Counseling after perineal laceration: does it improve functional outcome?

Facilitators and Barriers to Implementation of Perineal Techniques: A Scoping Review Applying the Consolidated Framework for Implementation Research

AIM

To summarise the barriers and facilitators to the clinical implementation of perineal techniques and to provide evidence-based insights for decision-making based on existing research.

DESIGN

A scoping review.

DATA SOURCES

Nine electronic databases (PubMed, Cochrane Library, Embase, CINAHL, ProQuest, CNKI, WanFang, VIP and SinoMed) were systematically searched on 4 February 2024.

REVIEW METHODS

This study followed Joanna Briggs Institute's scoping review methodology. The barriers and facilitators identified in the included studies were mapped to the domains of the Consolidated Framework for Implementation Research (CFIR): intervention characteristics, outer setting, inner setting, characteristics of individuals and process.

RESULTS

A total of 18 studies were finally included and analysed. The most frequently identified facilitator was theoretical education for midwives (inner setting). Common barriers included: lack of time to implement perineal techniques (intervention characteristics); labour pain and women's stress due to insufficient understanding of the birthing process, as well as women's reluctance to receive the perineal techniques (outer setting); risk factors for OASIS (inner setting); insufficient theoretical education for midwives and inadequate prenatal education for pregnant women (inner setting) and concerns about potential medical disputes among performers (characteristics of individuals).

CONCLUSIONS

Many of the factors influencing the implementation of perineal techniques identified in this review are modifiable. Developing implementation strategies based on these factors can promote the successful implementation of these perineal techniques in clinical settings.

IMPLICATIONS FOR THE PROFESSION

This scoping review could serve as a reference framework for health authorities in developing strategies to promote the use of perineal techniques in clinical practice.

IMPACT

Existing research has primarily focused on the outer setting, inner setting and characteristics of individuals implementing perineal techniques. Therefore, there is a need for more high-quality studies focusing on intervention characteristics and the implementation process.

REPORTING METHOD

This study followed the PRISMA extension for scoping reviews.

PATIENT AND PUBLIC CONTRIBUTION

Not applicable.

Skeletal Muscle Complex Between the Vagina and Anal Canal: Implications for Perineal Laceration

INTRODUCTION AND HYPOTHESIS

The anatomy of the skeletal muscles located between the vagina and anus is important during complex obstetric laceration reconstructions. We aimed to clarify the composition of skeletal muscles located between the vagina and anal canal and their three-dimensional configuration relevant to perineum repair.

METHODS

This observational study involved ten female cadavers. An anatomical dissection was performed to observe the muscles around the vagina and anal canal. Immunohistological analysis of the midsagittal section was performed to clarify the composition of the muscles, and dissection was performed to correspond to the cross-section. Wide-range serial sectioning and three-dimensional reconstruction were used to support these findings histologically and visualize the three-dimensional arrangement.

RESULTS

The region between the vagina and anal canal included the anterior part of the external anal sphincter, superficial transverse perineal muscle approaching from the lateral side, and levator ani, located cranially. They converge three-dimensionally in the median from each direction, forming a muscle complex between the vagina and anal canal.

CONCLUSIONS

The medial region between the vagina and anal canal in those giving birth includes a skeletal muscle complex formed by the confluence of the external anal sphincter, anterior bundle of the levator ani, and superficial transverse perineal muscle. In cases of severe perineal lacerations, these muscles could be injured. The anatomical knowledge that a part of the levator ani forms a muscle sling anterior to the anal canal is particularly important for obstetricians and gynecologists repairing obstetric lacerations and treating pelvic floor disorders.

Recommendations for postpartum athletes returning to sport: the past, present, and future

INTRODUCTION

There is a growing percentage of elite female athletes who choose to start a family during their athletic careers. Current guidelines to manage postpartum elite athletes returning to sport are weakly rooted in athlete-centered evidence and/or are restricted by small sample sizes. The purpose of this review was to collect and compare existing protocols and guidelines for elite athletes returning to sport following childbirth and to highlight the current culture surrounding postpartum athletes.

METHODS

Online databases including PubMed and BioMed Central were searched from September 2023 to May 2024. Studies of any design were included if they contained information on pregnancy and postpartum. Peer-reviewed research studies, systematic reviews, case reports, and data from organizational websites (American College of Obstetricians and Gynecologists, the World Health Organization, and the Official Olympics) were included.

RESULTS

Athlete-mothers face numerous challenges in their transition back to competitive sport following childbirth, including the societal expectations of a 'good' mother, potential loss of financial sponsorships, and limited guidance on postpartum training. Additionally, the healthcare community historically managed postpartum athletes in a reactionary manner by treating symptoms from pregnancy and childbirth as they arise. Recent literature is pointing toward adopting a preventive and proactive model of care to optimize an athlete's health prior to pregnancy and therefore support their safe return to sport postpartum.

CONCLUSION

Increased support for female participation in sports must also be met by increased support for pregnant and postpartum athletes. There is a continued need for research regarding return-to-sport guidelines for postpartum athletes, and their proper implementation.

Caesarean section and anal incontinence in women after obstetric anal sphincter injury: A systematic review and meta-analysis

BACKGROUND

Approximately 50% women who give birth after obstetric anal sphincter injury (OASI) develop anal incontinence (AI) over their lifetime.

OBJECTIVE

To evaluate current evidence for a protective benefit of planned caesarean section (CS) to prevent AI after OASI.

SEARCH STRATEGY

MEDLINE/PubMed, Embase 1974-2024, CINAHL and Cochrane to 7 February 2024 (PROSPERO CRD42022372442).

SELECTION CRITERIA

All studies reporting outcomes after OASI and a subsequent birth, by any mode.

DATA COLLECTION AND ANALYSIS

Eighty-six of 2646 screened studies met inclusion criteria, with nine studies suitable to meta-analyse the primary outcome of 'adjusted AI' after OASI and subsequent birth. Subgroups: short-term AI, long-term AI, AI in asymptomatic women.

SECONDARY OUTCOMES

total AI, quality of life, satisfaction/regret, solid/liquid/flatal incontinence, faecal urgency, AI in women with and without subsequent birth, change in AI pre- to post- subsequent birth.

MAIN RESULTS

There was no evidence of a difference in adjusted AI after subsequent vaginal birth compared with CS after OASI across all time periods (OR = 0.92, 95% CI 0.72-1.20; 9 studies, 2104 participants, I2 = 0% p = 0.58), for subgroup analyses or secondary outcomes. There was no evidence of a difference in AI in women with or without subsequent birth (OR = 1.00 95% CI 0.65-1.54; 10 studies, 970 participants, I2 = 35% p = 0.99), or pre- to post- subsequent birth (OR = 0.79 95% CI 0.51-1.25; 13 studies, 5496 participants, I2 = 73% p = 0.31).

CONCLUSIONS

Due to low evidence quality, we are unable to determine whether planned caesarean is protective against AI after OASI. Higher quality evidence is required to guide personalised decision-making for asymptomatic women and to determine the effect of subsequent birth mode on long-term AI outcomes.

Effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women: A systematic review and meta-analysis

BACKGROUND

Perineal massage during childbirth has been recommended as an effective measure to prevent perineal injury. However, the overall effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women remain inconclusive. Particularly, the effects of perineal massage begun during different stages of labor need to be further investigated.

OBJECTIVES

To comprehensively review the effects of perineal massage during childbirth on primiparous health outcomes, including perineal-related outcomes, duration of labor, hemorrhage and postpartum perineal pain, and neonatal outcomes, including Apgar scores and neonatal complications, and to further explore the effects of perineal massage begun during different stages of labor.

DESIGN

A systematic review and meta-analysis following the Cochrane Handbook guidelines and PRISMA2020.

METHODS

A systematic search strategy was developed following the three-phase search approach, and the literature search was conducted in electronic databases and clinical trial registers from inception to 7th January 2022. Study selection and data extraction were completed independently by two researchers. The updated Cochrane risk of bias 2.0 tool for randomized trials was chosen to evaluate the quality of included studies. Data analyses were conducted using the Revman5.4 software, and subgroup analyses were performed based on the different start times of perineal massage. Furthermore, the certainty of body of evidence for each outcome was assessed utilizing the GRADEpro online tool.

RESULTS

Seventeen randomized controlled trials involving 3248 primiparous women were included in the review. The pooled results of meta-analyses indicated that perineal massage begun during the second stage of labor significantly increased the occurrence of intact perineum (RR = 2.78, 95 % CI: [1.52, 5.05], P < 0.001), reduced the rate of second- and third-degree perineal lacerations (P < 0.05), and decreased the incidence of episiotomy (RR = 0.63, 95 % CI: [0.50, 0.79], P < 0.001), while perineal massage during the first stage of labor effectively shortened the duration of the first and second stages of labor (P < 0.05). The available evidence also suggests the potential role of perineal massage on hemorrhage and long-term postpartum perineal pain (P < 0.05). However, the aggregated results failed to demonstrate the beneficial effects of perineal massage on neonatal outcomes (P > 0.05).

CONCLUSIONS

Perineal massage begun during the second stage of labor effectively improves the perineal-related outcomes in primiparous women, while perineal massage during the first stage of labor significantly shortens the duration of labor. High-quality studies exploring the standardized procedure for perineal massage and the short- and long-term effects of perineal massage are warranted.

REGISTRATION NUMBER

CRD42022302336 (PROSPERO).

Factors determining the persistence of prenatal stress urinary incontinence 12 months postpartum

OBJECTIVE

Whilst many studies have explored the mechanisms of stress urinary incontinence (SUI) following various modes of delivery, few have examined outcomes of postpartum SUI in women who experienced new-onset SUI during their pregnancy. Our primary objective was to investigate the risk factors for persistent postpartum SUI in women with new-onset SUI during pregnancy at 1-year follow-up following vaginal delivery.

MATERIALS AND METHODS

303 women with new-onset SUI during pregnancy who underwent vaginal delivery in a university hospital between 2014 and 2015 were included. In-person interviews were conducted for all participants on the second postpartum day, followed by phone interviews at 12 months postpartum, with completion of structured questionnaires, including Urogenital Distress Inventory Short Form (UDI-6) and Incontinence Impact Questionnaire Short Form (IIQ-7). Demographic, obstetrics and questionnaire scores were analyzed and compared between the group of women who experienced persistent postpartum SUI and the group who did not.

RESULTS

At 12 months postpartum, 16.5% (n = 50) of women had persistent postpartum SUI, with 83.5% (n = 253) experiencing resolution of SUI symptoms. Maternal age ≥35 years (aOR = 2.62; 95% CI, 1.40-4.87, P = 0.002), gestational age at birth ≥40 weeks (aOR = 2.21; 95% CI, 1.12-4.37, P = 0.022), and severe perineal lacerations (aOR = 2.32; 95% CI, 1.27-4.45, P = 0.013) were independent risk factors for persistent postpartum SUI for women following vaginal delivery at 1-year follow-up.

CONCLUSION

The prevalence of persistent postpartum SUI at 1-year following vaginal delivery is 16.5%, with advanced maternal age, gestational age at birth ≥40 weeks and severe perineal lacerations being independent risk factors.

Women's experiences of obstetric anal sphincter injury and physical therapy interventions - A qualitative study

•

85% of all vaginal deliveries cause some form of obstetric tear injury.

•

The experienced recovery appears partially independent from the extent of injury.

•

Women feel uncertainty about what's normal after a vaginal tear.

•

Meeting each woman's needs and wishes in rehabilitation should be emphasized.

Background

During childbirth, women may suffer perineal injuries that can lead to persistent disorders. No interview study has investigated women's experience of obstetric anal sphincter injuries (OASIS) and physical therapy rehabilitation process after the injury.

Objective

To describe women's experiences of OASIS and the physical therapy rehabilitation process.

Methods

A qualitative study with an inductive approach based on semi-structured interviews was performed with 14 primi- and multi-parous women affected by OASIS. They had been sutured within 24 h and were recruited from a university hospital in Sweden. The interviews lasted between 35 and 66 min. Data were processed and analyzed using qualitative content analysis.

Results

Three main categories emerged from the analysis: The categories described experiences of a difficult time after the injury and physical therapy rehabilitation but also experiences of a safe follow-up. Moreover, experiences of that it wasn´t that bad after all when looking back.

Conclusion

Regardless of the extent of the injury, some women experienced a long and troublesome recovery with intense physical therapy rehabilitation, while other women felt that they fortunately got away lightly. Factors that can influence a woman's confidence in safely beginning pelvic floor muscle training at an early stage include individualizing when and how information about OASIS is provided. Meeting each woman's needs and wishes is emphasized by this study.

Parturition mode recommendation and symptoms of pelvic floor disorders after obstetric anal sphincter injuries

INTRODUCTION AND HYPOTHESIS

Our primary objective was to evaluate parturition mode (PM) recommendations following obstetric anal sphincter injuries (OASIs) and adherence to these recommendations and to evaluate recurrence of OASIs in women who had a subsequent vaginal delivery (VD). The hypothesis was that adherence to the PM recommendations leads to a reasonable OASI recurrence rate.

METHODS

This was a retrospective observational cohort study of patients with previous OASIs between 2010 and 2016. After an outpatient visit including 3D transperineal ultrasound to screen for pelvic floor and anal sphincter injuries, all patients received recommendations for a subsequent PM. Patients were invited to complete validated questionnaires 2 to 5 years post-OASIs.

RESULTS

The majority of invited patients (265/320) attended follow-up, with 264 receiving a recommendation for PM. Only 5.6% did not adhere to the received recommendation. One hundred sixty-one patients delivered again, 58% had a VD, and 42% had a cesarean section (CS). Recurrence of OASIs was observed in 4.3% of the patients that had a VD. Fecal incontinence occurred in 4.9%, however any form of anal incontinence in 48% of patients. While dyspareunia was common in patients with residual external anal sphincter (EAS) injuries and levator ani muscle (LAM) avulsions, anal pain occurred more frequently in EAS injuries and fecal incontinence in LAM avulsions.

CONCLUSIONS

This study showed that the vast majority of patients followed PM recommendations, and this resulted in a low recurrence of OASIs with a high CS rate. Fecal incontinence after OASIs was correlated with the degree of OASIs.