CONTRIBUTION OF PHOTOTHERAPY TO THE TREATMENT OF EPISIOTOMIES
1
CONTRIBUTION OF PHOTOTHERAPY TO THE TREATMENT OF EPISIOTOMIES
Jaroslava Kymplová, M.D., 1,2Leoš Navrátil*, Assoc. Prof., M.D., Ph.D., 3Jiří Knížek, Dipl.
Ing., Ph.D.
1,2
1
University of South Bohemia, Faculty of Social and Health Studies, Sect.. of Radiobiology
and Toxicology of Dept. of Radiology, Ceske Budejovice, Czech Republic
2
Department of Clinical Radiobiology, Institute of Biophysics, First Medical Faculty, Charles
University, Praha 2, Czech Republic
3
Czech Academy of Sciences ITIA, Prague, Czech Republic
email: Leos Navratil*, Assoc. Prof., M.D., Ph.D.
leos.navratil@volny.cz;
*Correspondence to Leoš Navrátil, Laser Centrum THERAP-TILIA, Seydlerova 2451, CZ
155 00 Praha 5, Czech Republic
Keywords
episiotomy, therapeutic laser, polarized light
Abstract
BACKGROUND AND OBJECTIVE
The purpose of the present study was an objective consideration of possible benefits of
phototherapy implemented with therapeutic laser or possibly polarized light in treating the
episiotomy, which is the most frequent obstetric intervention.
STUDY DESIGN/MATERIALS AND METHODS
In the present study, the authors treated total of 2436 women. The light sources were as
follows: a laser of a wave length 670 nm, power 20 mW, with continuous alternations of
frequencies 10 Hz, 25 Hz and 50 Hz, a polarized light source of a wave length in an interval
of 400 to 2000 nm, power 20 mW and frequency 100 Hz and a monochromatic light source of
a wave length 660 nm and power 40 mW, with simultaneous application of a magnetic field at
an induction 8 mT.
RESULTS
CONTRIBUTION OF PHOTOTHERAPY TO THE TREATMENT OF EPISIOTOMIES
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The work demonstrated high healing effects with minimum secondary complications in the
treatment of episiotomies with therapeutic laser at an energy density of 2 J/cm2. The
application of polarized light at an energy density of 5 J/cm2 also exerted favorable
therapeutic effects.
CONCLUSIONS
This study has been financially supported by the Ministry of Education, grant No.: FJ MSM
111100005 (New technologies and approaches in diagnostic, prevention and treatment).
Renaissance of the use of light energy in the therapy is currently encountered (1, 2).
This is a good direction of development with respect to negligible negative adverse effects (3).
Generally accepted therapeutic protocols are, however, missing. Each institution working with
light radiation sources has probably its own, in many cases adopted from other institutions,
approaches, which are not adequately verified. Even as sensitive discipline as obstetrics and
gynecology presents no exception from this rule.
Since 1990, our institutions try to bring their knowledge and experiences to eliminate
these drawbacks (4). Thus, our attention is also paid to problems of studying biological effects
of the light radiation on living tissues. We tried to bring a contribution to this topics by the
analysis of the non-invasive laser analgesic effect mechanisms (5).
The purpose of our study was an objective consideration of possible benefit of
phototherapy in the treatment of episiotomies, which are the most frequent interventions in
obstetrics (in as much as 90% of deliveries). This is a prophylactic intervention, which is
supposed to protect the perineum from its rupture. The episiotomy is implemented during the
top contraction, at the end of the second period of the delivery, in the course of the head
presentation, particularly in primiparae, where the perineum prevents further continuation of
the delivery and, in addition, there is a danger of the rupture. After the termination of the
delivery, the episiotomy is sutured layer by layer under local anesthesia with the use of catgut.
CONTRIBUTION OF PHOTOTHERAPY TO THE TREATMENT OF EPISIOTOMIES
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The episiotomy is suitable for studying healing, since this is a short wound (of about 3
to 5 cm) exposed to adverse conditions due to a possibility of easy infection, bruising and
frequently occurring hematomas.
Methods
Light sources
THERAPEUTIC LASER ML - MEDICA
Therapeutic laser for non-invasive laser therapy was made by the company EL-Medica
Kladno, Czech Republic. This is a semiconductor laser, which can operate in continuous as
well as pulsed regimes.
Laser medium:
laser diode GaA/As, infrared, 670 nm power
20 mW
Pulse modulation:
0 to 10 000 Hz
Method of application:
replaceable probe for point application
Presettable time of application:
6 s to 600 s
Beam spread:
15°
BIOPTRON
BIOPTRON, a product of the company Bioptron AG, Möchaldorf, Switzerland, is a
compact appliance having a halogen lamp as a light source. The light passes through a
polarizer utilizing Brewster mirrors. At the point of output, there is a filter for the elimination
of wave lengths shorter than 400 nm. The instrument operates in a continuous regime and it is
equipped with acoustic signalization.
Basic technical parameters of the appliance:
CONTRIBUTION OF PHOTOTHERAPY TO THE TREATMENT OF EPISIOTOMIES
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Light wave length:
400 to 2000 nm
Mean value of light power output during the halogen lamp emission:
20 W
Power density:
40 mW/cm2
Energy density:
2.4 J/cm2
FOTOMAGNETIK
The photomagnetic healing stimulator is an appliance produced and delivered by the
company AMBICO s.r.o., Rožnov pod Radhoštěm, Czech Republic. Its combined irradiation
head consists of a light source and magnetic applicator. The light source of the irradiation
head is equipped with a group of light emitting diodes (LEDs) circularly arranged about the
magnetic applicator (central prominence of the irradiation head). The light source of a
luminance of 70 cd at a distance of 1 cm from the head edge illuminates an area of 4 to 5 cm
in diameter. The instrument can provide two regimes as follows:
 pulsed operation with alternating the activity of the light and magnetic sources, the pulse
length is of 1 s, the magnetic applicator being active for 60% of the pulse period, the light
source for the remaining portion of time. The two sources never operate simultaneously;
 continuous operation of the light source.
Principal technical parameters of the appliance:
Light wave length:
660 nm
Mean value of light power:
40 mW
Power density:
2.9 mW/cm2
Modulation frequency:
100 Hz
Luminance:
70 cd
Magnetic induction:
8 mT
Magnetic field modulation:
100 Hz
Pulsed regime frequency:
1 Hz
CONTRIBUTION OF PHOTOTHERAPY TO THE TREATMENT OF EPISIOTOMIES
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Groups followed
Women, which were followed within the study, were divided into four groups (for age
characteristics of all the groups followed see Table 1).
Group A
In 748 women, therapeutic laser was applied once a day at an energy density of 2 J/cm2
with continuous alternation of frequencies of 10 Hz, 25 Hz and 50 Hz. The treatment was
started on the day of the delivery or on the next day and it continued for the whole
hospitalization period of the woman after the delivery. The average number of application
events was of 3.99.
Group B
Group B included 581 women. The episiotomy treatment was implemented with the
help of the BIOPTRON lamp in the light source continuous regime. It was started as soon as
possible after the delivery and it continued for the whole hospitalization period (typically for 4
to 6 days). The total energy density in the course of¨one application was of 5 J/cm2, the
average number of application events was of 4.37.
Group C
This group included 715 women. The phototherapy was applied once a day under
conditions of the same regime as in group A. In the PHOTOMAGNETIC appliance, a
combined regime was employed (for details see the technical description of the instrument). In
one application, the operation wound was exposed to a total light energy density of 0.7 J/cm2.
The period of the pulsed magnetic field application was of 3 min, the average number of
applications was of 4.83.
Group K
CONTRIBUTION OF PHOTOTHERAPY TO THE TREATMENT OF EPISIOTOMIES
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In the control group, there were 592 women, in which the episiotomy was
implemented in the course of the delivery and neither pharmacological nor physical methods
were employed in their treatment.
Statistical methods
The statistical evaluation of the age of patients in particular groups was carried out
with the help of the two-sided t-test of the difference between relevant polynomial regression
functions for dense networks (1 000 points) of an independent variable, i.e. age of the persons
examined. For testing the difference between the polynomial regression functions as whole,
mean integral probabilities (of agreement) were always used throughout the interval of the
independent variable, i.e. age of the persons examined. Treated groups A, B and C were
evaluated against control group K.
The statistical evaluation of the results obtained was carried out by the Fisher
(factorial) test (extended by data from binomial distributions) of equality of parameters 1 and
2 of two binomial distributions against the alternative of their difference 12. Treated
groups A, B and C were evaluated against the control group K.
Results
The percent abundance of the number of application events in particular groups
followed is summarized in Table 3, results of the statistical evaluation of the groups carried
out by the Fischer test in Table 4.
In the statistical evaluation of the age average of the groups studied, in none of the
mutually considered pairs of tabulated dependences, it was possible to conclude that the
groups exerted statistically significant differences, since the relevant mean integral probability
was always higher than 0.1. A statistically significant difference was found only in certain
(relatively narrow) age intervals.
CONTRIBUTION OF PHOTOTHERAPY TO THE TREATMENT OF EPISIOTOMIES
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The result shows a statistically significant higher abundance of complications in
controls.
Discussion
Laser treatment and the whole discipline named phototherapy was considerably
developed and found wide applications during the last years almost in all the clinical medical
but also veterinary disciplines. Its definite advantage is a minimum abundance of clearly
defined undesirable side effects and low number of contraindications (6, 7, 8).
As mentioned above, phototherapy may be employed in the most different indications
in obstetrics and gynecology. In the gravidity, we avoid the direct exposure of the abdomen
and the intravaginal application with therapeutic laser due to a possible damage to the fetus. It
is to emphasize that in special literature, no work has been yet published, which would
demonstrate teratogenic effects. This contraindication, however, does not hold for polarized
light. Works are of interest, where the effect of non-invasive laser therapy on certain
pathological conditions in the gravidity was investigated. The therapeutic laser was used in the
complex treatment of threatening abortion due to a hypofunction of the ovaria (7). A
beneficial effect of laser acupuncture on the condition of the fetus and general improvement of
problems of gravid women with late toxicosis was described, where a reduction of the blood
pressure, increase of the diuresis and reduction of the proteinuria were observed (3). During
the delivery, endonasal irradiation of pregnant women with assumed high degree of risk of a
weak uterus activity was employed. The method has no side effects, maturation of the cervix
score (neck index) was observed with reducing the length of the delivery time by 2 to 3 hours,
no
hypertonus
was
observed,
no
hasty
deliveries
were
encountered.
Repeated
cardiotocographic examination showed no pathological reactions in the fetus. No bleeding
was encountered in the puerperium, the lactation remained unaltered (9, 10).
In the present study, we compared three procedures (polarized light, polarized light
complemented by pulsed magnetic field and therapeutic laser) in the treatment of episiotomies
(11) where, due to complicated healing, a keloid scar or contracture on the perineum can be
formed (12, 13, 14). These two complications can be not only unpleasant in the sexual life of
the women, however, they can also result in problems during the next delivery. The
CONTRIBUTION OF PHOTOTHERAPY TO THE TREATMENT OF EPISIOTOMIES
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importance of the phototherapy is also given by the subjective feeling of the patient, where
multiparae reported that, in comparison with former deliveries, they can sit more comfortably,
their walking is improved and the perineum is not painful.
Phototherapy with any of the sources used reduced the occurrence of complications in
healing the episiotomies at a highly significant level (p<0.01). There was a considerable
reduction of complications in healing the scar. Absolutely best results were achieved after the
use of the therapeutic laser, when a slight complication in the course of healing (reddening in
the upper pole) was observed only in two cases.
When considering groups treated with polarized light (15) or possibly with a
combination of monochromatic light complemented by pulsed magnetotherapy, we observed
no statistically significant differences between these groups. In the group treated with
polarized light, we observed 3 complications (a coated suture and partial separation in the
upper pole), in the group treated with monochromatic light, 8 complications (in 3 cases
complete decay, in further 3 cases a partial skin dehiscence, in the remaining cases coated
suture without the dehiscence). We consider these complications to be due to a lower energy
density, which resulted in insufficient anti-inflammatory action.
The complications in women after the delivery, which were not treated with any form
of the phototherapy (control groups), were essentially more severe (complete decay with
resuture, subcutaneous and cutaneous dehiscence with purulent secretion), and they started to
occur most frequently of the fourth day after the delivery. The treatment typically consists of
the local pharmacotherapy and taking bath. The result of these procedures is usually a keloid
scar, which is of course unpleasant for the woman and which must sometimes be solved by a
plastic surgery intervention.
Conclusion
The results of the present study demonstrated a contribution of the phototherapy to the
treatment of the episiotomies. The authors achieved the best results after the application of
therapeutic laser. This therapy may be complemented by applying polarized light. It is
advantages that the woman after the delivery can implemented it herself at home, which is
CONTRIBUTION OF PHOTOTHERAPY TO THE TREATMENT OF EPISIOTOMIES
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impossible in the case of laser with respect to relevant safety regulations. Pulsed
magnetotherapy brings no benefit in the indication chosen.
References
1. Baxter, G. D., Diamantopoulos, C., Kane, S., Shields, T. D.: Therapeutic Lasers. Theory
and Practice. Edinburgh, London, Churchil Livingstone, 1994, 259 pp.
2. Kolářová, H., Ditrichová, D.: Laser radiation in medicine (in Czech). UP Publishing
House, ISBN 80-7067-608-6, Olomouc 1996, 15-25.
3. Pöntinen, P. J., Pothmann, R.: Laser in der Akupunktur, Stuttgart. Hippokrates Verlag,
1993, 191 pp.
4. Navrátil, L., Dylevský, I.: Mechanisms of biostimulating effects of therapeutic laser in
vivo. Sborn. lék. 1996, 97: 521-527.
5. Navrátil, L., Dylevský, I.: Mechanisms of the analgesic effect of therapeutic lasers in vivo.
Laser Therapy 1997, 9: 33-40.
6. Kert, J., Rose, L.: Clinical laser therapy. Low level laser therapy. Scandinavian Medical
Laser Technology, Veksoe 1986, 240 pp.
7. Navrátil, L. et al: Noninvasive laser therapy (in Czech). Manus, Praha 1997, 148 pp.
8. Pöntinen, P. J.: Low level laser therapy as a medical treatment modality. Art Urpo Ltd.,
Tampe, 1992, 215 pp.
9. Barták, A.: The use of low-level lasers in gynecology and obstetrics (in Czech).
Gynekolog 1995, 4: 71-74.
10. Havlík, I.: The use of low-level lasers in gynecology and obstetrics (in Czech). Gynekolog
1998, 7: 89-92.
11. Karu, T.: The Science of Low-Power laser Therapy. Gordon and Breach Science
Publishers, Amsterdam, 1998, 299 pp.
12. Bahmer, F., Seipp, W.: Dermatologische Lasertherapie, Stuttgart, Wiss. Verl.-Ges., 1996,
217 pp.
13. Karu, T. I., Pyatibrat, L. V., Kalendo, G. S., Esenaliev, R. O.: Effects of monochromatic
low-intensity light and laser irradiation on adhesion of HeLa cells in vitro. Lasers Surg.
Med 1996, 18: 171-177.
CONTRIBUTION OF PHOTOTHERAPY TO THE TREATMENT OF EPISIOTOMIES
10
14. Luža, J., Hubáèek, J.: In vitro He-Ne laser effect on phagocytic activity of the
polymorphonuclears (PMN) and monocytes (MO) in rabbits. Physiological Research, 44,
1995: 23-28.
15. Samoilova, K. A., Zubanova, O. I., Snopov, S. A., Mukhuradze, N. A., Mikhelson, V. M.:
Single skin exposure to visible polarized light induced rapid modification of entire
circulating blood. 2. Appearance of soluble factors restoring proliferation and
chromosome structure in X-damaged lymphocytes. EUROPTO Conference of Effects of
Low-Power Light on Biological Systems, Stockholm 1998: 26-33.
CONTRIBUTION OF PHOTOTHERAPY TO THE TREATMENT OF EPISIOTOMIES
Table 1 - Age distribution in particular groups followed.
Age
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
Number of patients in particular groups (n)
Treatment with
Treatment with
Treatment with
Controls
therapeutic laser polarized light
polarized light
(group K)
(group A)
(group B)
and pulsed
magnetic field
(group C)
0
0
1
0
3
3
4
0
4
7
5
2
27
23
23
7
29
24
26
23
39
50
50
35
72
60
61
49
91
71
77
87
88
67
79
66
62
45
84
67
61
41
58
57
55
37
54
41
49
38
34
35
39
27
32
27
27
19
21
30
22
23
24
19
17
9
14
25
17
12
21
24
12
9
18
13
9
7
9
13
7
2
4
8
6
3
5
5
4
1
2
4
3
0
2
3
2
1
4
2
1
1
1
4
1
1
1
1
1
0
1
1
11
CONTRIBUTION OF PHOTOTHERAPY TO THE TREATMENT OF EPISIOTOMIES
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Table 2 - Number of applications expressed in percent in particular groups followed.
Number of
applications
1
2
3
4
5
6
7
8
Number of patients in percent (%)
Treatment with
Treatment with
Treatment with polarized light and
therapeutic laser
polarized light
pulsed magnetic
(group A)
(group B)
field
(group C)
0
1.03
0
8.33
4.3
1.54
22.22
14.11
7.13
38.89
33.22
27.7
25
34.26
39.99
4.17
10.33
18.74
1.39
2.75
3.5
0
0
1.4
Table 3 - Fisher (two-sided) tests of the difference of the relative numbers of cases with
complications in treatment (x1/n1) in comparison with randomly selected
controls (x2/n2)
GROUP K
GROUP A
GROUP B
GROUP C
x1
2
3
8
n1
748
581
715
x2
58
58
58
n2
592
592
592
p
0.000***
0.000***
0.000***
n2
748
748
p
0.767
0.093*
n2
581
p
0.386
GROUP A
GROUP B
GROUP C
x1
3
8
n1
581
715
x2
2
2
GROUP B
GROUP C
x1
8
n1
715
x2
3
*
at a limit of statistical significance (p<0.1)
** statistically significant difference (p<0.05)
*** statistically highly significant difference (p<0.01).
CONTRIBUTION OF PHOTOTHERAPY TO THE TREATMENT OF EPISIOTOMIES
13
Table 4 – Comparison of particular groups including abundance in percent.
Type of group
controls (K)
laser treatment (A)
polarized light (B)
combined treatment (C)
Leoš Navrátil
Phone: +420603 435 273
Fax: +4202 41 77 06 80
E-mail: leos.navratil@volny.cz
Number of patients
(n)
592
748
581
715
Number of complications
n
%
58
9.8
2
0.27
3
0.52
8
1.1