الفهرس 
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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).
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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.
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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
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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.
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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.
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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.