Report Writing

Awareness about the Perineal Care in the Early Post Natal Period in
Married Women
Group: 04
Submitted to: Mam Fuldisia
Submitted By:
Sobia Aziz
Iqura Samad
Muqadas Arshad
Muqadas Ashraf
Afifa Karim
Kashif Murad
Mohammad Waqas

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 Report Writing

Introduction:
Perineal care involves cleansing of the external genitalia, anal area and surrounding skin.

“peri-care” or “perineal-genital” care is washing the external genitalia with soap and water or

with water alone or in combination with any commercially prepared peri wash (G.Manisha et al.,

2018). It should be done at least one a day during bed bath, shower, or tub bath. It is done more

often when a patient is incontinent. This prevents infection, odors and irritation.

Perineal infection is the type of infection that affects the perineum and shows sign and

symptoms includes redness, itching and burning sensation, pain while urinating or during

intercourse, abnormal vaginal discharge that has a bad smell and excessive bleeding and ranges

from mild to complicated and should be properly taken care of especially in women with health

issues such as diabetes and hypertension (P.Merlin et al., 2018).

WHO estimates on maternal health and safe motherhood programmer the major cause of

maternal deaths was due to puerperal sepsis which accounts for 15% of maternal deaths in

developing countries. The perineum is the anatomic area between the urethra, the tube that

carries urine from the bladder, and the anus.

In women, the perineum includes the vaginal opening (Fahmy et al., 2019). This area

undergoes a lot of stress and change during pregnancy and delivery, and it needs special care

afterwards. Perineal care is often referred to as “Peri care”. The postpartum period can often feel

like all the focus is on the new baby, but mother also spend time caring for herself, especially her

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perineal area, to ensure optimum recovery and reduce chance of infection. Mother’s physical

and psychological health is impaired during postnatal period by perineal trauma sustained during

child birth. More than 85% of women sustain some form of perineal trauma and 60%-70%

receive stitches, with 0.6-11% of all vaginal deliveries resulting in a third degree or forth degree

tear. These injuries can result in disabling immediate and long term complications in the woman

(Goh.R, 2018).

Perineal care is carried out as part of the patient’s bath or as a separate procedure. Perineal

area is conductive to the growth of pathogenic organism because it is warm, moist and is not well

ventilated. The purpose of perineal care is to prevent or eliminate infection of episiotomy wound,

bladder and uterus and promote healing. It also removes secretions and provide comfort.

Majority of maternal and neonatal deaths occurs during childbirth and post natal period. Perineal

care for mothers has been neglected area even for women who give birth in health facility. Many

mothers are uneducated and ignorant about health practices. Perineal care will not only help in

maintaining and promoting the health of women but it also provides an opportunity for health

professionals to identify, monitor and manage health conditions that may occur in mother after

delivery. Lack of perineal care may lead to some other complications like puerperal pyrexia;

perineal infection by hemolytic streptococci and other infections affect the genital tract (A Study

to Assess the Knowledge Regarding Perineal Care among the Post Natal Mothers in Selected

Hospitals of Pune City, 2018)

Literature Review:

Studies have indicated that postpartum is a critical period in women's life due to the

occurrence of various physiological and psychological changes and the development of severe

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complications that require emergent management (WHO, 2018). Self-care elements during

postpartum period include personal hygiene, perineal care, checking the funds, breast care,

nutrition, postnatal care (Rew, 2015). Perineal care procedure by postpartum mothers is very

important in preventing infection. Perineal care procedure can be done by applying ice pack

compress, applying topical medications such as antiseptic fluid and performing Kegel’s exercise

(Devita & Aspera, 2018).

Maternal mortality rate in Egypt are 33 deaths/100,000 live births according to World Health

Organization (2018). The main causes of maternal mortality related to bleeding and sepsis. There

is still wide disparity in maternal health across the country, with the areas such as Upper Egypt

and other rural areas facing challenges of lack of access to services, and lack of access to hygiene

and sanitation. Proper care of the perineum after childbirth is very important in order to avoid

infection and to speed healing of the rectal and pelvic muscles. This area can be very sore, and

cleaning and care can help relieve pain as well. After childbirth, it is crucial to take good care of

the perineum to prevent infection and hasten the recovery of the pelvic and rectal muscles.

Cleaning and caring for this area can also aid with pain relief since it can be a very

uncomfortable spot. After giving birth, many women report pain, tenderness, and swelling in the

perineal region (Brian, 2020).

Over 85% of women having a vaginal birth suffers perineal trauma. The rate of episiotomy

was determined as 93.3% in primipara women and as 30.2% in multipara women. One of the

most important aspects of perineal care is checking for signs of infection. Most women have

some degree of discomfort during the first few postpartum days. One of the common causes of

discomfort is episiotomy. These include swelling, lesions, rashes, sores and boils. Proper care of

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perineum after childbirth is very important in order to avoid infection and speed healing of rectal

and pelvic muscle (Samuel et al., 2021).

Examining for symptoms of infection is one of the most crucial parts of perineal care. During the

first few days after giving birth, the majority of women experience some level of discomfort.

Episiotomy is one of the frequent sources of discomfort. Among them are bloating, lesions,

rashes, blisters, and boils. After childbirth, it's crucial to take care of your perineum properly to

prevent infection and hasten the recovery of your pelvic and rectal muscles (Limbachiya et al.,

2022).

The majority of women who give birth vaginally and have their perineum patched experience

postpartum problems. One of the upsetting short-term morbidities that interferes with a mother's

capacity to perform everyday tasks and care for her child is pain. In some cases, wound infection

and dehiscence are common. During prenatal health education classes, supportive information on

postpartum perineal wound care received less focus, leaving expectant mothers unable to

understand and apply adequate wound care that will speed healing. Most mothers who sustained

perineal trauma during vaginal birth suffer some forms of postpartum complications such as pain

which interferes with activities of daily living and care for her baby, wound dehiscence, infection

and dyspareunia. Information on postpartum perineal wound care has been given less attention

during antenatal health education sessions (Samuel et al., 2019). Most of women who has

vaginal delivery is risky of perineum laceration even from spontaneous tears or episiotomy.

Perineum laceration can effect of many complication that cause morbidity and mortality

(Sulistianingsih & Wijayanti, 2019).

Perineal wound dehiscence is an uncommon but important postpartum complication. In many

cases, it leads to extreme pain and urinary and defecation problems. For up to several weeks, it

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can interfere with the mother’s daily activity, affecting psychosexual health and body image. The

best way to manage perineal wound breakdown after childbirth remains controversial

(Akhoundova et al., 2022). Notwithstanding the physical toll childbirth takes on the female body,

wound complications related to the birth can occur, often an unfortunate result of multiple

factors related to injury to skin and deeper tissues. Birth wound complications, such as trauma to

the perineum and vagina have a considerable impact on a woman’s physical and mental

wellbeing. Wound-related complications after delivery may last for many years, with the more

serious consequences requiring reconstructive surgery and patient rehabilitation. Attention is also

required to address a woman's needs in reducing physical and psychological pain and distress

arising from birth related wounds and infection-related complications (Childs et al,. 2020).

To effectively prevent postpartum infection, the principle of maintaining good hygiene is very

important. In particular, during pregnancy, if a woman has symptoms or has a vaginal infection,

she should be treated immediately under the examination and guidance of a doctor, absolutely do

not bathe or soak in the pond/lake, dirty water. Daily need to clean the intimate area with clean

water and do not douche the genitals deeply (Vinmec, 2019). Sitz bath is a type of treatment that

is done by sitting in warm water. The process of a sitz bath is to soak the perineal, anal, and

genital area. A warm sitz bath works by bringing blood flow to the area to relax the muscles and

promote wound healing and heals tears, stitches, or hemorrhoids and sores (Johnson, 2023).

Exercise is a critical protective factor for most chronic medical conditions and is strongly

recommended during pregnancy and early post-Partum period (Inge, 2022). Up to 50% of

women experience pregnancy related pelvic girdle pain (PGP) or lower back pain during

pregnancy or in the post-partum period. Up to 20% report pain persisting for years. Caesarean

delivery increases the risk of severe persistent PGP six months post-partum. (Orchard, 2022)

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One in three women develop urine incontinence after delivery and up to one in 10 experience

fecal incontinence. Up to 50% of all the pregnant women experience some degree of pelvic

organ prolapse. And this can make it difficult to resume exercising after birth. Thus to reduce all

the physical complications after delivery an early return to exercise is safe and should be

encouraged in the early post-partum, pelvic floor exercises can be initiated in the immediate

post-partum period. The body goes through many physical and hormonal changes during

exercise; so it is important to be patient as it will take time to return to pre pregnancy exercise

level. (Purdue, 2022).

Methodology:

Quantitative cross-sectional descriptive research was used to assess the level of knowledge

and awareness regarding perineal care among postnatal mothers in selected community of Bari

Imam, Islamabad. For this study, the target population was primipara and multipara women and

who fulfills the inclusion criteria are selected through a non-probability convenient sampling

technique. A sample size of 212 women of reproductive age group is selected for the study. To

assess the level of knowledge, 26 self-structured questionnaires were formulated. Questionnaires

contained dichotomous and multiple-choice questions.

The reliability of tool was established by conducting a pilot testing. The data collection was

conducted for three days in selected community of Bari Imam. The study was conducted after

receiving permission from the postnatal mothers (residents of Bari Imam). Informed written

consent was obtained from participants and confidentiality of the received information was

maintained. The collected data was tabulated and analyzed using SPSS26, percentages and pie

charts.

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Results:
Out of 212 participants, the mean age of the females is 31. The mean age at the time of

marriage is 20. (62.2%) females have one two and three number of children and (37.8%) have

more than 3 children. (7.1%) have one still birth and (1.4%) have 2 still births. (23.6%) have one

miscarriage and (7.1%) have 2 miscarriage. (25.5%) were uneducated and (75.5%) were

educated with mean level as matric. (91%) were housewives. With regards to the type of delivery

(56.6%) had sub vaginal delivery (34%) had episiotomy and (9.4%) had cesarean section.

Majority of them (54.7%) have Punjabi as their first language and (46.3%) speak other

languages.

With regards to the perineal care, most of the respondents had some sort of information. And

according to the data;

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Question: Yes (%) No (%)

Do you know what perineal

care is? 68.9% 36.1%

Do you know few hygiene

practices to follow after 41.5% 58.5%
birth?
Do you know taking enough
water can reduce the risk of 56.1% 43.9%
bladder infection?
Do you know how often
should you shower/bath after 54.7% 43.3%
delivery?
Do you know what should
you do if you experience any 58.5% 41.5%
sign of infection?
Do you know when should
you consult your health care 44.3% 55.7%
professional about your
issues?
Do you know what sitz bath 54.2% 45.8%
is?

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 Do you know the proper way 50.5% 49.5%
of sitz bath
Do you know how long
should you stay in the sitz 37.3% 62.7%
bath?
Do you know any exercise to
strengthen the perineal
muscle after delivery? 4.2% 95.8%

In this study the females that undergo episiotomy or C-Section had enough knowledge on

how to take care of incision or stitches. (47%) female use commercial and cotton sanitary pads

while (53%) females use clothe. (12.7%) females took their first bath after 24 hours of delivery,

(59.4%) after 72 hours and (24.5%) after 40 days of delivery. Majority of them (52%) used

normal water for bath and (44%) used warm water. Most of the respondents (56.1%) know the

redness is the sign of perineal infection and 46% females did not know the signs of perineal

infection. Regarding the recovery of the perineal area only (28.3%) females know the exact time

of recovery that is 4-6 weeks, (39.2%) respond 2 weeks as the recovery time, (27.8%) respond 5-

7 days while (4.7%) respond 3 months.

Discussion

Concerning general characteristics of the study subject, nearly two thirds of the mother’s age

ranged 16-45 years. The mean age was 31 years and also nearly two thirds of mothers were from

urban area, as well as near three forth of mothers with primary education. While, majority of

mothers were housewives and had normal delivery and some with episiotomy.

Regarding knowledge of studied mothers about perineal care and self -hygiene, the present

study revealed that nearly two fourth of mothers had incorrect and poor knowledge about

perineal care hygiene practices, this might be due to lack of health education about perineal care

before and after delivery. The previous study findings of M.Doaa et al.,(2018), who also assessed
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the knowledge of mothers personal care during post-partum period at maternal and gynecological

department in the selected hospital reported that nearly three-fourth of the postnatal mothers had

incorrect knowledge about the components of post-partum self-care .

The results of the current study indicated that nearly all the mothers had incorrect to no

awareness about the practiced exercises after delivery and this might be due to false beliefs and

very poor knowledge about the importance of exercises after birth. The previous study findings

of (Hassan et al., 2021) revealed that more than half of the mothers had knowledge about

postnatal exercises but they were not fully aware of the potential benefits of postnatal exercises.

The present study revealed that, most of the mothers had incorrect knowledge about postnatal

visits. This might be due to lack of awareness about postnatal check-up, as postnatal care is a

neglected part in our society. The previous study findings of (Beraki et al., 2020) contraindicated

that almost all 96% of the mothers responded correctly where to go if they note any sign of

infection.

The present study results revealed that almost half of the mothers had little to no knowledge

about post-partum danger signs, this might be due to lack of awareness regarding the possible

danger signs in the post-partum period. Meanwhile the previous study findings of R.Kamalia et

al.,(2018) also revealed that half of the mothers had incorrect knowledge about the post-partum

danger signs.

The present study results revealed that three fourth of the females had incorrect knowledge

about the precautionary measures to prevent perineal infection and complications after delivery,

this might be due to the negligence of mothers and their family members towards infection

precautions. On the other hand, the previous study findings of (Nchimbi & Joho, 2022),

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conducted a hospital based research in Dar e Salaam, Tanzania explored that about one third of

the population had inadequate knowledge about the precautionary measures of perineal infection.

Concerning the Perineal Care, the results of the present study revealed that one third of

postnatal mothers did not change their pads within 2-4 hours that is the recommended time,

instead they used to change their pad after 5-6 hours to one day, this might be due to lack of

awareness about the perineal care duration or they don’t follow perineal cleanliness proper

directions. The mothers were believing that “Perineal care is part of ordinary personal hygiene

and don’t need special care”. In line with (Doaa et al., n.d.), which revealed that two third of the

mothers did not remove the solid pads from front to back and did not follow perineal cleanliness

proper directions to change their pads.

The result of the present study indicated that there was a highly statistical significant

association between mothers educational level and their knowledge regarding perineal hygiene,

this may be due to women with educational background had correct knowledge than mothers

with limited educational background. Similarly, the previous study findings of (Hassan et al.,

2021) indicated that there was a strong correlation of educational level of mothers with the

awareness regarding perineal hygiene.

Implications:

 The present study can enhance awareness about perineal care among postnatal mothers

through outreach programs, emphasizing hygiene, episiotomy care, early detection of

complications and treatment for the detected complications. Perineal wounds during

childbirth can cause severe physical and psychological effects. Proper management can

enhance healing and reduce co-morbidities.

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  The finding of the study can help the gynecology and obstetrics nurses and students to

develop the inquiry baselines and measures.

 It helps women to make positive choices based on best ‐practice guidelines and may

contribute to an overall better quality of life.

 Further research is needed in this area to maximize large trails involving women from

various socio-economic groups and using various healthcare options.

 So for this concept in mind the significance of postpartum perineal infection prevention,

sitz bath to relief pain and improve blood circulation, proper cleaning of perineal area to

prevent form infection and application of ice packs to reduce risk of excessive bleeding.

Recommendations:

It is recommended to conduct an educational program for mothers in Bari Imam

Community and it must be started in the final stage of pregnancy.

 Conducting educational programs for mothers especially for first time mothers must be

started during late pregnancy to inform primigravida about self-care during postnatal

period.

 Regarding regular self-care during the post-partum period distributing flyers and posters

to pregnant mothers to raise awareness about the importance of postpartum hygiene.

 The study can be replicated on a larger sample in different settings and communities for

generalization of results.

 It is important that nurses must be updated with the necessary knowledge about perineal

care practices who work in obstetrics and gynecological areas.

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  These kinds of studies should be conducted considering the weather conditions of the

respected areas.

 Future studies should be conducted on these sensitive issues on a larger population as it is

the most neglected part in our society.

Limitations:

 Limited sample size, hence generalization is not possible.

 Convenient sampling, hence increased chances of biasness.

 Cross-sectional study therefore it is conducted one point in a time and does not help to

determine cause and effect.

 Because of the sensitiveness of the topic, it was difficult to conduct the research.

Conclusion:

The present study highlights the awareness about the perineal hygiene among post natal

mothers. It shows that participants had average knowledge on perineal hygiene. The study shows

that the most knowledgeable area was sign of infection and the least knowledgeable area was

exercises after delivery and preventive measures for perineal infection. Awareness campaign are

required to increase knowledge on the different aspects of perineal care. Additional research can

be done to clarify concepts about perineal hygiene and encourage the mothers to use perineal

hygiene practices.

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