.3
Volvo vaginal tears	Yes			11	4.2
	No			249	95.8
Perineal tears	Yes			44	16.9
	No			216	83.1
Cervical tears	Yes			8	3.1
	No			252	96.9
Using medication properly as prescribed	Antibiotic		Yes	260	100.0
			No	0	0.0
	Cream		Yes	260	100.0
			No	0	0.0
	Oil		Yes	0	0.0
			No	260	100.0
	Oral paracetamol as required		Yes	260	100.0
			No	0	0.0
	Oral NSAID in the absence of contraindications		Yes	260	100.0
			No	0	0.0
	Urinary alkalizes to reduce urine acidity and discomfort associated with grazes, unsutured tears		Yes	0	0.0
			No	260	100.0

As shown in table (2) the Types of episiotomy were (100%) Mediolateral incision (most common) and other types of episiotomy (Midline (median) incision, Lateral incision, shaped incision) obtained (0.0%). Then, 77.3% of total respondents did not have tears with episiotomy and only 22.7% of them have tears with episiotomy. 95.8% of total samples said no to Volvo vaginal tears and merely 4.2% of them said yes to Volvo vaginal tears. 16.9% have Perineal tears, and 3.1% have Cervical tears. Finally, using medication properly as prescribed: Antibiotic, Cream, Oral paracetamol as required, and Oral NSAID in the absence of contraindications were used in totally samples but Urinary alkalizes to reduce urine acidity and discomfort associated with grazes, unsutured tears, and oil they did not use as prescribed of Using medication properly.

Figure (2) the post episiotomy Self-care practice Levels

As shown in figure 2 the post episiotomy Self-care practice, 45.4% of patients have poor practice, 44.2% of the participants have a fair practice of post episiotomy Self-care and 10.4% of the respondents have good practice.

Table (3): Association between socio-demographic and post episiotomy Self-care practice

Socio-demographic	Post episiotomy Self-care practice			Significant Test	Result
	Poor	Fair	Good
	Fr. (%)	Fr. (%)	Fr. (%)
Age (Years)
< 18	2(1.7)	5(4.3)	6(22.2)	28.281 P = 0.000	Sig.
18 – 25	85(72)	74(64.3)	8(29.6)
> 25	31(26.3)	36(31.3)	13(48.1)
Level Education
Illiterate	3(2.5)	2(1.7)	0(0.0)	20.343 P = 0.009	Sig.
Able to Read &Write	3(2.5)	1(0.9)	1(3.7)
Primary School Graduated	17(14.4)	10(8.7)	2(7.4)
Secondary School Graduated	64(54.2)	42(36.5)	9(33.3)
Institution and College Graduated	31(26.3)	60(52.2)	15(55.6)
Occupation
Governmental employed	2(1.7)	2(1.7)	1(3.7)	0.507 P = 0.776	No-Sig.
Self-employed	0(0.0)	0(0.0)	0(0.0)
Housewife	116(98.3)	113(98.3)	26(96.3)
Residence
Urban	89(75.4)	85(73.9)	21(77.8)	1.551 P = 0.817	No-Sig.
Suburban	27(22.9)	26(22.6)	6(22.2)
Rural	2(1.7)	4(3.5)	0(0.0)
Fr.: (Frequency)

As shown in table (3) that there is a statistically significant difference (or association) between post-episiotomy Self-care practice in related age (p-value=0.000), Level of education (p-value=0.009). On other hand, there is no statistically significant difference (or association) between post episiotomy Self-care practice in related occupation (p-value=0.776) and residence (p-value=0.817), because the p-value was greater than 0.05.

DISCUSSION

Obstetric services in developing countries present a significant challenge to doctors and health care professionals. the nurse holds a key position in spreading knowledge of postpartum care, ensuring and providing adequate service to empower women's role in implementing efficient self-care practices and becoming more independent to date, little literature is available on what Kurdish women do in childbirth to take care of themselves, or what beliefs lie behind their activities. This study is considered to be the original study in Kurdistan and Iraq; therefore, the results of this study can be used to provide women with adequate information and knowledge about self-care activities, healthy practices, and lifestyles that will help the mother give birth to a healthy baby.

Analysis of demographic characteristics indicated that the majority of the studied primipara women were young and was (18-25) years old, and housewives with a Middle educational level (Secondary school graduates). The findings emerged due to the nature of the culture in which these women lived. In this culture, the most predominant female issues were marriage and having low opportunity to complete their education otherwise three-quarters were living in urban. Another hand, the study indicated that there was a significant association between women's self-perineal care practice and mothers’ age and education because the p-value was less than 0.05.

Regarding episiotomy history, whole participants had mediolateral incision based on our hospital policy mediolateral incision is the most common episiotomy type performed and considered fewer complications, this finding was a consented of Woretaw, E. (2021) study, and more than three-quarters of primiparous women did not have tears with episiotomy and less than a quarter of them have tear with episiotomy. In another study that was done by Mellizo-Gaviria et al (2018),the result was similar to our study.

Regarding using medication to prevent the complication of episiotomy total of participants used; Antibiotic, Cream, Oral paracetamol as required, and Oral NSAID, but mothers did not use oil and Urinary alkalizes to reduce urine acidity and discomfort associated with grazes. This finding is supported by another study that was done by Bonet et al., (2017), more than three-quarters of primiparous women for the treatment of episiotomy used medication such as; antibiotics as prophylaxis, paracetamol, cream, and nonsteroidal anti-inflammatory drug.

Women's self-care during the postpartum period is not a replacement for proper psychiatric or medical treatment, but it should be considered as part of an all-encompassing therapeutic strategy. The designed measure to assess Self-Care Practice was employed in the current study. Post-episiotomy care is divided into seven categories (Perineal Hygiene, Nutrition, Reducing Perianal discomfort and pain, Positioning and movement, Pelvic floor muscle exercises, Complications or risks), primiparous women in the current study reported a low level of Self-Care Practice of how to care for their perineum such as washing hands, cleaning the perineum from front to back, gently washing their stitches with soap and water, changing the pad at least 3 to 4 times a day, dry perineum, did not remove the stitch, merely and another practice. Good level Self-Care Practice for nutritional self-care drink, plenty of water, and eat fruit, and vegetables, (to avoid constipation). Reducing Perianal discomfort and perineal pain is sited in a warm bath (sitz bath) daily and using Ice-cool, but the positive aspect in this category is they knew to avoid sexual intercourse during the first 6 weeks for reducing Perianal discomfort and pain, which is related to religion and cultural norms. Positioning and movement also recorded a poor level of self-care practice, which is appropriate for pelvic floor muscle exercises, but thankfully, they have a good level of self-care practice concerning dealing with episiotomy complications or risks.

The poor level of self-care practice in our study sample related to women especially primiparous they do not have enough health background the most of the participants was housewives, the importance of employment is clarified by Atiya K, (2015) that these women receive comprehensive prenatal and postpartum health counselling, as working outside the home increases their chances of meeting someone with more expertise and learning useful social and health information. Other factors are that primiparous women are dependable and not attending antenatal classes. Although social conventions and a woman's culture offer some insight into what is expected of new mothers, there is no specific set of rules or guidelines, and a crowded labour ward and not enough caregivers for pregnant women to provide adequate health education about post-episiotomy self-care practice.

CONCLUSIONS

Puerperal women who had a vaginal delivery with episiotomy there is a statistically significant difference (or association) between post episiotomy Self-care practice in related age and Level of education.

Regarding the post-episiotomy Self-care practice, less than fifty of the participants have poor practice, another less than fifty of the participants have a fair practice of post-episiotomy Self-care, and only one-tenth of them have a good practice.

ETHICALCONSIDERATIONSCOMPLIANCEWITHETHICALGUIDELINES

Ethical approval from the University of Sulaimani and the ethics committee was granted. Study participants gave informed consent and participated without being induced or coaxed. Confidentiality, integrity, respect, and dignity of the subjects were insured. They were at liberty to withdraw without being victimized.

FUNDING
There are no funding sources.

AUTHOR’SCONTRIBUTIONS

All authors were responsible for the study conception and design, and were responsible for drafting the manuscript. All authors have critically reviewed and edited the manuscript for intellectual content.

DISCLOSURESTATEMENT:

There are no declared.

ACKNOWLEDGEMENTS

We are thanking all staff of Maternity Teaching Hospital/Sulaimani City, Iraq for their kind help and support for this study.

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