الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
With the dramatic rise in the rate of cesarean deliveries in the last two decades, postoperative pain management of these patients has become a major medical and nursing challenge. Although advances have been made in the understanding of pathophysiology of postoperative pain and development of new analgesics and delivery techniques, many patients including post-cesarean delivery women, still suffer from moderate to severe postoperative pain. Results from a recent United States national survey suggest that a patient has 50–70% chance of experiencing moderate to severe pain after surgery. (117)
Effective postoperative pain control can be achieved through combination of pharmacological and non – pharmacological therapies. Massage is one of the most widely used complimentary therapies in nursing practice. Foot and hand massage have the potential to aid pain relief. (67, 12)
The aim of this study was to determine the effect of hand and foot massage on post-cesarean pain intensity.
To fulfill the study aim: A quasi experimental research design was used.
Setting:
The study was conducted at the postnatal cesarean ward of El-Shatby Maternity University Hospital in Alexandria Governorate.
Subjects:
The study Subjects were selected by using the non probability sampling technique where a convenient sample of 100 post cesarean section women were recruited. The inclusion criteria included; Conscious, with intact hand and foot skin and free from arthritis, phlebitis, burn wound, injury, inflammation and eczema, free from any medical disease with normal course of pregnancy and willing to participate in the study.
The study subjects were equally assigned to one of two groups: a control and experimental group. Each group comprised 50 women.
The control group included 50 women who received post cesarean section hospital routine administration of pain medication in addition to the researcher’s physical presence
The study group comprised 50 women upon whom hand and foot massage was applied by the researcher. The massage included petrissage, kneading, and friction. The massage was applied through 2 sessions with 6 hours interval after surgery i.e. 1st session 4-6 hours post-operative, 2nd session 12 hours after surgery. The massage was conducted according to the following steps: the researcher held the mother’s hand gently in one of her hands and used thumb and fingers to make circles over the mother’s entire palm, all fingers, and the outer surface of the hand. The palm was spread by the researcher’s fingers. Hand massage was applied to each hand for 5 minutes avoiding an intravenous catheter inserted area if any. Following hand massage, the mother’s foot was elevated by supporting it with a pillow. The sole was spread and rubbed by the researcher’s fingers. The thumb was used to make circles over the entire sole of the foot. The knuckles of one hand stroked the sole with an up-and-down motion. The heel and ankle was kneaded between the researcher’s thumb and forefinger. The pillow support was removed to finish the massage. Also; foot massage was applied to each foot for 5 minutes.
Tools of the study:
Four tools were used for data collection. Tool I: Socio-demographic & clinical data structured interview schedules: this tool was developed and used by the researcher to collect the basic data. Tool II: Visual Analogue Scale (VAS) which was used to measure the intensity of post- cesarean pain. The scale line ranges from 0, denoting “no pain”; to 10, denoting “unbearable pain”. Tool III: A Modified Version of Johansson Pain-0- Meter Scale (JPOM) which was used to measure the intensity of affective and sensory components of pain (pain quality) after being translated &modified to suit the Egyptian culture. Tool IV: A modified version of Chamber Price pain rating scale (CPPRS) which was used to measure the behavioral responses to pain. Tools reliability was tested by Alpha Cronbach test (internal consistency) and results were satisfactory.
Using tool II, III, IV pain intensity was assessed for the experimental and control groups three times: once before applying the massage session and the 2nd time immediately after massage and the 3rd time one hour afterwards.
A pilot study was carried out on 10women who were excluded from the experimental sample to ascertain the clarity, relevance and the applicability of the tools, to estimate the time needed to complete the sheet and to detect any problem peculiar to the tools.
Collection of data consumed 6 months starting from February 2016 till the end of August 2016. Statistical analysis was done by the researcher after collection of data by using Statistical Package for Social Sciences (SPSS version 20) program. The collected data was revised, categorized, coded, computerized, tabulated and analyzed by the researcher using (SPSS) version 20 program.
The main findings of the study were:
- General characteristics:
Socio-demographic data:
- The mean age was almost the same among the experimental and the control groups (27.80±5.55 and 27.70±5.70 years) respectively.
- Secondary level of education or its equivalent was mentioned by 32% &14 % of the control and the experimental groups respectively.
- The majority (90%, 94%) of the experimental and the control groups respectively were housewives.
- A sizeable proportion (58% & 62%) of the experimental and the control groups respectively were urban dwellers.
- All women of the experimental and control groups were married
- No statistically significant difference was found between the two groups in relation to their socio-demographic characteristics
Reproductive history
- The mean number of pregnancy was almost the same (2.42 ± 1.071 and 2.34 ± 1.136) among the experimental and the control groups respectively.
- The mean number of deliveries was 1.92 ± 0.853 and 1.88 ± 0.895of the experimental and control groups respectively.
- No history of abortion was reported by 58 % and 62% of the experimental and control groups respectively
- The mean number of living children was 2.88 ± 0.872 and 2.84 ± 0.912 among the experimental and the control groups respectively.
- No significant difference was observed among the two groups in relation to their reproductive history
- Present history:
Gestational age: The mean gestational age was almost equal (38.53 ± 1.33 and 38.45 ± 1.119 weeks) among the experimental and control groups respectively
Type of anesthesia: A sizeable proportion (84% and 86%) of experimental and control groups respectively had spinal anesthesia.
Vital signs: no statistically significant difference was observed between the two groups concerning vital signs, where P= (0.949, 0.797, 0.247, 0.304, 0.573) respectively.
Effect of hand and foot massage on post-cesarean pain intensity:
Post-cesarean pain intensity as measured by VAS
- Before intervention, both groups had almost similar post-cesarean pain intensity, Almost one half (52% & 50%) of the experimental and the control groups had severe pain. Meanwhile, more than one third (34%) of the experimental group had moderate pain, compared to more than two fifth (42%) of control group. However, 14% of the study group had unbearable pain, compared to 8% of the control group.
- A highly statistically significant difference was observed among women of the experimental &control groups before and after intervention, where (P =<0.000). Moreover, another highly significant difference was also detected among women of the experimental group before & after intervention in relation to their intensity of post-cesarean pain as measured by VAS, where (P =0.000). Whereas, the intervention had a significant effect in reducing the post-cesarean pain intensity among the experimental group compared to the control group.
- Pain intensity score immediately and one hour after massage in the first and second session were significantly lower than those before massage, especially in the second session where the pain score continued to decrease and the lowest score was one hour after massage.
Sensory pain descriptions as measured by JPOM
- Before massage application, both groups had almost similar descriptions as follows: tearing (6%), burning (12%), sharp and burning (10%), sharp and cramping (8%), cutting, tearing and burning (4%).
- A highly significant reduction of post cesarean pain intensity was noticed within the experimental group immediately and 1 hour after massage in the first and second sessions of intervention, Whereas, a considerable proportion of the experimental group who described their pain as tearing before massage decreased dramatically to a very small proportion after massage. Also, none of those who had cutting, burning &pricking, sharp & pricking, cutting & burning pain before massage reported the same pain after such application.
Affective pain descriptions as measured by JPOMS
- Before intervention, both groups had almost similar descriptions as follows: terrifying pain (20%, 18%), dreadful (22%, 18%) terrifying & dreadful (10%, 14%) torturing & dreadful (12%, 14%) torturing & terrifying 12% among experimental and control group respectively.
- A highly significant reduction of post cesarean pain intensity was noticed within the experimental group immediately and 1 hour after massage in first and second session of intervention, literally, it was surprising to notice a sharp decrease in terrifying & dreadful, torturing& dreadful sensory responses.
Pain rating index rank as measured by JPOMS(sensory& affective part)
- Before massage application, both groups had almost similar scores.
- The relationship between the two groups was not statistically significant before massage application. However, a highly statistically significant difference was detected among the experimental and control groups immediately and 1 hour after intervention (P=0.000).
Intensity of post-cesarean pain as measured by CPPRS
- Before intervention, both groups had almost similar behavior scores; 44% of the experimental and control groups had severe pain. Moderate and unbearable pain was found among 36% and 20% respectively of the experimental group, compared to 44% and 16%respectively among the control group
- No statistically significant difference was found between the two groups in relation to their intensity of post-cesarean pain before massage application as measured by CPPRS. A highly statistically significant difference was noticed between them immediately and 1 hour after massage during the first and second sessions, where (P=0.000).
Based on the findings of the present study, the following recommendations are suggested:
• Hand and foot massage should be advocated as a non-pharmacological approach for management of post-cesarean pain
• Hand and foot massage should be recommended in hospital protocols for management of post-cesarean pain.
• Women and medical staff should be encouraged to utilize hand and foot massage for obstetric indications, since it is non-invasive, efficient and easy to use
• Useful potential effects of non-pharmacological modalities on pain management should be included in the maternity curricula at different educational settings.
• Mass media and professional journals can be used successfully to spot light on benefits of non- pharmacological methods of pain management.
• Further researches are recommended. Replication of the current study on a larger population size and different settings for better generalization and validation of results.