Journal of Women's Health Care
Open Access

Postnatal Perineal Pain after Vaginal Delivery in Comprehensive and Specialised Hospitals in Amhara Regional State, Ethiopia, April to June 2023

Hassen Ahmed Yimam¹, Abatneh Feleke Agengehu², Henos Enyew Ashagrie^2* and Tadesse Belayneh Melkie^{2 *}Correspondence: Henos Enyew Ashagrie, Department of Medicine, Boru General Hospital, Amhara Regional State, Ethiopia, Email:

Author info »

Introduction

Pain, as defined by the revised International Association for the Study of Pain, is "An unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage" [1]. Perineal pain has been recognised as a frequent issue in women's complaints during the postnatal period following vaginal delivery [2,3]. Postnatal perineal pain is the most common debilitating condition that limits the mother's mobility and has a significant impact on women's lives, yet this is the most neglected period for providing quality care and treatment for perineal pain.

It is a major problem affecting millions of women annually throughout the world [4]. According to evidence, postnatal perineal pain may affect more than 88% of women and is one of the worst effects from the first postnatal day to six weeks [5-7]. Moderate to severe perineal pain, which can have long-term outcomes, is one of the consequences of perineal injuries caused by childbirth [8]. It can also have a significant impact on a woman's physical and psychological well-being, including interference with daily activities following a vaginal delivery, whether the woman encountered perineal trauma or not [9-13]. It is very common after childbirth and can seriously impair a mother's ability to bond with her newborn and perform simple everyday activities like sitting, walking, urinating, defecating, breastfeeding and interacting with her family [14,15].

Every year, around 80% of women worldwide are exposed to perineal trauma following childbirth, from uncomplicated to more complicated one, as a result of perineal tears, forceps or vacuum deliveries and episiotomies. Of these, 70% of wounds need to be sutured, which is known to increase perineal pain [16,17]. And also, evidence shows that the incidence of persistent postnatal pain varies depending on the delivery method, research population and study design [18].

The most likely causes of post-natal perineal pain in women worldwide include perineal laceration, perineal tear, forceps or vacuum delivery and surgical episiotomy [19,20]. Women's primiparous and instrumental deliveries were the factors associated with the use of surgical episiotomies [21]. Most of the time, the severity of post-natal perineal pain caused by perineal traumas and the prolonged pain effects are commonly underestimated [22].

Evidence demonstrates that in the healthcare setting, from immediate vaginal delivery to months later, there are few and mostly overlooked treatments to alleviate perineal pain [3]. For the past 120 years, obstetric anaesthesia has concentrated on the management of labour and delivery pain and likewise post cesarean sections for the last 30 years, but post-natal perineal pain following vaginal delivery has not yet received the same attention to pain management. Another essential point is that critical narrative analysis of level one evidence reveals an overall lack of high-quality, focused studies to direct the treatment of postnatal perineal pain secondary to perineal injury (tear).

Perineal pain after childbirth negatively affects a woman's ability to perform her daily activities, however, healthcare professionals underestimate this fact and most women don't mention it because they think it's just a natural part of the delivery process. Pain-free immediate postnatal periods may encourage an early return to normal daily activity. In a prospective study, 92% of women reported perineal pain. Compared to intact perineum after first-degree tears, significantly more women report perineal pain after second, third and fourth-degree tears. At five days, a complicated episiotomy exacerbated significantly more perineal pain than a second to third degree tear following vaginal delivery.

According to a study from Belgium, which includes 233 participants, 73% of women complained pain during daily living activities, 47% during micturition and 19% during defecation. A prospective conducted in Thailand reported that the incidence of significant postnatal perineal pain scores greater than three was 41.1% on day one and 8.7% on day two in the post-natal period. The contributing factors were instrumental delivers and duration of the second stage of labour (>30 min). However, there is was no statistically significant difference in newborn birth weight or degree of perineal trauma on postnatal pain scores.

According to a cross-sectional study, the mean pain severity score was 4.8 ± 1.9. Only maternal age (OR=1.08) and episiotomy (OR=3.80) remained independent predictors of perineal pain and this study conclude that the immediate postnatal period was highly associated with the use of episiotomy, but the overall reporting of perineal pain was low. The present study investigated the incidence of clinically significant (moderate to severe) postnatal pain after vaginal delivery which is mostly overlooked issue in the study area.

Materials and Methods

A multi-center follow-up study was deployed on 374 women at randomly selected comprehensive and specialist hospitals in Amhara Regional State, Ethiopia, from April 1, 2022, to June 30, 2022. The sample size was calculated using the single population proportion calculation based on previous study done in Nigeria, with a confidence level of 95%, a degree of freedom 5% and a non-response rate of 10%, making a sample size of 374 study participants. The calculated sample size was proportionally allocated among the randomly selected institutions.

Ethical approval was obtained from ethical review committee of the College of Medicine and Health Sciences, University of Gondar. Study participants were selected using a simple random sampling technique. After we got verbal and written consent, we used a lottery method to select the participants by using coded envelopes. All parturient in the fertile age group who gave birth by unassisted or assisted vaginal delivery were candidates for participation. Those women who had pre-existing pain, abdominal cramp, a history of haemorrhoid and pelvic pain and women who had no functional telephone during the data collection period were excluded from the study.

Interviewer-administered sumi-structured questionnaire was used to collect data. Three female midwifery professionals were recruited. Training was given to data collectors before data collection and the data collector discussed the pain assessment tool and collected data on days one, three and seven in the postnatal period. Independent variables were extracted from the women’s chart (partograph summary sheet) documented by the healthcare provider except for educational level. The data collector has taken the first information, based on a structured questionnaire.

Data collectors used Numerical Rating Scale (NRS) as a pain assessment tool ranging from 0 to 10 and pain score of NRS ≥ 3, was considered as clinically significant on any of following up time whereas pain score of NRS<3 was considered as controlled pain or no pain.

Data were checked, cleaned and coded, entered into Epi Data Software version 4.6.05 and exported to the Statistical Package for the Social Sciences (SPSS) version 26 program for analysis. Descriptive statistics were performed and data were presented in frequencies and percentages. The mean and standard deviation were calculated and tables and figure were used to present the data. Chi-square assumptions were checked. Binary logistic regression was used for the analysis of relationships between each independent and dependent variable. Multicollinearity was checked and the variance inflation factor was 1.03. Model fitness was checked using the Hosmer-Lemeshow test Pvalue< 0.2 would be selected and included in multivariable analysis to control potential confounding factors. Crude and adjusted odds ratios with 95% confidence intervals were reported to measure the strength of the association. And also, those variables with a p-value<0.05 were considered to have significant associations with moderate to severe post-natal perineal pain.

The numerical rating scale is a valid and reliable pain assessment tool with numbers assigned from 0 to 10 to represent the severity of pain: 0=no pain, 1-3=mild pain, 4-6=moderate pain and 7-10=severe pain. It is the most preferred scale for patient self-reporting of pain due to its simplicity and easier to understand for most people. On the first day, perineal pain was assessed at 6 hours after vaginal delivery in the hospital and then, data were collated by telephone interview on the third and seventh days. Women were asked only about perineal pain that existed on the day of the interview. Finally, a yes or no question was used to measure how much pain interfered with their ability to sit comfortably, urinate, walk and sleep. Each data collection quality, clarity and completeness was closely checked by the supervisor.

Results

Socio-demographic and obstetric characteristics of the study participants

Among 374 eligible women, a total of 356 were included in the final data analysis with a 95% response rate. Eighteen (5%) parturient were excluded from the analysis due to missing data. The mean age was 26.83 ± 4.96; 171 were primiparous and 158 were multiparous women. One hundred fourteen (32.0%) women gave birth by SVD with an intact perineum; 108 (30.3%) had an episiotomy; 21 (5.9%), had forceps or vacuum delivery; and the other 113 (31.8%) had SVD with perineal tears (Table 1).

Table 1: Socio-demographic and obstetric characteristics of the women in the comprehensive specialized hospitals, Amhara regional state, Ethiopia April 1 to June 30, 2023 (n=356).

Incidence of moderate to severe postnatal perineal pain

In our study, the overall incidence of moderate to severe postnatal perineal pain was 213 (59.8%) (95%, CI=54.8-65.4) at day one, 126 (35.4%), 95%, CI=30.6-39.9) at day three and 30 (8.4 %, 95%, CI=5.6-11.8) at day seven, respectively.

Incidence of postoperative perineal pain with independent variables

The result of the present study shows that 30.7% of parturient with intact perineum complained moderate or severe postnatal perineal pain on day one and 17.6% of primiparous participants with episiotomies had moderate or severe perineal pain on day seven (Table 2).

Table 2: Incidence of moderate to severe perineal pain on days one, three, seven with independent variables at comprehensive and specialised hospitals, Amhara regional state of Ethiopia, from April 1 to June 30, 2023 (n=356).

Interference of postnatal perineal pain in daily living activity

The results of our study show that pain affected daily activities on days one, three and seven and revealed that women who reported perineal pain decreased their levels of daily activity when sitting, urinating, walking, sleeping and taking care of young children, especially in those who had experienced perineal trauma (Table 3).

Table 3: Frequency of post-natal perineal pain interfering with daily activity life (yes/no) in comprehensive and specialised hospitals, Amhara Region, Ethiopia, from April 1 to June 30, 2023 (n=356).

Factor associated with moderate to severe postnatal perineal pain

During bivariable logistic analysis, maternal age, residency, educational status, parity, mode of delivery such as spontaneous delivery, episiotomy, instrumental delivery and degree of perineal tear (1^st, 2^nd, 3^rd or 4^th), met the threshold (p-value<0.2) to fit multivariate analysis.

However, after controlling the potential confounding factors using multivariable logistic regression analysis, we found that the odds of having higher education were 3.6 times (AOR=3.615, 95% CI=0.99-13.08) more likely to experience moderate to severe perineal pain on day one when compared to those who cannot read and write.

Primiparous women more likely experienced moderate to severe post-natal perineal pain three times (AOR=3.22=95%, CI=1.91-5.42) on day one, 2.6 times (AOR=2.66=95% CI=1.57-4.50) on day three as compared to multiparous women. Women who underwent episiotomies develop moderate to severe perineal pain 11.9 times (AOR=11.90=95% CI=5.98-23.75) on day one, 18.17 times (AOR=18.176 95%, CI=7.90-41.81) on day three, 9.7 times (AOR=9.76,95% CI=2.19-43.54) on days seven and instrumental delivery 4.5 times (AOR=4.54, 95% CI=1.593-12.91, P<0.005) on day one, when compared to intact perineum, respectively (Table 4).

Table 4: Bivariable and multivariable binary logistic regression analysis factors associated with moderate to severe postnatal perineal pain on days one, day three and day seven in comprehensive and specialized hospitals, Amhara Region, Ethiopia, from April 1 to June 30, 2023 (n=356).

First-degree perineal tears after vaginal delivery increased a woman's chances of having moderate to severe perineal pain by 5.6 times (AOR=5.62, 95% CI=2.42-13.19) on day one and 7.9 times (AOR=7.90, 95% CI=3.018-20.701) on day three (Table 2). Besides, second-degree perineal tears increase the odds of having moderate to severe perineal pain by 2.9 times (AOR=2.99, 95% CI=1.42-6.32) on day one, 12.8 times (AOR=12.8, 95% CI=4.62-30.25) on day three and 5.9 times (AOR=5.99, 95% CI=1.08-33.19) on day seven. Women with third to fourthdegree perineal tears also had an increased chance of feeling moderate to severe postpartum perineal pain 4.78 times (AOR=4.870, 95% CI=1.4-16.4) on day one, 10.21 times (AOR=10.21, 95% CI=3.018-34.5) on day three and 8.37 times (AOR=8.37, 95% CI=1.218-57.51) on day seven when compared to intact perineum.

Discussion

Women throughout the world have been experiencing perineal pain as a result of continuous perineal trauma following delivery. This study aimed to assess the incidence, severity and associated factors of postnatal perineal pain after vaginal delivery. Our results show that postnatal perineal pain occurs commonly in the first two days (day one and day three) and that higher perineal injury were associated with more moderate-tosevere perineal pain.

The incidence of moderate to severe post-natal perineal pain in our study was 59.8% (95% CI=54.8-65.4) on day one, 35.4% (95% CI=30.6-39.9) on day three and 8.4% (95%, CI=5.6-11.8) on day seven. The incidence was 30.7%, 7.0% and 1.8% in intact perineum on days one, three and seven, respectively; in episiotomy, it was 83.3%, 58.3%, 17.6%; for instrumental delivery, was 61.9%, 9.5%, 4.8%; first degree tears were 75.0%, 43.2%, 6.8%; second-degree tears were 56.9%, 49.0%, 9.8%; and third-and fourth-degree tears were 72.2%, on days one, three and seven respectively. However, these results are lower than the prospective study done in Nigeria, with intact perineum (38%, 27.7%), episiotomy (86.8%, 69.1%) and first or second degree tear (71%, 50%) on days one and three, respectively. A cohort study conducted in Canada found that the incidence of postnatal perineal pain was 75% and 38% in intact perineum, 97% and 71% in episiotomies, 95% and 60% first or second degree tears and 100% and 91% third or fourth degree tears on days one and seven, respectively. The difference may be due to differences in sample size, the study area, study design and population differences.

We found that having a university degree increased the probability of having moderate to severe perineal pain on day one by 3.6 times compared to not being able to read and write. But there was no statistical significance on the 3^rd or 7^th days. The possible reason may be basic demographic covariates; a residence is all associated significantly with higher reporting of pain. This result supported a study done in the USA, on the education and pain among adults and in France, by NRS assessment tool on days 1, 4 and 8, predictive factors of postsurgical pain results show that high school diploma level report more pain than other groups. But, one study discrepancy from our results of the study conducted the impact of educational status on postoperative pain perception (Red Cross Athens General Hospital, Greece, pain assessment tool NRS), to compared lower education up to junior school and high school up university, lower education ( junior school) more pain than higher education in the post-operative the 2nd, 3rd, 4th and 6th day due to different reason low understanding of preoperative information, level of anxiety to. So, health care providers should provide non-pharmacological treatments to relieve pain in women, like awareness creation and reassuring the parturient and they might be informed of these modifying factors as they are directly involved in their pain management.

In this study, primiparous women who had vaginal deliveries 3.2 times on day one and 2.6 times on day three had a significant association with moderate to severe postnatal perineal pain as compared to those with a multiparous woman. Possible reasons: Some postnatal perineal pain following vaginal delivery in primiparous women is associated with high pain scores, perineum exposure to tears, surgical episiotomy and instrumental delivery. This finding was supported by the studies done in Brazil and Turkey. Besides this, other studies conclude that post-natal perineal pain is significantly associated with primiparous women at the time of hospital-home discharge. Therefore, it may be possible to support and be aware of the problematic ways that pain and stress are related to parity, such as the management of anxiety including meditation, relaxation therapy and individualization of privacy. Understanding the causes will shed light on the several modifiable factors by which social factors cause distress.

In women who had undergone delivery with surgical episiotomy, the odds of having moderate to severe perineal pain were 11.9 times on day one, 18.17 times on day three and 10.5 times on day seven, when compared to those women with an intact perineum. This may be because episiotomy increased the risk for perineal pain and delayed wound healing until the third-week postpartum period, welling, the collection of blood in the perineal tissue, the increased risk of infection and perineal scars. These results supported research done in the USA, Brazil, Turkey and Sweden. In light of the above-mentioned facts, increase awareness of restricted episiotomies, conduct in-service training programmes and encourage medical professionals to risk-stratify labouring women, manage according to their experience of perineal pain and give the best possible care, like labor epidural analgesia.

In our study, we found that women who experienced perineal tears during childbirth were more likely to have moderate to severe painful postnatal periods. The likelihood of having pain on patients with first degree perineal tears was 5.6 times on day one, 7-fold on day three, but not statistically significant on day seven. On the other hand, the likelihood of having pain on second-degree tear was 2.95 times on day one, 12.48-fold on day three and 3.3 times on day seven. And also, the likely of having pain with the third or fourth-degree perineal tear was 4.66 times on day one, 10.1 times on day three and 8.7 times on day seven, as compared with that of SVD with an intact perineum. The scientific reason for postnatal perineal pain after encountering a perineal tear is usually perineal oedema, which heals in 4-6 weeks, with poor wound care and scar formation. This result is higher than the studies conducted in Brazil and Canada. Hence, healthcare providers should take preventative steps to provide women with a choice of appropriate pain treatment options due to the frequency of perineal pain and the scientific evidence for procedures that can prevent perineal trauma, such as the restricted use of episiotomies.

For participants who underwent delivery assisted with a vacuum or forceps, the odds of having moderate to severe perineal pain was 4.54-fold on day one, but on days three and seven, were not statistically significant when compared to those with an intact perineum. Possible reasons may be lower genital tract lacerations (such as a deep laceration of the vaginal sulcus), vulvar or vaginal hematomas, haemorrhage, local infection and hematoma, cervical laceration and vaginal laceration. However, compared to a study conducted in Thailand on day one, our findings are higher than on day one. The reason may be due to the sample size and the difference on the setup. Another study from New York concludes that instrumental delivery was significantly associated with personal discomfort or perineal pain.

Similar to research conducted in Thailand and Brazil, our results showed that the first, third and seventh-day post-natal perineal pain was not statistically significantly associated with bivariable and multiple logistic regression analysis, variables like the mother's age, the newborn's weight or the suturing material. A Cochrane database systematic review reported that catgut sutures resulted in more pain experiences as compared to synthetic sutures.

Conclusion

According to this study, a considerable percentage of women feel moderate to severe postpartum perineal pain. Being primiparous, having an episiotomy and having a perineal tear were all revealed to be significant risk factors for the incidence of moderate to severe postnatal perineal pain. The result should inevitably inspire reflection on medical professionals' efforts to avoid and decrease perineal trauma. In addition, the same study under consideration may have important ramifications for post-natal pain management, the quality of care and current practices of discharge following vaginal delivery.

Strengths

Our study had several strengths. We used primary data and conducted a follow-up study and the first study in our country.

Limitations of the Study

Because primary pain is a subjective response that is self-reported using a questionnaire, it was not assessed using an objective tool. Women have difficulty remembering the details of their pain and medications may have been mentioned during the period of data collection. For those who couldn't read or write, measuring pain with a numerical rating scale was difficult.

Recommendation

To researchers: Scholars urge high-level, ongoing research to be conducted in this area because postnatal perineal pain is a prominent problem, particularly for women when exposed to perineal trauma and the prolonged impact of postnatal pain on mothers.

To clinicians: Based on this result, we recommend health care providers consider and act accordingly to treat the pain, especially obstetricians, midwives and anaesthetists should be able to provide prompt and helpful support for the relief of pain into consideration and pain management practice following vaginal delivery and prepared guidelines.

Programmer: The programmer and policymaker need to emphasise on postnatal follow-up care.

References

1. Raja SN, Carr DB, Cohen M, Finnerup NB, Flor H, Gibson S, et al. The revised international association for the study of pain definition of pain: concepts, challenges and compromises. Pain. 2020;161(9):1976-1982.

   [Crossref] [Google Scholar] [PubMed]

2. Morais Í, Lemos A, Katz L, Melo LFRd, Maciel MM, Amorim MMRd. Perineal pain management with cryotherapy after vaginal delivery: A randomized clinical trial. Rev Bras Ginecol Obstet. 2016;38(7):325-332.

   [Crossref] [Google Scholar] [PubMed]

3. Fahey JO. Best practices in management of postpartum pain. J Perinat Neonatal Nurs. 2017;31(2):126-136.

   [Crossref] [Google Scholar] [PubMed]

4. Hedayati H, Parsons J, Crowther CA. Topically applied anaesthetics for treating perineal pain after childbirth. Cochrane Database Syst Rev. 2005;18(2):CD004223.

   [Crossref] [Google Scholar] [PubMed]

5. East CE, Sherburn M, Nagle C, Said J, Forster D. Perineal pain following childbirth: Prevalence, effects on postnatal recovery and analgesia usage. Midwifery. 2012;28(1):93-97.

   [Crossref] [Google Scholar] [PubMed]

6. Persico G, Vergani P, Cestaro C, Grandolfo M, Nespoli A. Assessment of postpartum perineal pain after vaginal delivery: Prevalence, severity and determinants. A prospective observational study. Minerva Ginecol. 2013;65(6):669-678.

   [Google Scholar] [PubMed]

7. Priddis H, Dahlen H, Schmied V. Women's experiences following severe perineal trauma: A meta‐ethnographic synthesis. J Adv Nurs. 2013;69(4):748-759.

   [Crossref] [Google Scholar] [PubMed]

8. Jones K, Webb S, Manresa M, Hodgetts-Morton V, Morris RK. The incidence of wound infection and dehiscence following childbirth-related perineal trauma: A systematic review of the evidence. Eur J Obstet Gynecol Reprod Biol. 2019;240:1-8

   [Crossref] [Google Scholar] [PubMed]

9. Morris A, Berg M, Dencker A. Professional’s skills in assessment of perineal tears after childbirth-A systematic review. Open J Obstet Gynecol. 2013;3:7-15.

   [Crossref] [Google Scholar]

10. Zhang Y, Huang L, Ding Y, Shi Y, Chen J, McArthur A. Management of perineal pain among postpartum women in an obstetric and gynecological hospital in China: A best practice implementation project. JBI Evid Synth. 2017;15(1):165-177.

    [Crossref] [Google Scholar] [PubMed]

11. Byrom A. Perineal pain in focus: Reviewing topical anaesthetic treatments. Pract Midwife. 2015;18(7):24:6-7.

    [Google Scholar]

12. Lopes GA, Leister N, Riesco MLG. Perineal care and outcomes in a birth center. Texto Contexto-Enfermagem. 2019;28.

    [Crossref] [Google Scholar]

13. Tomaz RGO, Brito APA, Riesco MLG. Implementation of evidence-based practices in the perineal pain management in the postpartum period. Rev Bras Enferm. 2021;75(2):e20210084.

    [Crossref] [Google Scholar] [PubMed]

14. Neels H, de Wachter S, Wyndaele JJ, Wyndaele M, Vermandel A. Does pelvic floor muscle contraction early after delivery cause perineal pain in postpartum women?. Eur J Obstet Gynecol Reprod Biol. 2017;208:1-5.

    [Crossref] [Google Scholar] [PubMed]

15. Steen M. I can't sit down'–easing genital tract trauma. British J Midwifery. 2005;13(5):311-314.

    [Crossref] [Google Scholar]

16. Webb S, Sherburn M, Ismail KMK. Managing perineal trauma after childbirth. British Med J. 2014;349:g6829.

    [Crossref] [Google Scholar] [PubMed]

17. Bick D, Bassett S. How to provide postnatal perineal care. Midwives. 2013;16(2):34-35.

    [Google Scholar]

18. Komatsu R, Ando K, Flood PD. Factors associated with persistent pain after childbirth: A narrative review. Br J Anaesth. 2020;124(3):e117-e130.

    [Crossref] [Google Scholar] [PubMed]

19. Andrews V, Thakar R, Sultan AH, Jones PW. Evaluation of postpartum perineal pain and dyspareunia-A prospective study. Eur J Obstet Gynecol Reprod Biol. 2008;137(2):152-156.

    [Crossref] [Google Scholar] [PubMed]

20. Francisco AA, de Oliveira SMJV, da Silva FMB, Bick D, Riesco MLG. Women's experiences of perineal pain during the immediate postnatal period: A cross-sectional study in Brazil. Midwifery. 2011;27(6):e254-e259.

    [Crossref] [Google Scholar] [PubMed]

21. Deyaso ZF, Chekole TT, Bedada RG, Molla W, Uddo EB, Mamo TT. Prevalence of episiotomy practice and factors associated with it in Ethiopia, systematic review and meta-analysis. Women's Health. 2022;18:17455057221091659.

    [Crossref] [Google Scholar] [PubMed]

22. Swain J, Dahlen HG. Putting evidence into practice: A quality activity of proactive pain relief for postpartum perineal pain. Women and Birth. 2013;26(1):65-70.

    [Crossref] [Google Scholar] [PubMed]