Cases in High Value Care

Dermoplast and Epifoam Use after Vaginal Delivery

Shannon M. Wentworth, Medical student
Lauren Demonsthenes, MD Faculty Mentor
8/16/17

Scenario A
A 32 year old G1P0 presents at 39 weeks 2 days to labor and delivery with painful contractions. Cervical examination on arrival is 5 cm dilated, 80% effaced, and 1+ station. Seven hours after admission, she delivers a healthy female infant with APGARS of 8 and 9.  Her delivery was complicated only by a second degree perineal laceration that was repaired in standard fashion. The physicians chooses the “Standard postpartum” orderset in the EMR.  This order set includes an order for ice packs to be placed on the perineum and for, Epifoam * to be applied to the perienum every three hours. 

Scenario B
Same scenario
This hospital’s standard postpartum order set includes an order for Dermoplast and icepacks. 

Discussion Questions

  1. What are the benefits of using Epifoam or Dermoplast after a vaginal delivery?
  2. Is there a significant cost difference between Epifoam and Dermoplast?
  3. What are the benefits of using ice after a vaginal delivery?

Costs

Pain Relief

Retail Price

Dermoplast

$12.49

Epifoam

$91.86

Medline Perineal Ice Packs

$1.10

Retail prices obtained from Walgreens pharmacy and Amazon

For a hospital with approximately 3,000 vaginal deliveries per year the cost savings would be approximately: $238, 110. 

Benefits of using Epifoam or Dermoplast after a vaginal delivery|
A Cochrane review evaluated topically applied anesthetics for treating perineal pain after childbirth (3).  Although they did cite an article which showed a decreased need for additional analgesia in the Epifoam group compared to placebo, they did not find a decreased need for additional analgesia in the lidocaine group.  Complicating matters, one study cited in the review found that women given Epifoam or Lidocaine reported decreased pain values versus placebo. However, their overall conclusion was that there is not compelling evidence for the effectiveness of topical analgesia for perineal pain post delivery. Supporting this conclusion is a Midwifery study that showed the use of traditional regimes including Epifoam and ice packs, were inferior to maternity gel packs (1).

Significant cost difference between Epifoam and Dermoplast
Epifoam retails for much more than Dermoplast, at more than fifteen times the base cost of Dermoplast. A 2015 quality improvement study performed at Greenville Health System demonstrated that physicians had a poor working knowledge of the cost of epifoam (4). Physicians were educated about the cost difference and the prechecked order for Epifoam was removed from the standing orders. Epifoam could, however, be ordered if desired. Following this project, utilization of Epifoam decreased from 2287 in a calendar year to 228 post intervention.  The projected cost savings of this transition—approximately  $189,140— at the main hospital campus alone, favored Dermoplast. In another study, Epifoam had been removed from the hospital formulary due to cost.  They performed a randomized control trial that focused on the reduction of perineal pain with the application of hydrocortisone cream, placebo cream, and no cream (5).   In this cross-over trial, each patient served as her own control, as each of the creams and no cream were applied to a witch hazel pad that was used for application.  This study found that while there was significant reduction in pain when cream was applied, there was no difference in whether the cream contained hydrocortisone or was a bland emollient cream.  This further supports their institution’s decision to remove Epifoam from formulary as the addition of the anesthetic Pramoxine, and even the Hydrocortisone to the cream provided no significant increase in pain relief. 

Benefits of using ice after a vaginal delivery
A Midwifery study found that ice packs help to numb superficial tissue and decrease edema, leading to reduced pain (1).  A randomized control trial in Brazil, where episiotomies are routinely performed, found that ice packs placed within hours of delivery provided significant pain relief (6).  Pain relief was correlated to skin temperature, with decreased temperatures leading to improved pain scores.  As ice packs are relatively inexpensive, it would be reasonable to suggest that ice packs be considered standard of care for post delivery pain. It should be noted that a Cochrane review of local cooling and pain relief found only limited evidence for the use of cooling treatments in the perinatal period (4).  It is reasonable to conclude that while the efficacy of local cooling has tenable evidence at best, none of these studies found harm or significant costs that hindered their use.

Teaching Moment
It has been found that most women experience perineal pain after childbirth.  The use of any agent to alleviate pain in the puerperium is preferred by patients (1) and health care providers often order topical anesthetics and/or ice packs for their patients. The issue of pain relief in the postpartum period is so pervasive, novel strategies are being developed to compete with the traditional methods of pain control.  One new method studied, involved intrapartum injection of hyaluronidase to prevent perineal trauma before it could lead to pain (2).  However, there has been no clear evidence of superior benefit from any of these novel approaches to perineal pain relief. When a method of pain control is ordered, cost of the product should be considered as no one product has been shown to be more efficacious than another. 

References
1. Steen, Mary et al. (2000). A randomised controlled trial to compare the effectiveness of ice packs and Epifoam with cooling maternity gel pads at alleviating postnatal perineal trauma.Midwifery , Volume 16 , Issue 1, 48 - 55.
2. Zhou, F., Wang, X. D., Li, J., Huang, G. Q., & Gao, B. X. (2014). Hyaluronidase for reducing perineal trauma. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd010441.pub2
3. Hedayati H, Parsons J, Crowther CA. Topically applied anaesthetics for treating perineal pain after childbirth. Cochrane Database Syst Rev 2005;2:CD004223
4.. Demosthenes, L. D., Lane, A. S., & Blackhurst, D. W. (2015). Implementing High-Value Care. Southern Medical Journal, 108(11), 645-648. doi:10.14423/smj.0000000000000360
5. Manfre, M., Adams, D., Callahan, G., Gould, P., Lang, S., McCubbins, H., … Chulay, M. (2015). Hydrocortisone Cream to Reduce Perineal Pain after Vaginal Birth. MCN, The American Journal of Maternal/Child Nursing. Ovid Technologies (Wolters Kluwer Health). https://doi.org/10.1097/nmc.0000000000000165
6. Effect of cryotherapy on relief of perineal pain after vaginal childbirth with episiotomy: a randomized and controlled clinical trial.
Beleza AC, Ferreira CH, Driusso P, Dos Santos CB, Nakano AM - Physiotherapy - November 9, 2016.
7. East CE, Begg L, Henshall NE, Marchant PR, Wallace K. Local cooling for relieving pain from perineal trauma sustained during childbirth. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD006304. DOI: 10.1002/14651858.CD006304.pub3

*Dermoplast: 20% benzocaine+0.2% benzethonium chloride
*Epifoam: hydrocortisone + pramoxine hydrochloride 

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