الفهرس | Only 14 pages are availabe for public view |
Abstract SUMMARY Choice of method of analgesia, suture material, suture technique and the operator’s surgical competence can influence short and long term morbidity related to perineal repair (Johanson and Kettle, 2000). Perineal infiltration with local anesthetics is the most common technique to provide anesthesia during perineal suturing. Although infiltrative anesthesia remains a main stay for pain relief goals during minor surgical procedures, topical anesthetics in the form of sprays, goles, and ointment have emerged as a valuable alternative in several medical specialties (Kaweskis, 2008). The advantages of using topical anesthetics include their localized action with negligible systemic absorption, case of administration, painless application, and absence of edema at the surgical site that distorts wound margins in laceration repair. Lidocaine-prilocaine cream (EMLA cream; AstraZeneca, Basiglio, Italy) is an eutectic mixture of 2.5% lidocaine and 2.5% prilocaine that is used widely as topical anesthetic for pediatric, dermatologic, reconstructive, and gynecologic minor procedures. Absorption from the genital mucosa is rapid, and onset time is between 5 and 10 Summary 83 minutes with an average duration of effective analgesia from 15-20 minutes; however, on intact skin, the cream should be applied for at least 1 hour to provide satisfactory dermal analgesia Safety and efficacy of EMLA cream have been shown consistently in a number of clinical trials across many medical specialities since 1990 (Kaweski, 2008; Friedman et al., 2001). EMLA cream provides analgesia by the release of lidocaine and prilocaine, which are two amide anesthetics, from the cream into the dem1al layers before penetrating the smooth and striated muscle and the individual axons within the nerve. Nerve conduction becomes impeded because an action potential is prevented by an inward flux of sodium ions through the nerve membrane. Although EMLA cream is indicated as atopical anesthetic for use on intact skin, several studies have shown that EMLA cream can also be used effectively for laceration repair (Zempsky et al., 1997; Sillger et al., 2001). Moreover, EMLA cream has been shown to work effectively on genital mucosa during minor gynecological Summary 84 surgical procedures, such as laser treatment of condyloma accuminata (Rylalltler et al., 1990, Monsonego et al., 2000). This study was conducted to assess the effectiveness of the topically applied lidocaine-prilocaine cream in the reduction of pain during perineal suturing of an episiotomy as well as short term post partum pain. This study is a prospective single-blinded randomized controlled study. A total of 100 women were included in our study during the period from October 2013 till March 2014, at Benha and Al Galaa Teaching Hospitals. They were randomly allocated into two groups: group A and group B. Randomization would be applied using a blockrandomized computer-generated list. Women would be blinded as to which of the groups they were allocated to: Allocation was written in a cord that was sealed in sequentially numbered opaque envelopes. These women were divided into 2 groups: Group A: Including 50 women with lidocaine prilocaine cream (EMLA cream). Summary 85 Group B: Including 50 women without EMLA cream, received local infiltration with lidocaine Women who enrolled in the study were guaranteed to obtain additional anesthesia during perineal repair whenever pain exceeded the tolerability threshold. Inclusion criteria: Any case that needed episiotomy. Exclusion criteria: Any contraindication for episiotomy e.g. abnormalities of the perineum, severe perineal scarring, previous 4th degree perineal tear, if there is reasonable doubt that vaginal delivery is possible and the patients absolute refusal for the procedure to be performed Those who looked for more anesthesia Those who refused to participate in the study Instrumental delivery Neither systemic opioids nor inhalation methods will be used to relieve pain 2 hours before episiotomy Emergency vaginal delivery. All cases were subjected to: Verbal consent History taking: it was taken in brief to fulfill inclusion criteria and exclude exclusion criteria. Summary 86 General examination including vital signs: Blood pressure, pulse, temperature, pallor, general condition, and respiratory rate.Abdominal examination including assessment of gestational age, fetal lie and presentation, fetal heart sounds, uterine contraction, and scar of previous surgeries. Local pelvic examination to assess: cervix, presentation, station, position, pelvic adequacy. Women in group A received 5 gm dose of EMLA cream to be applied to the intact surface of perineum and the area was covered by an occlusive dressing to facilitate penetration through the stratum corneum. The cream was applied 1 hour before the expected time of labor. At childbirth, the residue of the cream was removed to prevent contact with the fetus and avoid eye irritation (Mckinaly et al., 1999). Women in group B received local infiltration with 8 ml of 2% lidocaine. All episiotomies were performed at the top of contraction as mediolateral episiotomies Summary 87 1. In all cases, episiotomy was repaired with a continuous, chromic non-locking suture to close the vaginal mucosa and the muscular layer of the perineum. Skin will be closed by the same continuous suture to approximate the subcutaneous tissue. Finally, interrupted sutures will be applied to the skin. The same suturing material, number zero chromic cat gut suture was used. - Moreover, the request of additional anesthetic (ie, 8 ml of 2% lidocaine solution for both groups) was recorded. Before leaving the delivery suite (approximately 2 hours after delivery), each patient will be asked to record the severity of pain that she will experience during perineal repair in a 10 cm visual analog scale, where 0 cm means no pain and 10 cm means unbearable pain (Ludington, 1998). The patient was educated to assess the pain degree on the visual analog scale. The patient was asked to mark the point that best indicates her perception of pain on the visual analog scale. Finally, women were asked about their overall satisfaction with the anesthesia method during episiotomy with ”Yes” or ”No” answers. Summary 88 Primary outcome was pain during perineal repair according to pain scale. Secondary outcomes were need for additional anaesthesia and overall satisfaction. As regarding our results, the study showed no significant statistical difference between the two studied groups regarding the mean maternal age, parity, gestational age, body mass index, neonatal birth weight. As regard pain scores during perineal suturing that were assessed by a 10-cm visual analog scale. Our result showed that there was non significantly higher in EMLA group than control group with lidocaine infiltration (4.6±0.5 vs 4.4±0.7, P= 0.094). As regard the patients overall satisfaction with the method of anesthesia during perineal repair. Our result showed that their was statistically significant difference between the two groups as the patient who received topical application of EMLA cream was more satisfied than the patient who received lidocaine infiltration. As regard the request of additional anesthetic. Our result showed that the request of additional anesthetic was more in the ”EMLA” group than in the control group with lidocaine infiltration. Summary 89 We reported that EMLA cream may be less active on the perineal muscular layers than local infiltration of lidocaine due to limited penetration beneath the skin which could account for higher requirement of additional analgesia in group A of the study. The cream is a safe, highly satisfactory and easy-to-use agent with comparable efficacy to local lidocaine perineal infiltration for episiotomy repair and is better tolerated on account of reduced needle anxiety and painful injections. |