Effect of Dry Heat Application on Perineal Pain and Episiotomy Wound Healing among Primipara Women

Background Women who undergo perineal episiotomy can be affected by several complications such as bleeding, infection, perineal pain, dyspareunia, reduction of sexual desire, as well as urinary and anal incontinence. Perineal pain related to episiotomy has been reported to interfere with women's daily activities postpartum and can prevent proper breastfeeding, proper rooming-in, and maternal-infant bonding. The purpose of this study was to determine the effect of dry heat application on perineal pain and episiotomy wound Healing among primipara women. Method A quasi-experimental, two-group, pre-post-test research study was conducted at the postnatal inpatient ward and the outpatient clinic of the El-Shatby Maternity University Hospital in Alexandria. A sample of 100 parturient women was divided into the following two groups at random: dry heat and moist (control) heat. Women in the moist heat group were advised to sit in a basin (tub) of warm water for 10 minutes, while those in the dry heat group were instructed to set an infrared light (230 volts) at a distance of 45 cm from the perineum after 12 hours post episiotomy. Both interventions were applied twice a day for ten consecutive days. They evaluated the severity of their perineal pain at baseline and repeated it on the 5th and 10th days after obtaining the interventions while the episiotomy wound healing was assessed on the 5th and 10th days. Results It was discovered that the dry heat group had a significantly improved episiotomy wound healing as regards perineal redness, edema of the perineal area, ecchymosis, wound discharge, and approximation of wound edges on the 5th (P < 0.001, P < 0.001, P < 0.007, P < 0.003, and P < 0.001, respectively) and 10th day after intervention (P < 0.001, P < 0.001, P < 0.001, P < 0.005, and P < 0.001, respectively) than the moist heat group. The primipara women had significantly lower perineal pain intensity in the dry heat group on the 5th and 10th days after intervention than in the moist heat group (MHP < 0.001 for the dry heat group and MHP = 0.004 for the moist heat group). Conclusion The application of dry heat promoted episiotomy wound healing among primipara women and reduced their perineal pain during early postpartum days than moist heat.


Introduction
Although the postpartum period is a wonderful and joyful experience for mothers, it is life-challenging and full of many stressful events [1]. Many health problems may arise during the postpartum period and, if not treated promptly and efectively, can lead to ill health and even death of the mother, her neonate, or both [2]. Perineal discomfort is the most common problem encountered in the postnatal period.
It occurs in 42% of women after spontaneous delivery and persists after the frst three months. Perineal pain worsens following instrumental delivery, spontaneous tears, or episiotomy [3].
An episiotomy or perineotomy is a deliberate surgical incision to the perineum, made either during the second stage of labor or just before delivery, to widen the vaginal orifce [4]. It is the most common surgical procedure performed during the labor of primiparous women and was introduced to clinical practice in the eighteenth century [5]. Tere are four types of episiotomies; median, mediolateral left or right, lateral, and J-shape [6]. Globally, the prevalence of episiotomy has a wide geographic variation between countries and institutions because of diferences in attitudes and training. Up to now, high episiotomy rates are still being reported in many countries [7]. In Egypt, according to the Statistical Department of the postnatal inpatient ward and the outpatient clinic of the El-Shatby Maternity University Hospital, the episiotomy rate was 94% of vaginal births in 2015, while in 2016 it was 93% of vaginal births [8]. Despite the World Health Organization [9] recommending a reduction in the episiotomy rate to 10% for normal vaginal deliveries, the procedure is still performed by 30% to 50% of women [9]. Episiotomy is associated with clinically relevant morbidities for newly delivered women including perineal trauma, the need for suturing, and healing complications [4].
Episiotomy-related morbidity can infuence the physical, psychological, and social well-being of women, both in the immediate and long-term postnatal period [10]. Women who undergo perineal episiotomy can consequently be affected by several complications, such as bleeding, infection, damage to the anal sphincter and mucosa, wound opening, dyspareunia, reduction of sexual desire, perineal pain, as well as urinary and anal incontinence. Perineal pain and discomfort related to episiotomy have been reported to interfere with women's daily activities, such as sitting, walking, and lifting the neonate. Moreover, it can interrupt proper breastfeeding, rooming-in, as well as maternal-infant bonding [11].
Postpartum is a sensitive time when mothers must juggle their recovery while dealing with the needs of their newborns. Efective episiotomy management is a major aspect of postpartum care that can positively afect women's lives [12]. Several interventions are available for relieving perineal discomfort, promoting healing, and reducing perineal edema, redness, and pain. Tese interventions include perineal hygiene, keeping the wound dry, and using various pharmacological and nonpharmacological treatments [13]. Te maternity nurse should be aware of efcient episiotomy wound management which can decrease the sufering of postpartum mothers and improve healing. Many nonpharmacological measures are assisting the healing process, which encompasses acupuncture, cryotherapy, laser therapy, electrical stimulation, the performance of Kegel's exercise, dry heat (infrared therapy), and moist heat topical applications (sitz bath) [14].
Moist heat is one of the techniques that can alleviate perineal pain and enhance wound healing. It requires immersion of the perineal area and buttocks for 15 to 20 minutes in warm water at a temperature of 110°-115°F. It can be used to lessen perineal discomfort, itching, or muscle spasms [15]. Moist heat can also facilitate wound healing by soaking the perineum and anus, improving circulation, decreasing edema, and infammation, and promoting muscle relaxation [16]. It seems that heat stimulates heat receptors of the skin and deeper tissues, and it may reduce pain, as proposed in gate control theory [17]. On the other hand, dry heat using the infrared lamp is a special type of therapy in which episiotomy is treated using the healing efect of light. At a distance of 45-50 cm and for 10-15 minutes, the incision site or the diseased portion of the perineum is exposed to infrared radiation with a light source of 230 volts. Terefore, these rays relax muscles, promote circulation, and provide pain relief [18]. Recently, studies have shown conficting fndings on the most efective strategies to alleviate pain from episiotomy and improve wound healing [19,20]. Terefore, this study was carried out to compare the efects of dry heat versus moist heat application in reducing perineal pain and promoting episiotomy wound healing among primiparous women.

Aim of the Study.
Tis study aimed to determine the efect of dry heat application on perineal pain and episiotomy wound Healing among primipara women.

Research
Hypothesis. Primipara women who receive dry heat application on their episiotomy wound exhibit episiotomy wound healing and lower perineal pain intensity than those who receive moist heat.

Research Design and Setting.
A quasi-experimental, twogroup, pre-post-test research study was conducted at the postnatal inpatient ward and the outpatient clinic of the El-Shatby Maternity University Hospital in Alexandria. Tis setting was chosen as it is the largest maternity health agency in Alexandria and also episiotomy procedure is routinely performed on all primipara attending for delivery.

Subjects.
Te study used a convenience sample of 100 parturient women who met the following inclusion criteria; had a normal vaginal delivery with episiotomy; primipara during the frst 2 hours after delivery; complained of perineal discomfort (pain); and agreed to participate in the study. While illiterate women and those who used any painrelieving drug (painkillers may mask the impact of the intervention), had labor or postpartum complications, diabetes and anemia were excluded from the study.
In the beginning, the researchers spoke with 900 parturient women to identify individuals who ft the prerequisites. 127 parturient women were among the instances that were found. Te sample size was calculated using the Epi Info program version 10 with the following parameters: a population size of 127, a confdence level of 95%, an expected frequency of 50%, and an acceptable error of 5%. 100 parturient women made up the required minimum sample size.
During the study period (January 2021-May 2021), a sample of 100 out of 127 parturient-eligible women was randomly assigned to two equal parallel groups in the postpartum inpatient ward and the outpatient clinic from 8 AM to 1 PM, three days a week. As shown in Figure 1, one participant was placed in the dry heat group, while the next was placed in the moist heat group. (i) Tis tool was adopted by Melzack and Katz (1994) to measure pain intensity. It is a self-reported scale consisting of a horizontal line used for the subjective estimation of a patient's pain. It is comprised of a 10-point numerical scale, corresponding to the degree of pain, with zero representing no pain and 10 representing the worst degree of pain. Scores 1, 2, and 3 indicate mild pain, while scores 4, 5, and 6 indicate moderate pain, and scores 7, 8, and 9 indicate severe pain; fnally, a score of 10 indicates the worst unbearable pain [21]. (ii) Te sociodemographic data such as age, level of education, occupation, current residence, and type of family as well as data about episiotomy such as indications of episiotomy and type of episiotomy were attached to this tool. . It is an observational checklist used for assessing episiotomy wound healing. It can be used to assess all types of postpartum perineal trauma. It has fve components, namely, redness, edema, ecchymosis, discharge, and approximation of the wound edges. Each component takes a score ranging from 0 to 3 as follows: (a) Redness: 0 � none, 1 � mild within 0.25 cm of incision, 2 � moderate within 0.5 cm of incision bilaterally, and 3 � severe beyond 0.5 cm of incision bilaterally. (b) Edema: 0 � none, 1 � mild perineal, less than 1 cm from the incision, 2 � moderate perineal and\or vulvar, between 1 and 2 cm from the incision, and 3 � severe perineal and\or vulvar, greater than 2 cm from an incision (c) Ecchymosis: 0 � none, 1 � mild within 0.25 cm bilaterally or 0.5 cm unilaterally, 2 � moderate between 0.25 and 1 cm bilaterally or between 0.5 and 2 cm unilaterally, and 3 � severe greater than 1 cm bilaterally or 2 cm unilaterally. (d) Discharge: (0 � none, 1 � serous, 2 � serosanguinous, and 3 � bloody, purulent) (e) Approximation: 0 � closed, 1 � mild skin separation of 3 mm or less, 2 � moderate skin and subcutaneous fat separation, and 3 � severe skin and subcutaneous fat and fascial layer separation). (ii) Total REEDA score ranges between 0 and 15. A higher score indicates poor wound healing while a lower score indicates good wound healing. Te total score of the REEDA scale was categorized as follows: (a) Completely healed from 0 to 2 (b) Moderately healed from 3 to 5 (c) Mildly healed from 6 to 8 (d) Not healed from 9 to 15 Parturient women delivered and meet the inclusion criteria and agreed to participate in the study (n=127) Used painkillers

Obstetrics and Gynecology International
Te kappa coefcient was used in the reliability analysis of the REEDA scale by Alvarenga et al. (2015), where the discharge item (0.75 < Kappa ≥ 0.88), assessment of edema (0.16 < Kappa ≥ 0.46), ecchymosis (0.25 < Kappa ≥ 0.42), and redness (0.46 < Kappa ≥ 0.66). For the item correspondence, the agreement decreased from excellent in the frst assessment to good in the last assessment. In the fourth evaluation, the assessment of all items displayed excellent or good agreement among the evaluators.

Method
Te parturient woman was initially addressed by the researchers, who established a report and collected the sociodemographic information during the initial 15-20 minute interview that occurred within the frst two hours after delivery at the hospital stay in the postpartum inpatient ward. Additionally, the degree of episiotomy wound healing and baseline perineal pain intensity were evaluated. Following the evaluation, the researchers gave the participants a health education session while using illustrative pamphlets for both groups.

Interventions.
For the moist heat group, women were encouraged to sit in a basin (tub) of warm water (110°-115°F) without pressure on the perineum and with their feet fat on the foor for 10 minutes twice a day for ten consecutive days [15]. Te researchers demonstrated to each woman how to do a warm sitz bath, and it was followed by demonstrations and discussions. After 12 hours of episiotomy, this procedure was carried out in the morning and evening for ten consecutive days [15].
For the dry heat group, an infrared lamp was placed at a distance of 45 cm from the perineum, and the heat was produced at 230 volts for ten minutes. But the women were checked after the frst fve minutes to make sure that the heat temperature was suitable. Te researchers demonstrated to each woman how to use the infrared lamp, and it was followed by redemonstrations and discussions. After 12 hours of episiotomy, this procedure was carried out in the morning and evening for ten consecutive days. Te researcher gave the infrared lamp device to each woman and then restored it after the completion of the study.
Te researchers provided each woman with health education regarding the value of follow-up at the conclusion of the session in order to ensure compliance with the interventions they had assigned to them and to evaluate wound healing. Trough daily phone calls, the researchers encouraged the women to carry out the interventions they had given them by reassuring them of their advantages and the necessity of follow-up.

Follow-Up.
Te researchers contacted the parturient women of the two groups daily and ascertained that they had performed the interventions. Tey were also instructed to attend the outpatient clinic of the El-Shatby Maternity University Hospital on the 5 th and 10 th days after the frst session during the morning shift for follow-up where the episiotomy wound healing process and perineal pain intensity were reassessed. Te perineal area was observed for redness, edema, ecchymosis, discharge, and approximation of the skin as well as perineal pain.

Ethical Considerations.
On 13 December 2020, approvals for performing the study were gotten from the Ethical Research Committee review board of the Faculty of Nursing, Alexandria University, and ClinicalTrials.gov also reported the study as having received approval (https:// clinicaltrials.gov/ct2/show/NCT05186532). Te relevant authorities of the studied area provided the researchers with authorization to perform the study. Te 7th revision of the Declaration of Helsinki's Principles guided the study's conduct (World Medical Association, 2013). Prior to implementing the interventions, the researchers spoke with parturient women who met the inclusion requirements and gave them a thorough explanation of the nature of the interventions, their advantages, and any potential hazards. Additionally, researchers confrmed that participation in the study is completely voluntary. Also highlighted was their ability to decline participation or exit from the study at any moment without any impact on the quality of treatment they got. Te anonymity and privacy of the obtained women were guaranteed. Te participants completed a written informed consent form after reaching an agreement.

Statistical
Analysis. Data analysis was done using SPSS version 20.0 (Statistical Package for Social Sciences). Descriptive statistics such as frequencies, percentages, mean, and standard deviations were used to describe parturient women's sociodemographics. Data were tested for normality using the Kolmogorov-Smirnov test, and all variables showed non-normal distribution. As for diferential statistics, a comparison between the parturient women in the two studied groups regarding their mean age was made using the T-test (T), Te severity of perineal pain before and on the ffth and tenth days after the interventions, as well as the evaluation of episiotomy wound healing on the ffth and tenth days, were all assessed using Mann-Whitney (Z) tests. All of the statistical analyses were considered signifcant at P < 0.05. Table 1 displays that 58% of parturient women in the dry heat group and 64% of the moist heat group were 20 to less than 30 years old. Te mean age of parturient women in the dry heat group was 26.444 ± 4.785 years and 25.08 ± 5.014 years in the moist heat group. Te vast majority (92% and 86%) of them, respectively, were housewives. However, majorities (82% and 72%) of dry and moist heat groups were rural residents, about two-ffths (46% and 40%) of them, respectively, live with their extended family. Figure 2 exhibits that in about three-quarters of dry heat and moist heat groups, respectively (80% and 83%), their indication of episiotomy was primipara.

Results
It is evident from Figure 3 that most of the dry and moist heat groups, respectively (90% and 94%), had Mediolateral episiotomy. Table 2 reveals that 28% and 40% of parturient women in the dry heat group and 38% and 36% in the moist heat groups, respectively, had experienced moderate and severe perineal pain intensity before applying the interventions. On the 5 th day after the intervention, there was an obvious decline in perineal pain intensity among both groups in favor of the dry heat group, where 24% of the dry heat group had severe perineal pain intensity, compared to 28% of the moist heat group, respectively. However, on the 10 th day after the intervention, it was observed that only 6% of the dry heat group had severe pain compared to 10% of the moist heat group. Signifcant diferences were found between the within groups on the 5 th day and 10 th day ( MH P < 0.001 for the dry heat group and MHP�0.004 for the moist heat group). Table 3 manifests there were no signifcant diferences between both groups regarding all components of the REEDA scale before intervention (P � 0.89, P � 0.96, P � 0.82, P � 0.5, and P � 0.5, respectively). On the 5 th day after intervention, there was a statistically signifcant diference between both groups on 5 th day after intervention as regards all components of the REEDA scale as presented by redness, edema, ecchymosis, discharge, and approximation where (P < 0.001, P < 0.001, P < 0.007, P < 0.003, and P < 0.001, respectively). Furthermore, signifcant diferences were observed between both groups on the 10 th day after intervention as regards all components of the REEDA scale as presented by redness, edema, ecchymosis, discharge, and approximation where (P < 0.001, P < 0.001, P < 0.001, P < 0.005, and P < 0.001, respectively). Table 4 shows an obvious decline in the mean perineal healing scores among the dry and moist heat groups on the 5 th day (2.34 ± 1.661 and 6.24 ± 3.274) and 10 th day after the interventions (0.84 ± 0.739 and 3.32 ± 2.645), with highly signifcant diferences (P < 0.001) between them in the favor of the dry heat group. Where, on the 5 th day after intervention more than three-quarters (78%) of the dry heat group had complete healing of episiotomy wounds compared to only 20% of the moist heat group. Furthermore, on the 10 th day after intervention, most (96%) of the dry heat group did achieve complete healing of episiotomy wounds compared to 52% of the moist heat group. Signifcant differences were found within the dry heat group (P < 0.001 c ) and within the moist heat group (P < 0.021 a ) on the 5th day and the 10th day after the interventions, respectively, in favor of the dry heat group.

Discussion
Giving birth is a powerful and life-changing event with a lasting impact on women and their families. To facilitate the birthing process and prevent perineal tears during vaginal delivery, episiotomy is done. Unfortunately, such a kind of wound is associated with many complications. Women who underwent this procedure were at greater risk for greater blood loss during labor, delayed wound healing, and increased perineal pain during the early postpartum period. Moreover, poor episiotomy healing can infuence the physical, psychological, and social well-being of women throughout the postnatal period [10]. With proper episiotomy care, the infection can be prevented and healing takes place more quickly. Healthcare is a dynamic feld where maternity nurses are ever-spiraling towards greater improvement and adopting innovative technologies and      Obstetrics and Gynecology International 7 interventions. Among these interventions, dry heat and sitz baths are the most efective methods of relieving episiotomy discomfort, and pain as well as fostering wound healing [22]. Te secondary outcomes of such interventions were to improve women's quality of life, fasten their resume to daily life activities and decrease episiotomy-related morbidity. Moreover, alleviating perineal pain enables the mothers to sit comfortably and assume a proper breastfeeding posture that ultimately would enhance the mother-infant bond. On investigating the perineal pain level, the results of the present study revealed that the pain was signifcantly reduced in the dry heat group than in the moist heat group on the 5 th and 10 th days after the interventions. Te pain reduction could be attributed to the fact that heat application induces vasodilatation and increases blood circulation to the area. Tis could enhance tissue oxygenation, reduce muscle spasms, accelerate waste product removal, reduce infammation, and promote episiotomy wound healing. Moreover, the heat application had soothing efects on the superfcial sensory nerve endings. Te results of the present study agree with the fndings of Boddupalli [23]; who reported that the intensity of pain decreased with the infrared light fomentation on episiotomy, and pain relief was seen at the end of the 4 th day of follow-up. Te author further added that dry heat is superior due to the fact that it continues for a longer duration than a moist one, keeps the wound dry, and improves healing. Te present fnding is also consistent with the study done by El-Lassy and Madian [24]; who found that the pain mean score was statistically signifcantly lower after the application of infrared lamp therapy among the study group than the control one. In addition, Gomathi et al. [25] reported that the infrared light application was efective in relieving pain levels among postnatal mothers. Tey added that Infrared rays have a therapeutic efect in aggregating the blood supply and releasing the pain. Moreover, a similar result was observed in Rani's [26] research, which found that there was a signifcant reduction in episiotomy pain score in the experimental group after infrared radiation therapy than in the control group. In addition, [27] concluded that both dry heat and moist heat interventions were efective, but dry heat was more efective than moist heat with sitz baths in reducing the severity of episiotomyassociated pain among postnatal mothers.
On the contrary, Chandraleka et al. [19] indicated that the sitz bath is more efective in reducing the level of episiotomy pain among postnatal mothers. Tey attributed the pain relief to the sedative efect of the warm water sitz bath that inhibits perineal irritation and itching in the genital area. It also prevents soreness and burning sensations around the perineum, which helps in reducing pain, itching, and discomfort. Te present study's fndings also contradict Huang et al. [28]; who investigated the efect of far-infrared radiation on perineal wound pain and sexual function in primiparous women undergoing an episiotomy. Te study revealed no signifcant diference between the intervention and comparison groups regarding the perineal pain intensity immediately after delivery, one week, or six weeks postpartum.
Concerning episiotomy wound healing using the REEDA scale, the present study indicated highly signifcant statistical diferences between both groups in favor of the dry heat group on the 5 th and 10 th days after the intervention. Tis improvement in episiotomy wound healing may be due to the penetration of the emitted infrared light energy up to 8.75 cm. Tis promotes nitric oxide release and thereby leads to vasodilatation of vessels, which stimulates the lymphatic system, increases circulation, removes toxins, and delivers higher levels of oxygen and nutrients to the injured cells [29]. Fostering the elimination of toxins and cellular waste products and helping to reduce infammation. From another perspective, the infrared heat application keeps the episiotomy wound dry, absorbs fuids, plummets edema, prevents the growth of microorganisms, and hastens the cure of the episiotomy wound [22]. It also has the benefts of improving metabolism, helping in the regeneration of the body's cells, and developing pH in the body, so it can aid in healing damaged tissue [29].
Te result of the current study is in agreement with the study [30] about the efectiveness of infrared lamp therapy in the healing of episiotomy wounds among postnatal mothers admitted to Adesh Hospital. Tey revealed that there was a signifcant statistical diference between the pre-test and posttest overall healing scores of episiotomy wounds between experimental and control groups. Tey concluded that the episiotomy wound healing is faster in the experimental group as the day progresses than in the control one. In addition, the present fnding is consistent with a study conducted by Gomathi et al. [25] who revealed that infrared light application was efective in enhancing wound healing among postnatal mothers. Moreover, it is in accordance with a previously mentioned study by Rani [26]; who reported a signifcant decline in the mean wound healing score after infrared Obstetrics and Gynecology International radiation therapy. Further, a similar result was observed in Khosla p (2017) research, which added that infrared radiation therapy is a simple and painless treatment when it is applied to the episiotomy injury site and painful areas because it promotes circulation, reduces infammation, relaxes tissues, and enhances healing. In contrast, Chandraleka et al. [19] concluded that using a sitz bath is more efective in improving wound healing among postnatal mothers than infrared ray therapy. In addition, Kalaivani [31] found that the application of the sitz bath is more efective in the experimental group based on REEDA parameters than in the control group. He concluded that the application of the sitz bath is efective in the episiotomy wound healing process. Surprisingly, Girsang and Elfra [32] revealed that the cold sitz bath hydrotherapy had a signifcantly greater efect in reducing perineal pain than the infrared heat application.

Limitations of the Study.
Te researchers faced the challenge of maintaining blindness during data collection where the raters were able to distinguish between parturient women in the study who received the dry and the control group who received warm water application. Although the current study showed a favorable impact of dry heat in promoting episiotomy wound healing and reduces their perineal pain, the study has limitations related to the small sample size. Further studies with larger sample sizes are needed to confrm the fndings.

Conclusion
Application of the Primipara women of dry heat promotes episiotomy wound healing and reduces their perineal pain during early postpartum days than moist heat.

Recommendations.
According to the present study's fndings, it is advised that dry heat be included in the postnatal units' protocol as a useful nonpharmacological intervention to promote episiotomy wound healing and lessen perineal pain during the postpartum period.