Evaluation of postpartum perineal pain and dyspareunia—A prospective study

Topical lidocaine-prilocaine cream versus rectal meloxicam suppository for relief of post-episiotomy pain in primigravidae: A randomized clinical trial

OBJECTIVES

To compare the analgesic effect of topical lidocaine-prilocaine (LP) cream and rectal meloxicam suppository on the post-episiotomy pain in primigravidae.

PATIENTS AND METHODS

A randomized open-label clinical trial included primigravidae delivered vaginally with episiotomy. Eligible women were recruited and randomized to topical LP cream on the episiotomy line or rectal meloxicam suppository 15 mg. The intensity of the perineal pain was assessed using a visual analog scale (VAS) immediately, at 6, 12 h and after 5 days post-episiotomy.

RESULTS

One hundred ninety women were enrolled (n = 95 in each arm). No difference between both groups in the VAS scores immediately (mean ± SD: 8.54 ± 1.35 vs. 8.33 ± 1.50, p = 0.419) and 6 h after episiotomy (p = 0.859). However, women in the LP arm were more likely to report lower VAS scores at 12 h and 5 days post-episiotomy (mean ± SD: 1.20 ± 0.50 vs. 5.65 ± 1.65, p = 0.0001; 1.19 ± 0.49 vs. 2.64 ± 1.73, p < 0.001; respectively).

CONCLUSION

Application of topical LP cream after repair of episiotomy in primigravidae seems to substantially alleviate the induced pain with subsequent less need for additional analgesia and more patients' satisfaction.

Biased Partner Perceptions of Women's Pain Self-Efficacy in Postpartum Pain During Intercourse: A Dyadic Longitudinal Examination

Postpartum pain during intercourse is a prevalent and distressing problem that has substantial consequences for affected couples. Partner perceptions-such as how partners perceive women's pain self-efficacy-contribute to an individual's pain experience. This study examined whether partners under- or over-estimate women's intercourse pain self-efficacy at 3-months postpartum and the implications of this bias for women's pain and couples' sexual functioning at 3- and 6-months postpartum. Women who reported pain during intercourse and their partners (N = 89 couples) completed online measures assessing pain self-efficacy (own or partner perceptions), pain intensity, and sexual functioning at 3- and 6-months postpartum. Analyses were based on the Truth and Bias Model of Judgement and Response Surface Analysis. Partners were accurate in their estimates of women's pain self-efficacy (ie, their estimates were positively correlated with women's), but they also underestimated it by perceiving women to be less efficacious than women themselves reported. When couples showed greater agreement for lower levels of pain self-efficacy at 3 months, women reported greater pain intensity and both partners reported poorer sexual functioning at 3- and 6-months postpartum. Findings may inform interventions that promote pain self-efficacy to improve partner support and couples' sexual functioning. PERSPECTIVE: When women report-and their partners perceive-low levels of women's self-efficacy for managing painful intercourse, women report greater postpartum pain during intercourse and couples indicate poorer sexual functioning. These findings suggest that interventions aimed at promoting couples' agreement at high pain self-efficacy may improve their adjustment to postpartum pain.

The impact of obstetric interventions and complications on women's satisfaction with childbirth a population based cohort study including 16,000 women

Background

As a quality marker and a tool for benchmarking between units, a visual analogue scale (VAS) (ranging from 1 to 10) to estimate woman’s satisfaction with childbirth was introduced in 2014. This study aimed to assess how obstetric interventions and complications affected women’s satisfaction with childbirth.

Methods

A retrospective cohort study including 16,775 women with an available VAS score who gave birth between January 2016 and December 2017. VAS score, maternal and obstetric characteristics were obtained from electronic medical records and crude and adjusted odds ratios (aOR) were calculated.

Results

The total prevalence of dissatisfaction with childbirth (VAS 1–3) was 5.7%. The main risk factors for dissatisfaction with childbirth were emergency cesarean section, aOR 3.98 95% confidence interval (CI) 3.27–4.86, postpartum hemorrhage ≥2000 ml, aOR 1.85 95%CI 1.24–2.76 and Apgar score < 7 at five minutes, aOR 2.95 95%CI 1.95–4.47. The amount of postpartum hemorrhage showed a dose-response relation to dissatisfaction with childbirth. Moreover, labor induction, instrumental vaginal delivery, and obstetric anal sphincter injury were significantly associated with women’s dissatisfaction with childbirth. A total number of 4429/21204 (21%) women giving birth during the study period had missing values on VAS. A comparison of characteristics between women with and without a recorded VAS score was performed. There were statistically significant differences in maternal age and maternal BMI between the study population and excluded women due to missing values on VAS. Moreover, 64% of the women excluded were multiparas, compared to 59% in the study population.

Conclusions

Obstetric interventions and complications, including emergency cesareans section and postpartum hemorrhage, were significantly related to dissatisfaction with childbirth.

Such events are common and awareness of these associations might lead to a more individualized care of women during and after childbirth.

The effects of a severe perineal trauma prevention program in an Australian tertiary hospital: An observational study

BACKGROUND

Severe perineal trauma during childbirth is associated with significant morbidity and rates internationally, are on the rise.

AIMS

To determine the impact of a prevention program on severe perineal trauma in a nulliparous population at a tertiary hospital in Australia.

METHODS

Routinely collected maternity data were used comparing outcomes in two time periods; two years before and two years after the introduction of the program. Categorical data were compared using the Chi Squared statistic and continuous data Student's t-test. Logistic regression examined the association between independent and dependent variables using unadjusted and adjusted odds ratios, with 95% confidence intervals and p -values with significance set at 0.05. The main outcome of interest is severe perineal trauma.

RESULTS

The proportion of women in this nulliparous population experiencing severe perineal trauma during vaginal birth decreased from 8.8% in the first time period to 5.6% in the second. Reductions were achieved in all modes of vaginal birth but were most pronounced in vacuum births. Rates of episiotomy increased between time periods and further analysis found that this was protective of severe perineal trauma in all modes of birth for women of Asian country of birth and only in forceps birth for non-Asian women. Factors found to contribute to severe perineal trauma in this population were Asian country of birth, neonatal weight ≥4000gm, forceps birth and maternal age.

CONCLUSIONS

The prevention program is associated with reduced rates of severe perineal trauma. The challenge for the service is to maintain this positive change.

[Perineal risk and obstetrical protection: A survey with birth professionals]

OBJECTIVES

The main objective was to evaluate the practices declared by birth professionals in the Lorraine region about perineal obstetric protection (any perineal tear combined). The secondary objective was to evaluate prevention measures performed in practice by birth professionals according to the perineal risk subjectively estimated for each obstetric situation.

METHODS

This is a practice survey conducted through an anonymous questionnaire distributed to birth professionals (gynecologists, interns, midwife and midwife student) in October 2016. Topics covered concerned maternal, obstetric and fetal risk factors associated with perineal (1st to 4th degrees) lesions and the associated protective measures. A descriptive analysis of the data collected was conducted.

RESULTS

One hundred and five professionals answered the questionnaire. The identified risk factors were consistent with those highlighted in the literature. Other factors, not known as associated with perineal risk, were cited by professionals (smoking, phototype). If the professional perceived a significant perineal risk, they more frequently practiced an episiotomy (15% vs. 0%, P<0.001) or considered that the delivery should be performed by an obstetrician (34% vs 8%, P<0.001).

CONCLUSION

This evaluation shows that birth professionals know the main risk factors for perineal injury. On the other hand, they easily use perineal protection maneuvers (episiotomy for example) without real demonstrated effectiveness.

Perineal massage and training reduce perineal trauma in pregnant women older than 35 years: a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

The aim of this study was to evaluate the effectiveness of perineal massage, pelvic floor muscle training (PFMT) and a pelvic floor dysfunction (PFD) prevention educational program in pregnant women above the age of 35 years to prevent perineal tear and episiotomy.

METHODS

A randomized parallel assignment study involved two groups of pregnant women at the obstetrics outpatient clinic 4 weeks prior to their due date. The first group (n = 200) was educated to do digital perineal massage and pelvic floor muscle training and received an educational PFD prevention program. The second group (n = 200) received only the prevention education program. Occurrence of perineal laceration was reported at time of delivery as a primary outcome. Statistical analysis was done using the IBM SPSS computer program (Statistical Package for the Social Sciences; IBM Corp, Armonk, NY, USA), release 22 for Microsoft Windows.

RESULTS

Delivery was significantly less complicated by perineal tear, episiotomy and postnatal pain in the first than in the second group (p < 0.05). Grades of perineal tear were mostly of first and second degree in the first group compared with the second group. We found a significantly lower need for analgesia and fewer ampoules required during the hospital stay in the first group (p < 0.001, 0.002, respectively).

CONCLUSIONS

Performing antenatal digital perineal massage and PFMT in addition to health education is recommended to reduce perineal complications.

Deep Dyspareunia: Review of Pathophysiology and Proposed Future Research Priorities

INTRODUCTION

Dyspareunia has been traditionally divided into superficial (introital) dyspareunia and deep dyspareunia (pain with deep penetration). While deep dyspareunia can coexist with a variety of conditions, recent work in endometriosis has demonstrated that coexistence does not necessarily imply causation. Therefore, a reconsideration of the literature is required to clarify the pathophysiology of deep dyspareunia.

AIMS

To review the pathophysiology of deep dyspareunia, and to propose future research priorities.

METHODS

A narrative review after appraisal of published frameworks and literature search with the terms (dyspareunia AND endometriosis), (dyspareunia AND deep), (dyspareunia AND (pathophysiology OR etiology)).

MAIN OUTCOME VARIABLE

Deep dyspareunia (present/absent or along a pain severity scale).

RESULTS

The narrative review demonstrates potential etiologies for deep dyspareunia, including gynecologic-, urologic-, gastrointestinal-, nervous system-, psychological-, and musculoskeletal system-related disorders. These etiologies can be classified according to anatomic mechanism, such as contact with a tender pouch of Douglas, uterus-cervix, bladder, or pelvic floor, with deep penetration. Etiologies of deep dyspareunia can also be stratified into 4 categories, as previously proposed for endometriosis specifically, to personalize management: type I (primarily gynecologic), type II (nongynecologic comorbid conditions), type III (central sensitization and genito-pelvic pain/penetration disorder), and type IV (mixed). We also identified gaps in the literature, such as lack of a validated patient-reported questionnaire or an objective measurement tool for deep dyspareunia and clinical trials not powered for sexual outcomes.

CONCLUSION

We propose the following research priorities for deep dyspareunia: deep dyspareunia measurement tools, inclusion of the population avoiding intercourse due to deep dyspareunia, nongynecologic conditions in the generation of deep dyspareunia, exploration of sociocultural factors, clinical trials with adequate power for deep dyspareunia outcomes, partner variables, female sexual response, pathways between psychological factors and deep dyspareunia, and personalized approaches to deep dyspareunia. Orr N, Wahl K, Joannou A, et al. Deep Dyspareunia: Review of Pathophysiology and Proposed Future Research Priorities. Sex Med Rev 2020;8:3-17.

Resumption of sex after a second birth: An Australian prospective cohort

BACKGROUND

Few longitudinal studies have examined women's experiences of sex after childbirth. Much of the advice given to couples about what to expect in relation to sex after childbirth is based on cross-sectional studies.

OBJECTIVE

To investigate timing of resumption of sex after a second birth and assess associations with obstetric factors (method of birth and perineal trauma) and time interval between first and second births.

METHOD

Prospective cohort of 1507 nulliparous women recruited before 25 weeks' gestation in Melbourne, Australia followed up at 3, 6, 9, and 12 months after first births, and 6 and 12 months after second births. Measures include: obstetric factors and resumption of vaginal sex after first and second births.

RESULTS

By 8 weeks after their second birth, 56% of women had resumed vaginal sex, compared with 65% after their first birth. Women were more likely to resume sex later than 8 weeks postpartum if they had a spontaneous vaginal birth with episiotomy or sutured perineal tear (aOR: 2.21, 95% CI: 1.5-3.2), operative vaginal birth (aOR: 2.60, 95% CI: 1.3-5.3) or cesarean delivery (aOR: 2.15, 95% CI: 1.4-3.3) compared with a vaginal birth with minimal or no perineal trauma. There was no association between timing of resumption of sex and the time interval between births.

CONCLUSION

For almost half of the cohort, sex was not resumed until at least 8 weeks after the second birth. Timing of resumption of sex was influenced by obstetric factors, but not the time interval between births.

Infection and wound breakdown in spontaneous second-degree perineal tears: An exploratory mixed methods study

BACKGROUND

Perineal trauma affects large numbers of women who have a vaginal birth. This study explores the incidence, etiology and women's experiences of wound infection/breakdown associated with spontaneous second degree tears.

METHODS

This was an exploratory mixed methods study set in an urban tertiary National Health Service hospital in 2014-2015. The study included a prospective observational study of second-degree tears using electronic patient records. Infection was defined using criteria adapted from Public Health England's Surgical Site Infection Surveillance Service. We also did a case-control study of maternity records to explore factors associated with perineal infection/wound breakdown, and semi-structured interviews with a purposeful sample of women who experienced wound infection/breakdown.

RESULTS

Of 2892 vaginal births during the study period, 76.8% sustained perineal trauma, with second-degree tears most commonly recorded (n = 828/28.6%). Sixteen (1.9%) had a documented infection/wound breakdown which were associated with "compromised wound status" (increased severity of wound/poor suturing; P = 0.033) Women complained of a lack of information about their perineum and poor postnatal surveillance by midwives and physicians. Diagnosis and treatment were often delayed by clinicians' reliance on external signs of wound infection. Although the sample size was small, there were no differences in rates of infection between sutured and unsutured second-degree tears.

CONCLUSIONS

Although second-degree tears were common after vaginal birth, wound infection/breakdown was relatively uncommon. Women who report feeling unwell or develop pyrexia postnatally should be assessed urgently. A prospective longitudinal study exploring the long-term sequelae of second-degree tears is needed.

Genital tract tears in women giving birth on a birth seat: A cohort study with prospectively collected data

BACKGROUND

Birth positions may influence the risk of tears in the genital tract during birth. Birth positions are widely studied yet knowledge on genital tract tears following birth on a birth seat is inconclusive.

AIM

The objective of this study was to describe the proportion of genital tract tears in women who gave birth on a birth seat compared to women who did not.

METHOD

An observational cohort study based on birth information collected prospectively. In total 10 629 live, singleton, non-instrumental births in cephalic presentation were studied.

RESULTS

Fewer women who gave birth on a birth seat experienced an overall intact genital tract compared to women who gave birth in any other position. Women who gave birth on a birth seat were less likely to have an episiotomy performed. Women who gave birth vaginally on a birth seat after a previous caesarean section may have an increased risk for sustaining a sphincter tear.

DISCUSSION

It is important to be aware of the decreased chance of an overall intact genital tract area when giving birth on a birth seat. Furthermore, there is a possibly increased risk of sphincter tear in women having a vaginal birth after caesarean. It is required and of importance to provide pregnant women with evidence-based information on factors associated with genital tract tears including birth positions.

"Struggling to settle with a damaged body" - A Swedish qualitative study of women's experiences one year after obstetric anal sphincter muscle injury (OASIS) at childbirth

OBJECTIVE

This study aimed to explore women's experiences related to recovery from obstetric anal sphincter muscle injuries (OASIS) one year after childbirth.

METHOD

This is a qualitative study based on written responses from 625 women approximately one year after childbirth in which OASIS occurred. Data was obtained from a questionnaire distributed by the national Perineal Laceration Register (PLR) in Sweden. Inductive qualitative content analysis was applied for analysis.

RESULTS

The theme "Struggling to settle with a damaged body" indicated that the first year after OASIS involved a struggle to settle to and accept living with a changed and sometimes still-wounded body. Many participants described problems related to a non-functional sexual life, physical and psychological problems that left them feeling used and broken, and increased worries for their future health and pregnancies. However, some women had adjusted to their situation, had moved on with their lives, and felt recovered and strong. Encountering a supportive and helpful health care professional was emphasized as vital for recovery after OASIS.

CONCLUSION

This study provides important insights on how women experience their recovery approximately one year after having had OASIS at childbirth, wherein many women still struggled to settle into their damaged bodies. Clear pathways are needed within health care organizations to appropriate health care services that address both physical and psychological health problems of women with prolonged recovery after OASIS.

Health Care-Seeking Characteristics of Women With Pelvic Floor Disorders After Obstetric Anal Sphincter Injury

OBJECTIVES

Obstetric anal sphincter injury (OASIS) is a potentially serious complication of vaginal delivery and can lead to both short-term and long-term sequelae. This study sought to identify health care seeking patterns of women who developed pelvic floor symptoms including pelvic pain after OASIS. It also identified demographic and clinical factors associated with seeking subspecialty care from a pelvic floor specialist and demographic and clinical factors associated with seeking care for pelvic pain after OASIS.

METHODS

This study is a retrospective cohort study of 69 women who developed pelvic floor disorders after OASIS.

RESULTS

For women diagnosed with a pelvic floor symptom, the mean time to follow-up was 2.4 years, the mean number of visits until diagnosis was 2.2 visits, and 2.9 visits were needed for treatment. The most common diagnoses were pelvic pain, lower urinary tract symptoms including incontinence, and defecatory dysfunction. Twenty-five percent of the cohort received treatment from a pelvic floor specialist. These women were more likely to be older and have urinary incontinence. Women with pain were more likely to be seen by a primary care provider and have longer time to diagnosis.

CONCLUSIONS

The study showed that multiple visits were needed to both diagnose and treat pelvic floor disorders (PFD) after OASIS. Pelvic pain was the most common primary PFD after OASIS. There should be a high level of suspicion for pelvic floor disorders, especially pain disorders, in women who have sustained a third- or fourth-degree laceration.

The effect of green tea ointment on episiotomy pain and wound healing in primiparous women: A randomized, double-blind, placebo-controlled clinical trial

The delayed healing of episiotomy wound and its associated pain is a major problem in obstetrics. Because green tea has analgesic and wound-healing properties, the present study was conducted to determine the effect of green tea ointment on episiotomy pain and wound-healing. The green tea extract was also standardized by measuring its Phenolic and flavonoid compounds, antioxidant activity, and one of its active components, that is, Epigallocatechin gallate. The present clinical trial was conducted on 99 primiparous women visiting Afzalipour Hospital in Kerman in 2015. The subjects were randomly divided into 3 groups, including a green tea ointment group, a placebo ointment group, and a routine care group. The 2 ointment groups smeared 2 cm of the green tea or placebo ointments onto their sutured area twice daily for a total of 10 days. The severity of pain was assessed in the subjects using the visual pain scale and wound-healing using the Redness, Edema, Ecchymosis, Discharge, Approximation (REEDA) scale before the intervention and on the 5th and 10th days after delivery. To standardize the extract, Epigallocatechin gallate was measured by high-performance liquid chromatography (HPLC). Phenolic and flavonoid compounds, as well as antioxidant activity of the extract were also determined by spectrometry methods. Before the intervention, no significant differences were observed between the 3 groups in terms of their personal and obstetric details (p > .05), the severity of pain (p = .118), and the REEDA score (p = .212). On the 5th and 10th days after delivery, the severity of pain was significantly lower in the green tea group than in the other 2 groups (p < .0001). The mean REEDA score on the 5th and 10th days showed a better and faster healing in the green tea group compared to the other 2 groups (p < .0001). Total content of phenolic and flavonoids contents of green tea were 74.2 mg/g Gallic acid equivalent and 16.3 mg/g Rutin equivalent, respectively, and its antioxidant capacity was 46% of b-carotene. Green tea ointment appears to be effective in relieving episiotomy pain and improving wound-healing in this study. Further studies are recommended to be conducted on the effectiveness and safety of the different doses of green tea ointment.

The effect of perineal massage during the second stage of birth on nulliparous women perineal: A randomization clinical trial

Background

Childbirth and puerperium are of the most important periods in women's lives and can affect different aspects of their lives.

Objective

To determine the effect of perineal massage in the second stage of labor on perineal lacerations, episiotomy, and perineal pain in nulliparous women.

Methods

This randomization clinical trial was conducted at Be'sat Hospital in Sanandaj, Iran, from 2013 to 2014. A total of 195 nulliparous women were included in the study. The participants were selected through convenience sampling, and randomly assigned to two groups: intervention and control groups. The intervention group received 30-minute perineal massage during second stage of labor. Subsequently, we analyzed perineal laceration, episiotomy, and perineal pain among the two groups. All of them were taught about postpartum perineal pain and its severity, and the researcher followed them up 3 days, 10 days, and 3 months after childbirth by telephone. The data were analyzed using SPSS version 18. We used descriptive statistics and analytical statistics, including t test, Chi-square test, and Fisher's test.

Results

Frequency of episiotomy was 69.47% in the intervention group and 92.31% in the control group, and the difference was statistically significant (p<0.05). The results revealed 23.16% of first-degree perineal laceration and 2.11% of second-degree perineal laceration in the intervention group, and no vestibular laceration or third- and fourth-degree lacerations in the intervention group. However, there were 5.13% of vestibular laceration, 7.69% of first-degree laceration, 2.56% of second-degree laceration, and 1.05% of third-degree laceration (one woman) in the control group. Based on the results, the postpartum perineal pain was significantly different in both groups.

Conclusion

Regarding the results of this study and those of other studies, perineal massage during the second stage of labor can reduce the need to episiotomy, perineal injuries, and perineal pain.

Trial registration

The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the Irct.ID: IRCT2013090314556N1.

Funding

This study received by financial support of Kurdistan University of Medical Sciences, Sanandaj, Iran.

The MOVE-trial: Monocryl® vs. Vicryl Rapide™ for skin repair in mediolateral episiotomies: a randomized controlled trial

BACKGROUND

Previous studies have shown that complaints after episiotomy repair depend on the method and material used for repair. The objective of our study was to determine which of two frequently used suture materials, Monocryl® (poliglecaprone 25) and Vicryl Rapide™ (polyglactin 910), is superior for intracutaneous closure of the skin in mediolateral episiotomies.

METHODS

In a randomized controlled trial performed in a teaching hospital in the Netherlands between 2010 and 2013 250 primiparous women with uncomplicated mediolateral episiotomies were randomly allocated to intracutaneous skin closure with either Monocryl® or Vicryl Rapide™. All other layers were sutured with Vicryl 2-0 and Vicryl 0 in both groups. Pain scores and complications were documented using questionnaires during the first three months post partum. The primary outcome was pain 10 days after delivery in sitting position established by Visual Analogous Scale (VAS). Secondary outcomes were pain scores at different time points and reported complications such as infections, dehiscence and dyspareunia one day, 10 days, six weeks and three months after delivery.

RESULTS

Of 250 allocated women 54% returned questionnaires. No statistical difference was found between both groups for the primary outcome (VAS 2,8 (95% CI 2,18-3,44) vs. VAS 2,5 (95% CI 2,00-2,98), p = 0,43). With regard to secondary outcomes only self-reported dehiscence was significantly different, favouring Monocryl® (10% vs. 25%, p = 0.016).

CONCLUSIONS

Use of Monocryl® 3-0 and Vicryl Rapide™ 3-0 for intracutaneous closure of the skin after mediolateral episiotomy leads to equal pain scores ten days after delivery and therefore both materials may be considered for this use. Monocryl® 3-0 might be favourable over Vicryl Rapide™ 3-0 due to less self-reported dehiscence after intracutaneous closure of the skin in mediolateral episiotomies.

TRIAL REGISTRATION

The trial was retrospectively registered under trial nr. ISRCTN29869308 on 20-04-2016.

Irish and New Zealand Midwives' expertise at preserving the perineum intact (the MEPPI study): Perspectives on preparations for birth

OBJECTIVES

perineal trauma during birth can result in short or long term morbidity for women. Internationally, rates of episiotomy and severe perineal tears vary considerably. In New Zealand, in 2011, and in a trial of midwife-led care in Ireland, episiotomy rates were found to be considerably lower than those in many other countries. A qualitative exploratory study was undertaken to ascertain how midwives achieve these low rates, in these countries and settings.

DESIGN AND PARTICIPANTS

a qualitative exploratory study was conducted. Midwives expert in preserving the perineum intact (PPI) from two maternity units in the Republic of Ireland and from varied birth settings in New Zealand, were eligible to participate. Twenty-one consenting midwives took part, seven from Ireland and 14 from New Zealand.

METHODS

university ethical approval was granted. Face-to-face, semi-structured interviews were used to collect the data. Interviews were recorded and transcribed verbatim. The data were analysed using Ethnograph software and were organised into prominent themes.

FINDINGS

four themes were identified; 'Sources of knowledge for PPI', 'Associated factors', 'Decision-making on episiotomy', and 'Preparations for PPI'. Participants drew heavily on multiple sources of knowledge in building their own expertise for PPI. Physical characteristics of the perineum featured prominently as factors leading to PPI. Episiotomy was, in the main, only performed when there were signs of fetal distress. Antenatal perineal massage was supported.

CONCLUSION

this study provides valuable insight into the views and skills of midwives, with expertise in PPI at birth, adding to the body of evidence on this topic.

Incidence of episiotomy in Slovenia: The story behind the numbers

Episiotomy is a surgical cut of the perineum performed in the second stage of labor in order to widen the vaginal opening and thus facilitate the birth of an infant. Despite current recommendations against the routine use of episiotomy, it is one of the most commonly performed surgical interventions during childbirth. This retrospective study explores the number of episiotomies performed in Slovenian maternity hospitals and the differences in episiotomy rates in relation to parity. Data were obtained from the Slovenian National Perinatal Information System and pooled for 2013. A causal and non-experimental method of empirical research was used. The results of the study show that episiotomy rates vary widely across Slovenian maternity hospitals, ranging from 2.5% to 51.7%. Moreover, the majority of Slovenian maternity hospitals exceed the recommended rate, with an overall incidence of episiotomy as high as 31.3%. Further research is recommended to obtain relevant information from women as well as from midwives and to draw new, evidence-based conclusions related to the maternal benefits and adverse effects of episiotomy.

Perineal techniques during the second stage of labour for reducing perineal trauma

BACKGROUND

Most vaginal births are associated with trauma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including perineal massage, warm or cold compresses, and perineal management techniques have been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011.

OBJECTIVES

To assess the effect of perineal techniques during the second stage of labour on the incidence and morbidity associated with perineal trauma.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (26 September 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Published and unpublished randomised and quasi-randomised controlled trials evaluating perineal techniques during the second stage of labour. Cross-over trials were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. We checked data for accuracy.

MAIN RESULTS

Twenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Overall, trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques.Most studies did not report data on our secondary outcomes. We downgraded evidence for risk of bias, inconsistency, and imprecision for all comparisons. Hands off (or poised) compared to hands onHands on or hands off the perineum made no clear difference in incidence of intact perineum (average risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.12, two studies, Tau² 0.00, I² 37%, 6547 women; moderate-quality evidence), first-degree perineal tears (average RR 1.32, 95% CI 0.99 to 1.77, two studies, 700 women; low-quality evidence), second-degree tears (average RR 0.77, 95% CI 0.47 to 1.28, two studies, 700 women; low-quality evidence), or third- or fourth-degree tears (average RR 0.68, 95% CI 0.21 to 2.26, five studies, Tau² 0.92, I² 72%, 7317 women; very low-quality evidence). Substantial heterogeneity for third- or fourth-degree tears means these data should be interpreted with caution. Episiotomy was more frequent in the hands-on group (average RR 0.58, 95% CI 0.43 to 0.79, Tau² 0.07, I² 74%, four studies, 7247 women; low-quality evidence), but there was considerable heterogeneity between the four included studies.There were no data for perineal trauma requiring suturing. Warm compresses versus control (hands off or no warm compress)A warm compress did not have any clear effect on the incidence of intact perineum (average RR 1.02, 95% CI 0.85 to 1.21; 1799 women; four studies; moderate-quality evidence), perineal trauma requiring suturing (average RR 1.14, 95% CI 0.79 to 1.66; 76 women; one study; very low-quality evidence), second-degree tears (average RR 0.95, 95% CI 0.58 to 1.56; 274 women; two studies; very low-quality evidence), or episiotomy (average RR 0.86, 95% CI 0.60 to 1.23; 1799 women; four studies; low-quality evidence). It is uncertain whether warm compress increases or reduces the incidence of first-degree tears (average RR 1.19, 95% CI 0.38 to 3.79; 274 women; two studies; I² 88%; very low-quality evidence).Fewer third- or fourth-degree perineal tears were reported in the warm-compress group (average RR 0.46, 95% CI 0.27 to 0.79; 1799 women; four studies; moderate-quality evidence). Massage versus control (hands off or routine care)The incidence of intact perineum was increased in the perineal-massage group (average RR 1.74, 95% CI 1.11 to 2.73, six studies, 2618 women; I² 83% low-quality evidence) but there was substantial heterogeneity between studies). This group experienced fewer third- or fourth-degree tears (average RR 0.49, 95% CI 0.25 to 0.94, five studies, 2477 women; moderate-quality evidence).There were no clear differences between groups for perineal trauma requiring suturing (average RR 1.10, 95% CI 0.75 to 1.61, one study, 76 women; very low-quality evidence), first-degree tears (average RR 1.55, 95% CI 0.79 to 3.05, five studies, Tau² 0.47, I² 85%, 537 women; very low-quality evidence), or second-degree tears (average RR 1.08, 95% CI 0.55 to 2.12, five studies, Tau² 0.32, I² 62%, 537 women; very low-quality evidence). Perineal massage may reduce episiotomy although there was considerable uncertainty around the effect estimate (average RR 0.55, 95% CI 0.29 to 1.03, seven studies, Tau² 0.43, I² 92%, 2684 women; very low-quality evidence). Heterogeneity was high for first-degree tear, second-degree tear and for episiotomy - these data should be interpreted with caution. Ritgen's manoeuvre versus standard careOne study (66 women) found that women receiving Ritgen's manoeuvre were less likely to have a first-degree tear (RR 0.32, 95% CI 0.14 to 0.69; very low-quality evidence), more likely to have a second-degree tear (RR 3.25, 95% CI 1.73 to 6.09; very low-quality evidence), and neither more nor less likely to have an intact perineum (RR 0.17, 95% CI 0.02 to 1.31; very low-quality evidence). One larger study reported that Ritgen's manoeuvre did not have an effect on incidence of third- or fourth-degree tears (RR 1.24, 95% CI 0.78 to 1.96,1423 women; low-quality evidence). Episiotomy was not clearly different between groups (RR 0.81, 95% CI 0.63 to 1.03, two studies, 1489 women; low-quality evidence). Other comparisonsThe delivery of posterior versus anterior shoulder first, use of a perineal protection device, different oils/wax, and cold compresses did not show any effects on perineal outcomes. Only one study contributed to each of these comparisons, so data were insufficient to draw conclusions.

AUTHORS' CONCLUSIONS

Moderate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent. Poor-quality evidence suggests hands-off techniques may reduce episiotomy, but this technique had no clear impact on other outcomes. There were insufficient data to show whether other perineal techniques result in improved outcomes.Further research could be performed evaluating perineal techniques, warm compresses and massage, and how different types of oil used during massage affect women and their babies. It is important for any future research to collect information on women's views.

Clinical profile of persistent genito-pelvic postpartum pain

OBJECTIVE*: the primary aim was to describe the pain characteristics of persistent genito-pelvic postpartum pain (PPP) and compare these characteristics by mode of delivery. The secondary aim was to incorporate psychosocial variables into the conceptualization of PPP by exploring the relationship among postpartum depressive symptoms, fatigue, and PPP.

DESIGN

cross-sectional study design.

SETTING

online survey.

PARTICIPANTS

106 women recruited from the community who gave birth within twelve months prior to completing the survey.

MEASUREMENTS AND FINDINGS

questionnaire regarding sociodemographic information, pregnancy and childbirth variables, depressive symptoms (Edinburgh Postnatal Depression Scale), and fatigue (Fatigue Symptom Checklist). Women who were ≥3 months postpartum and indicated they were still experiencing any genito-pelvic pain from childbirth were provided questions about their current pain experience. Twenty-seven (25.5%) women were between 3-12 months postpartum and currently experiencing PPP. The intensity of pain was mild, and had multiple locations and triggers. Compared to women whose acute pain resolved after childbirth, women with PPP were more likely to have had a Caesarean section (15.2% versus 33.3%). Other birth-related (i.e., epidural/spinal anesthesia use during vaginal birth) and psychosocial variables (income) also differentiated women with PPP from women whose gentio-pelvic pain resolved. Postpartum fatigue independently predicted PPP (Odds ratio = 4.7), while postpartum depressive symptoms did not.

KEY CONCLUSIONS

PPP was quite prevalent in this sample, and while the intensity of pain was on average, mild, the pain was widespread in terms of location and triggers. Multiple biopsychosocial factors differentiated women with persistent postpartum pain from those women whose pain resolved.

IMPLICATIONS FOR PRACTICE

PPP is a common health concern for new mothers in the first year postpartum, and may be best addressed by health care professionals using a multidimensional approach, which focuses on the psychosocial aspects of pain.

The impact of anal sphincter injury on perceived body image

OBJECTIVE

Obstetric anal sphincter injury is common but the effect on body image is unreported. The aim of this study was to explore patient perceived changes in body image and other psychological aspects in women attending a perineal follow-up clinic.

STUDY DESIGN

This retrospective study analysed women's responses to a self-reported questionnaire. Consecutive women with anal sphincter injury who attended a United Kingdom Maternity Hospital perineal follow-up clinic between January 1999 and January 2012 were identified and the records obtained and reviewed. Multivariate regression analyses were performed to examine variables influencing self-reported change in body image.

RESULTS

Questionnaires and operation notes were analysed from 422 women who attended at a median of four months after delivery. 222 (53%) reported a change in body image with 80 (19%) reporting lower self-esteem and 75 (18%) a change in their personality due to the change in body image. 248 (59%) perceived an anatomical change due to the delivery. Factors associated with increased likelihood of reporting a change in body image were reporting a perceived change in anatomy due to the delivery, adjusted OR 6.11 (3.56-10.49), anal incontinence, OR 1.97 (1.16-3.36), and delivery by forceps, OR 2.59 (1.23-5.43).

CONCLUSIONS

This is the first study to quantify body image changes in women after anal sphincter injury sustained in childbirth. These were found to be very common, affecting up to 50% of women. The study has several limitations but it does highlight the significant psychosocial problems of negative self-esteem and personality changes associated with a perceived change in body image that has not previously been reported. It also outlines the further research questions that need to be addressed.

Midwives' Management during the Second Stage of Labor in Relation to Second-Degree Tears-An Experimental Study

INTRODUCTION

Most women who give birth for the first time experience some form of perineal trauma. Second-degree tears contribute to long-term consequences for women and are a risk factor for occult anal sphincter injuries. The objective of this study was to evaluate a multifaceted midwifery intervention designed to reduce second-degree tears among primiparous women.

METHODS

An experimental cohort study where a multifaceted intervention consisting of 1) spontaneous pushing, 2) all birth positions with flexibility in the sacro-iliac joints, and 3) a two-step head-to-body delivery was compared with standard care. Crude and Adjusted OR (95% CI) were calculated between the intervention and the standard care group, for the various explanatory variables.

RESULTS

A total of 597 primiparous women participated in the study, 296 in the intervention group and 301 in the standard care group. The prevalence of second-degree tears was lower in the intervention group: [Adj. OR 0.53 (95% CI 0.33-0.84)]. A low prevalence of episiotomy was found in both groups (1.7 and 3.0%). The prevalence of epidural analgesia was 61.1 percent. Despite the high use of epidural analgesia, the midwives in the intervention group managed to use the intervention.

CONCLUSION

It is possible to reduce second-degree tears among primiparous women with the use of a multifaceted midwifery intervention without increasing the prevalence of episiotomy. Furthermore, the intervention is possible to employ in larger maternity wards with midwives caring for women with both low- and high-risk pregnancies.

Postpartum Sexual Functioning and Its Predicting Factors among Iranian Women

BACKGROUND

Many women experience sexual dysfunction following childbirth but this has not been well investigated in Iran. The aim of this study was to evaluate women's sexual function in the postpartum period in Iran. It also sought to determine predicting factors associated with their sexual function.

METHODS

This was a cross-sectional study among 380 postpartum women attending 10 urban health centers in Ilam province in southwestern Iran. Participants were selected using random cluster sampling. Data was collected using the female sexual function index (FSFI) and a checklist of socio-demographic and maternal status for each of the women. Sexual dysfunction was classified according to an FSFI score of ≤ 28. Data were analysed using SPSS version 22.

RESULTS

The majority of participants (76.3%) had sexual dysfunction. Primiparity (adjusted odds ratio (aOR): 1.78 (95% Confidence Interval (CI): 1.11, 2.94); P = 0.006) and exclusive breastfeeding (aOR: 2.47 (95% CI: 1.21, 5.03); P = 0.012) were associated with increased odds of experiencing sexual dysfunction in the postpartum period. Other factors such as age, type of delivery, education, time since delivery and family income did not predict women's postpartum sexual function.

CONCLUSION

This study confirmed findings of previous studies on factors that may have an adverse effect on new mothers' sexual function in the postpartum period. However the effect of type of delivery on postpartum sexual function remains unclear.

Does pelvic floor muscle contraction early after delivery cause perineal pain in postpartum women?

OBJECTIVE

Pelvic floor muscle training is effective and necessary in the prevention and treatment of pelvic floor dysfunction during pregnancy and after childbirth. But because of the high prevalence of perineal pain observed in women after childbirth, many women and caregivers fear to start pelvic floor muscle training immediately after childbirth. However, it is unknown whether pelvic floor muscle contractions (PFMC) provoke perineal pain in women shortly after childbirth. Therefore, the main objective is to study whether PFMC performed immediately after childbirth is painful or not.

STUDY DESIGN

Observational longitudinal study. Perineal pain was assessed (1-6 days and 9 weeks postpartum) using a visual analogue scale (VAS 0-10) during PFMC and during several activities of daily living (ADL), during micturition and defecation. Descriptive statistics, Wilcoxon and McNemar tests were used.

RESULTS

A total of 233 women participated (148 primiparous and 85 multiparous). Immediately postpartum the prevalence and intensity of pain during ADL (73%; VAS 4.9 (±2.3)), micturition (47%; VAS 3.4 (±1.7)) and defecation (19%; VAS 3.6 (±2.2)) were significantly higher (all p<0.000) than during PFMC (8%; VAS 2.2 (±0.9)). At 9 weeks postpartum, 30% experienced perineal pain during sexual intercourse (VAS 4.6 +/- 2.3) and 18% during defecation (VAS 4.7 +/- 2.3), but none during PFMC.

CONCLUSION

Perineal pain is highly prevalent immediately after childbirth during ADL, micturition and defecation, but not during PFMC (only 8%). In case perineal pain occurs during PFMC, the intensity of pain is low (VAS 2). These results show that fear of perineal pain should not discourage women to start pelvic floor muscle training shortly after childbirth.

Sexual functioning and commitment to their current relationship among breastfeeding and regularly cycling women in Manila, Philippines

This project investigates the relationship between lactation and female sexual functioning and relationship commitment among partnered women in urban Manila. Previous literature suggests that the time after giving birth is often rife with lower sexual functioning and relationship dissatisfaction. Given the important role of caregiving by multiple individuals in humans, the current cross-sectional study suggests that female sexuality may decline immediately after giving birth but then may increase afterwards. Non-cycling, breastfeeding (n = 86); cycling, breastfeeding (n = 48); and nulliparous, regularly cycling (n = 105) women were recruited from neighborhood health centers in Manila to complete questionnaires that assessed sexual functioning and relationship satisfaction, along with demographic variables. Cycling, breastfeeding women report the highest sexual functioning scores and commitment scores. Females undergoing life history trade-offs between mating effort and parenting effort during the postpartum phase may employ a strategy in which they continue investment both in their offspring and in a romantic relationship. Variations in self-reported sexual functioning, level of commitment in a relationship, and love toward her current partner may indicate that breastfeeding women engage in sexual activities as part of a relationship maintenance strategy. Cultural and life history factors will serve as a framework for the findings. The current findings suggest women in Manila may experience a post-birth increase in sexual functioning that may be higher than pre-pregnancy levels. Future studies should incorporate a longitudinal component or a memory recall on pre-pregnancy and post-birth sexual functioning levels.

Fabrication of non-dissolving analgesic suppositories using 3D printed moulds

Conventional suppositories sometimes fail in exerting their therapeutic activity as the base materials melt inside body cavities. Also they are not suitable to provide long term treatment. Biomedical grade silicone elastomers may be used to fabricate non-dissolvable suppositories to overcome these disadvantages. We kneaded 4 analgesics into the 2 kinds of silicone polymers at 1%, 5% and 10% drug loading, respectively, to test their mechanical properties and drug release profiles. The optimized drug-polymer combinations were used to fabricate suppositories, and three dimensional printing (3DP) was used to create the suppository moulds. Subsequently, the drug release profiles and biocompatibility of the suppositories were studied. It was found that, the mechanical properties of the drug laden silicone elastomers and the rate of drug release from the elastomers can be tuned by varying drug-polymer combinations. The silicone elastomers containing 1% (w/w) and 5% (w/w) diclofenac sodium were the optimal formulations with prolonged drug release and biocompatibility at cellular level. These properties, together with complex geometries offered by 3DP technique, potentially made the non-dissolving suppositories promising therapeutic agents for personalized medicine.

Factors Associated With Timing of Return to Intercourse After Obstetric Anal Sphincter Injuries

INTRODUCTION

The impact of obstetric perineal trauma on timing of return to intercourse is unclear, although sexual desire is clearly decreased in these women. In addition, studies examining timing of return to intercourse are cross-sectional and therefore cannot delineate potential reasons that patients might delay return to intercourse.

AIM

To identify factors associated with delayed return to intercourse after obstetric anal sphincter injuries.

METHODS

This was a planned secondary analysis of a prospective cohort study of women sustaining obstetric anal sphincter injuries during delivery of a full-term singleton infant. Patients completed the Fecal Incontinence Severity Index at every postpartum visit (1, 2, 6, and 12 weeks) and the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-12 once resuming vaginal intercourse. Intercourse was considered "delayed" if patients did not resume intercourse by the 12-week visit. This cutoff was chosen because it was subsequent to the 6-week visit, when patients were instructed to return to normal pelvic activity. Continuous variables were compared using the Student t-test (parametric) or Mann-Whitney U-test (non-parametric). The χ(2) test was used for categorical variables. Statistical significance was assigned with a P value less than .05.

MAIN OUTCOME MEASURES

Primary outcome measurements were differences in pelvic floor symptoms on validated surveys between the "delayed" and "not-delayed" groups at the first postpartum visit and at the time the subjects returned to intercourse. We used the Patient Health Questionnaire-9 for depression, the Urinary Distress Inventory-6 and Incontinence Impact Questionnaire-7 for urinary symptoms, the visual analog scale for pain, the Fecal Incontinence Severity Index for bowel symptoms, and the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-12 at the return to intercourse visit only.

RESULTS

One hundred ninety-nine women were included in this analysis. Most were Caucasian (77%) and primiparous (86%). One hundred nineteen women (60%) did not resume vaginal intercourse until after the 12-week visit and were deemed "delayed." Patients who delayed intercourse scored higher on the Fecal Incontinence Severity Index (more anal incontinence) than those who resumed intercourse before 12 weeks (15.4 ± 12.3 vs 12.0 ± 12.8, P = .02). The delayed group also had worse sexual function, shown as lower Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-12 scores (35.4 ± 5.9 vs 38.4 ± 4.1, P ≤ .001) and persistently higher Fecal Incontinence Severity Index scores (4.1 ± 7.3 vs 1.6 ± 4.4, P = .001), at the first visit after returning to intercourse.

CONCLUSION

Patients with obstetric anal sphincter injuries who do not resume intercourse by 12 weeks postpartum report more severe anal incontinence symptoms and worse sexual function after return to coitus.

Oral non-steroidal anti-inflammatory drugs (single dose) for perineal pain in the early postpartum period

BACKGROUND

Many women experience perineal pain after childbirth, especially after having sustained perineal trauma. Perineal pain-management strategies are thus an important part of postnatal care. Non-steroidal anti-inflammatory drugs (NSAIDs) are a commonly used type of medication in the management of postpartum pain and their effectiveness and safety should be assessed.

OBJECTIVES

To determine the effectiveness of a single dose of an oral NSAID for relief of acute perineal pain in the early postpartum period.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2016), OpenSIGLE, ProQuest Dissertations and Theses, the ISRCTN Registry and ClinicalTrials.gov (31 March 2016). We also reviewed reference lists of retrieved papers and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) assessing a single dose of a NSAID versus a single dose of placebo, paracetamol or another NSAID for women with perineal pain in the early postpartum period. Quasi-RCTs and cross-over trials were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors (FW and VS) independently assessed all identified papers for inclusion and risk of bias. Any discrepancies were resolved through discussion and consensus. Data extraction, including calculations of pain relief scores, was also conducted independently by two review authors and checked for accuracy.

MAIN RESULTS

We included 28 studies that examined 13 different NSAIDs and involved 4181 women (none of whom were breastfeeding). Studies were published between 1967 and 2013, with the majority published in the 1980s. Of the 4181 women involved in the studies, 2642 received a NSAID and 1539 received placebo or paracetamol. Risk of bias was generally unclear due to poor reporting, but in most studies the participants and personnel were blinded, outcome data were complete and the outcomes that were specified in the methods section were reported.None of the included studies reported on any of this review's secondary outcomes: prolonged hospitalisation or re-hospitalisation due to perineal pain; breastfeeding (fully or mixed) at discharge; breastfeeding (fully or mixed) at six weeks; perineal pain at six weeks; maternal views; postpartum depression; instrumental measures of disability due to perineal pain. NSAID versus placeboCompared to women who received a placebo, more women who received a single dose NSAID achieved adequate pain relief at four hours (risk ratio (RR) 1.91, 95% confidence interval (CI) 1.64 to 2.23, 10 studies, 1573 participants (low-quality evidence)) and adequate pain relief at six hours (RR 1.92, 95% CI 1.69 to 2.17, 17 studies, 2079 participants (very low-quality evidence)). Women who received a NSAID were also less likely to need additional analgesia compared to women who received placebo at four hours (RR 0.39, 95% CI 0.26 to 0.58, four studies, 486 participants (low-quality evidence)) and at six hours after initial administration (RR 0.32, 95% CI 0.26 to 0.40, 10 studies, 1012 participants (low-quality evidence)). Fourteen maternal adverse effects were reported in the NSAID group (drowsiness (5), abdominal discomfort (2), weakness (1), dizziness (2), headache (2), moderate epigastralgia (1), not specified (1)) and eight in the placebo group (drowsiness (2), light headed (1), nausea (1), backache (1), dizziness (1), epigastric pain (1), not specified (1)), although not all studies assessed adverse effects. There was no difference in overall maternal adverse effects between NSAIDs and placebo at six hours post-administration (RR 1.38, 95% CI 0.71 to 2.70, 13 studies, 1388 participants (very low-quality evidence)). One small study (with two treatment arms) assessed maternal adverse effects at four hours post-administration, but there were no maternal adverse effects observed (one study, 90 participants (low-quality evidence)). Neonatal adverse effects were not assessed in any of the included studies. NSAID versus paracetamolNSAIDs versus paracetamol were also more effective for adequate pain relief at four hours (RR 1.54, 95% CI 1.07 to 2.22, three studies, 342 participants) but not at six hours post-administration. There was no difference in the need for additional analgesia between the two groups at four hours (RR 0.55, 95% CI 0.27 to 1.13, one study, 73 participants), but women in the NSAID group were less likely to need any additional analgesia at six hours (RR 0.28, 95% CI 0.12 to 0.67, one study, 59 participants). No maternal adverse effects were reported four hours after drug administration (one study). Six hours post-administration, there was no difference between the groups in the number of maternal adverse effects (RR 0.74, 95% CI 0.27 to 2.08, three studies, 300 participants), with one case of pruritis in the NSAID group and one case of sleepiness in the paracetamol group. Neonatal adverse effects were not assessed in any of the included studies.Comparisons of different NSAIDs and different doses of the same NSAID did not demonstrate any differences in their effectiveness on any of the primary outcome measures; however, few data were available on some NSAIDs.

AUTHORS' CONCLUSIONS

In women who are not breastfeeding and who sustained perineal trauma, NSAIDs (compared to placebo) provide greater pain relief for acute postpartum perineal pain and fewer women need additional analgesia when treated with a NSAID. However, the risk of bias was unclear for many of the included studies, adverse effects were often not assessed and breastfeeding women were not included in the studies. The overall quality of the evidence (GRADE) was low with the evidence for all outcomes rated as low or very low. The main reasons for downgrading were inclusion of studies with high risk of bias and inconsistency of findings of individual studies.NSAIDs also appear to be more effective in providing relief for perineal pain than paracetamol, but few studies were included in this analysis.Future studies should examine NSAIDs' adverse effects profile including neonatal adverse effects and the compatibility of NSAIDs with breastfeeding, and assess other important secondary outcomes of this review. Moreover, studies mostly included women who had episiotomies. Future research should consider women with and without perineal trauma, including perineal tears. High-quality studies should be conducted to further assess the efficacy of NSAIDs versus paracetamol and the efficacy of multimodal treatments.

Sexual activity and dyspareunia the first year postpartum in relation to degree of perineal trauma

INTRODUCTION AND HYPOTHESIS

Knowledge on sexual complaints and time to sexual resumption after obstetric anal sphincter injury (OASI) is scarce. The aim of the study was to investigate self-reported sexual activity and coital problems 1 year postpartum in relation to perineal trauma, in addition to delivery mode.

METHODS

Among 2,846 women recruited during pregnancy, all women who delivered with OASI (n = 42, all third-degree perineal tears), in addition to 20 randomly selected controls per OASI case, a total of 882 women, were sent a self-administered questionnaire addressing time to coital resumption after delivery and potential coital difficulty 1 year postpartum.

RESULTS

By 8 weeks, half of the 561 responders (51.4 %) had resumed intercourse, increasing to 75.2 % by 12 weeks and 94.7 % 1 year postpartum. In multivariate regression analysis OASI was the strongest predictor for postponed coital onset, defined as after 8 weeks (aOR 5.52, CI 1.59-19.16). OASI was also the only significant predictor for dyspareunia 1 year after delivery (aOR 3.57, CI 1.39-9.19). Episiotomy was neither a risk factor for postponed coital onset nor for dyspareunia. There were no differences between episiotomy and second-degree laceration injury groups regarding postponed coital onset (p = 0.45) or dyspareunia (p = 0.67) 1 year postpartum.

CONCLUSIONS

Obstetric anal sphincter injury was a strong and independent predictor for both postponed coital resumption after delivery and for dyspareunia 1 year postpartum, whereas episiotomy and spontaneous second-degree lacerations were not. Our main finding of affected sexual activity after OASI further supports the need to reduce the rates of this obstetric injury to a minimum.

Knowledge of the pelvic floor in nulliparous women

[Purpose] Proper pelvic floor function is important to avoid serious dysfunctions including incontinence, prolapse, and sexual problems. The current study evaluated the knowledge of young nulliparous women about their pelvic floor and identified what additional information they wanted. [Subjects and Methods] In this cross-sectional survey, a validated, 36 item questionnaire was distributed to 212 nulliparous women. The questionnaire addressed demography, pelvic floor muscles, pelvic floor dysfunction, and possible information sources. Descriptive statistics were generated for all variables. Stability and validity testing were performed using Kappa statistics and intra class correlation coefficients to define agreement for each question. The study was approved by the ethics Committee (B300201318334). [Results] Using a VAS scale (0 to 10), the women rated their knowledge about the pelvic floor as a mean of 2.4 (SD 2.01). A total of 93% of the women were insufficiently informed and requested more information; 25% had concerns about developing urinary incontinence, and 14% about fecal incontinence. Many of the women were unaware what pelvic floor training meant. [Conclusion] There was a significant lack of knowledge about pelvic floor function among nulliparous women. The majority of nulliparous women expressed a need for education, which might offer a way to reduce dysfunction.

Episiotomy preferences, indication, and classification--a survey among Nordic doctors

INTRODUCTION

Episiotomy performance impacts perineal health and rates of obstetric anal sphincter injuries (OASIS). Our objective was to assess self-reported episiotomy practice and opinions on clinical indication for episiotomy among Nordic physicians and to investigate potential misclassification.

MATERIAL AND METHODS

A survey was conducted among doctors attending the 2012 Nordic obstetrical and gynecological conference. Participants were asked to draw an episiotomy on a photo of a perineum with a crowning fetal head similarly to their clinical practice if an episiotomy was clinically indicated, and to name the technique drawn. Differences in outcome measures were compared by country of practice and seniority.

RESULTS

The majority of the 297 participants (47%) drew a lateral episiotomy according to our classification by incision point and angle, but as many as 64% of these 138 doctors misclassified this as mediolateral episiotomy. Only 20% drew a mediolateral episiotomy, the great majority classifying it accurately, but 8% misclassified their mediolateral cut as a lateral episiotomy. One-third of episiotomies were nonclassifiable. In general, doctors in Finland, Sweden, and Norway more often favored lateral episiotomies compared with doctors in Denmark and Iceland. There were significant differences between Finnish and Norwegian vs. Danish and Swedish doctors in perception of clinical indications for episiotomy.

CONCLUSIONS

The great variation in self-reported episiotomy performance between Nordic physicians and large misclassification rates indicate that educational programs are warranted. Use of uniform classification and appropriate techniques may be crucial to investigate the role of episiotomies in preventing OASIS.

Comparing the Prevalence, Risk Factors, and Repercussions of Postpartum Genito-Pelvic Pain and Dyspareunia

INTRODUCTION

Childbirth is a risk factor for developing genito-pelvic pain and/or dyspareunia during the postpartum period and potentially in the longer term. These two types of pain can occur simultaneously or sequentially and could be affected by different risk factors and have a range of repercussions to women's lives, including their sexual functioning.

AIM

This study reviewed the available evidence to compare and contrast the prevalence, risk factors, and repercussions of postpartum genito-pelvic pain vs dyspareunia.

METHODS

All available data related to postpartum genito-pelvic pain and dyspareunia were reviewed.

MAIN OUTCOME MEASURES

A description of the prevalence, risk factors, and sexual and psychological consequences of postpartum genito-pelvic pain and dyspareunia and the methodologic limitations of previous studies.

RESULTS

The prevalence of postpartum genito-pelvic pain is much lower than that of postpartum dyspareunia. There is evidence of converging and differential risk factors for acute and persistent experiences of these two types of pain. Postpartum genito-pelvic pain and dyspareunia are associated with impaired sexual functioning. Rarely are these pain experiences examined together to make direct comparisons.

CONCLUSION

There has been a critical lack of studies examining postpartum genito-pelvic pain and dyspareunia together and integrating biomedical and psychosocial risk factors. This approach should be spearheaded by a multidisciplinary group of researchers of diverse and relevant expertise, including obstetricians, gynecologists, anesthesiologists, and psychologists.

[Impact of pelvic floor muscle training on prevention of perineal pain and dyspareunia in postpartum]

OBJECTIVE

Assessing the impact of perineal rehabilitation and massage on perineal pain and dyspareunia in the postpartum period, between 15days and 12months after delivery.

METHODS

We conducted an exhaustive review of the literature concerning pelvic floor rehabilitation in the postpartum between 1987 and May 2015, grading data by levels of evidence (LOE) according to the methodology recommendations for clinical guidelines.

RESULTS

Pelvic floor rehabilitation in the postpartum is not associated with a decreased prevalence of perineal pain and dyspareunia at 1year (LOE3). The practice of digital perineal massage during the third trimester of pregnancy is not associated with decreased prevalence at 3-month postpartum of perineal pain or dyspareunia (RR=0.64; 95% CI [0.39-1.08] and RR=0.96; 95% CI [0.84-1.08], respectively), except for women who have delivered vaginally (RR=0.45; 95% CI [0,24-0.87]) (LOE2). The practice of digital perineal massage or application of warm packs in the second stage of labor does not reduce perineal pain (RR=0.93; 95% CI [0.66-1.32]) or dyspareunia (RR=0.99; 95% CI [0.74-1.34]) at 3-month postpartum (LOE2).

CONCLUSION

There is no evidence of long-term benefit of perineal rehabilitation and perineal massage on perineal pain and dyspareunia in the year following childbirth. Further studies are needed to accurately assess the impact of therapeutic strategies proposed in France.

Birth position and obstetric anal sphincter injury: a population-based study of 113 000 spontaneous births

BACKGROUND

The association between birth position and obstetric anal sphincter injury (OASIS) in spontaneous vaginal deliveries is unclear.

METHODS

The study was based on the Stockholm-Gotland Obstetric Database (Sweden) from Jan 1(st) 2008 to Oct 22(nd) 2014 and included 113 279 singleton spontaneous vaginal births with no episiotomy. We studied risk of OASIS with respect to the following birth positions: a) sitting, b) lithotomy, c) lateral, d) standing on knees, e) birth seat, f) supine, g) squatting, h) standing and i) all fours. All analyses were stratified for parity. General linear models were used to calculate risk ratios (RR) adjusted for maternal, pregnancy and fetal characteristics.

RESULTS

The rates of OASIS among nulliparous women, parous women and women undergoing vaginal birth after a caesarean (VBAC) were 5.7%, 1.3% and 10.6%, respectively. The rates varied by birth position: from 3.7 to 7.1% in nulliparous women, 0.6% to 2.6% in parous women and 5.6% to 18.2% in women undergoing VBAC. Regardless of parity, the lowest rates were found among women giving birth in standing position and the highest rates among women birthing in the lithotomy position. Compared with sitting position, the lithotomy position involved an increased risk of OASIS among nulliparous (adjusted RR 1.17, 95% CI 1.06-1.29) and parous women (adjusted RR 1.66, 95% CI 1.35-2.05). Birth seat and squatting position involved an increased risk of OASIS among parous women (adjusted RR [95% CI] 1.36 [1.03-1.80] and 2.16 [1.15-4.07], respectively). Independent risk factors for OASIS were maternal age, head circumference ≥35 cm, birth weight ≥4000 g, length of gestation ≥ 40 weeks, prolonged second stage of labour, non-occiput anterior presentation and oxytocin augmentation.

CONCLUSIONS

Compared with sitting position, lateral position has a slightly protective effect in nulliparous women whilst an increased risk is noted among women in the lithotomy position, irrespective of parity. Squatting and birth seat position involve an increase in risk among parous women.