Obstetric perineal tears: risk factors, wound infection and dehiscence: a prospective cohort study

Analysis of risk factors and prediction model construction for poor healing of perineal wounds after vaginal delivery: A retrospective case-control study

Background

Perineal wounds after vaginal delivery are very common, but the existing evidence for poor healing of perineal wounds is limited. Although some studies have analyzed the risk factors for poor perineal wound healing, there are currently no simple and practical predictive tools available for clinical use.

Objective

To retrospectively analyze the independent risk factors for poor perineal wound healing after vaginal delivery and to establish a risk prediction model for poor perineal wound healing.

Design

A Retrospective Case-Control Study.

Data Source

A total of 167 cases of poor perineal wound healing after vaginal delivery who visited the emergency department from May 2021 to September 2023 in our hospital were selected as the poor perineal wound healing group. The control group was randomly selected by the random number table method at a ratio of 1:2 from those with normal perineal wound healing during the same period.

Methods

Clinical indicators of the two groups were analyzed, and the risk factors for poor perineal wound healing were analyzed using univariate and multivariate Logistic regression analysis, and a risk prediction model was constructed. A nomogram was drawn, and the model was evaluated by discrimination and calibration.

Results

This study ultimately included four independent risk factors to construct the risk prediction model, including primiparity, perineal laceration, perineal laceration combined with laceration, and vaginal hematoma. The model formula was Z = 2.256 + 2.7 × (episiotomy with laceration) + 1.5 × (episiotomy) + 1.321 × (vaginal hematoma) + 0.904 × (primiparity). The area under the ROC curve of the constructed model was 0.757 (95 % CI: 0.712-0.803), and the optimal cutoff value was 0.194, at which the model sensitivity was 0.952 and specificity was 0.759.

Conclusions

The risk prediction model for poor perineal wound healing after vaginal delivery can reasonably predict the risk of poor incision healing, providing a basis for obstetric medical staff to take preventive management measures for high-risk groups before the discharge of parturient women, thereby reducing the occurrence of poor perineal wound healing.

Antibiotic prophylaxis for childbirth-related perineal trauma: A systematic review and meta-analysis

INTRODUCTION

Childbirth-related perineal trauma affects the vast majority of women who give birth vaginally and subsequent complications such as wound infection occur frequently. Antibiotic prophylaxis is not currently recommended following first or second degree tears, or episiotomies. We aimed to evaluate the effectiveness of prophylactic antibiotics for preventing complications from perineal trauma across all types of childbirth-related perineal trauma.

MATERIALS AND METHODS

Databases were searched from inception to February 2024. Randomised controlled trials, non-randomised interventional studies and observational studies were eligible for inclusion where women experienced childbirth-related perineal trauma and received antibiotic prophylaxis or placebo, including any type of tear or episiotomy. The primary outcome was perineal wound infection. Results were combined into meta-analysis using a random effects model.

RESULTS

14 studies were eligible for inclusion (eight randomised controlled trials, six observational) involving 8,878 women. Ten studies were deemed to have a high overall risk of bias. Overall the GRADE certainty of findings were low. Twelve studies were included in the analysis for perineal wound infection, involving 8,438 women. There was a reduced rate of perineal wound infection when prophylactic antibiotics were received (relative risk 0.57, 95% confidence interval 0.48 to 0.67). The subgroup analysis by type of tear demonstrated association with reduced risk of infection when prophylactic antibiotics were received, in the non-obstetric anal sphincter injuries combined subgroup (relative risk 0.50, 95% confidence interval 0.41-0.63) and the episiotomy only subgroup (relative risk 0.57, 95% confidence interval 0.36-0.91).

CONCLUSIONS

Prophylactic antibiotics are associated with a reduced risk of perineal wound infection. Despite these findings, there are not sufficient high-quality randomised controlled trials to adequately inform guideline change amongst women with first/second degree tears or episiotomies. We recommend that an adequately powered, robust, randomised controlled trial is needed amongst women with first/second degree tears or episiotomies after spontaneous birth.

Epidemiology, etiology and treatment of female vaginal injury

The preservation of vaginal anatomical structure and physiological function is critical for women's health and should not be ignored. Vaginal injuries have a negative impact on women's quality of life. Vaginal delivery is the most common cause of vaginal injuries, 53-79% of women suffer from perineal and vaginal lacerations during labor. The incident of vaginal atrophy caused by decreased estrogen in menopausal women is growing, reaching 39%. The primary medical treatment of menopause-related vaginal atrophy is estrogen, which has a recognized therapeutic effect. Severe obstetric lacerations and trauma-related vaginal damage must be identified promptly and treated surgically. Radiotherapy-induced vaginal stenosis and adhesion could be treated with a vaginal dilator, however, there is a lack of consensus on therapy plans. Furthermore, surgical closure of genitourinary fistulas arise from the tumor or vaginal delivery is technically challenging. Stem cells have been proven to be effective in treating vaginal atrophy in animal models. Traditional treatments for Mayer-Rokitansky-Küster-Hauser syndrome, which is caused by a congenital anomaly of vaginal development, include vaginal dilation and vaginoplasty with autologous tissue. However, due to poor compliance and surgical complications, tissue engineering technology has received considerable attention for vaginal reconstruction because of its preferred characteristics. Nonetheless, the biological therapy of stem cell and tissue engineering technology still faces severe challenges, without application for clinical translation. Therefore, for women with vaginal injuries, the choice of treatment should be guided by the etiology and symptom severity. Stem cell therapy and tissue engineering technology show promising application prospects for vaginal injury repair and reconstruction, in addition to medical and surgical treatments. However, it is necessary to conduct additional pre-clinical animals and clinical trials in order to provide reliable references for future clinical practice.

The PLUS study: efficacy of triclosan coated suture (VicrylPlus®) to reduce infection in primary suture of childbirth related perineal tears - a randomized controlled trial

BACKGROUND

Preventing infection in primary sutured perineal tears after childbirth is crucial to avoid systemic antibiotic use and potential complications from poor healing. This study aimed to investigate the efficacy of an antibacterial, triclosan-coated suture (VicrylPlus®) in reducing infection in primary sutured childbirth-related perineal tears.

METHODS

The PLUS study was a single-center, single-blinded, adaptive parallel-group randomized trial conducted at Lund University Hospital, Sweden. Women aged ≥ 18 years with a perineal tear at childbirth were randomly assigned in a 1:1 ratio to either the control group (conventional-absorbable suture, Vicryl®) or the intervention group (triclosan-coated- absorbable suture, VicrylPlus®).

RESULTS

Out of 1921 eligible women, 1890 were randomized to either Vicryl® (n = 953) or VicrylPlus® (n = 937). There were no significant demographic differences between the groups. The most common type of tear in both groups was a second-degree tear (Vicryl® 66.2% (n = 625), VicrylPlus® 67.5% (n = 625)). Encompassing all types of deeper tears in the analysis there was a significantly decrease in infection after suturing with VicrylPlus® 4% (n = 28) versus Vicryl® 6.8% (n = 47); (OR 0.57, 95% CI 0.35-0.91, P = 0.024). When analyzing different tears separately, there was a non-significant increase in infection for first-degree tears with VicrylPlus® 0.8% (n = 2) versus Vicryl® 3.9% (n = 8); (OR 4.75, 95% CI 1.00-22.63, P = 0.050). However, for second-degree tears, the infection rate was significantly reduced with VicrylPlus® 4.4% (n = 27) versus Vicryl® 7.2% (n = 44); (OR 0.63, 95% CI 0.36-0.98, P = 0.05) and for third-degree and unclassified tears there was a non-significant decrease in infections with VicrylPlus® 5.3% (n = 1) versus Vicryl® 14.3% (n = 2); (OR 0.33, 95% CI 0.03-4.10, P = 0.561), respectively, VicrylPlus® 0% versus Vicryl® 1.7% (n = 1); (OR 0.98, 95% CI 0.95-1.02, P = 0.462).

CONCLUSION

The use of triclosan coated sutures significantly reduces the risk of infection in primary sutured childbirth-related perineal tears by 43%, except for first-degree tears. Further research is needed to determine whether their effectiveness remains consistent across the other specific types of deeper tears in a larger study population.

TRIAL REGISTRATION

ClinicalTrials (NCT02863874), posted 11/08/2016, retrospectively registered. Approved by the regional ethical committee before start of enrollment (Dnr 2015/774).

Parenting stress after perineal tear during childbirth: the role of physical health and depressive symptoms

Introduction

This study investigates the impact of the severity of perineal tear during childbirth on parenting stress at 10-12 weeks postpartum. Studies have shown that up to 80% of primiparous mothers may suffer a perineal tear, which can have important physical and psychological consequences. As the adjustment to parenthood can be highly demanding and stressful for primiparous parents, we hypothesized that having experienced a perineal tear during childbirth could be an additional stressor reducing the resources to cope, which could increase parenting stress. We also hypothesized that this increase in parenting stress could be explained by the consequences of the perineal tear on mothers' physical health and depressive symptoms.

Methods

This study included 155 primiparous mothers with various degrees of perineal tear (from an intact perineum to a 4th degree tear).

Results

Results showed that perineal tear was not directly associated with parenting stress at 10-12 weeks postpartum. However, we found an indirect pathway of influence through mothers' physical health and depressive symptoms. Higher degrees of perineal tear were associated with worse physical health in mothers causing an increase in depressive symptoms that, in turn, was associated with higher parenting stress.

Discussion

The results indicate that perineal tear is indirectly associated with parenting stress, through its influence on physical health and depressive symptoms. Therefore, it seems crucial to focus on managing the physical consequences of perineal tear in the first weeks postpartum, to avoid detrimental consequences on mothers' mental health and parenting.

Episiotomy to prevent obstetric anal sphincter injuries during instrumental delivery in nulliparous women: a national prospective comparative cohort study

BACKGROUND

We are lacking data with a high level of evidence on the use of episiotomy during instrumental delivery to prevent anal sphincter injury, which nonetheless presents the highest risk.

OBJECTIVE

Our main objective was to assess the protective effect of episiotomy against obstetric anal sphincter injury in nulliparous women during instrumental delivery according to type of instrument. We also investigated its impact on immediate maternal and neonatal morbidity.

STUDY DESIGN

We conducted a prospective comparative cohort study for clinical trial emulation by means of propensity score weighting. The study was especially designed for consideration of possible confounders. This was a nationwide observational multicenter study including 111 French public and private maternity units between April 2021 and March 2022. We included nulliparous women, with singleton cephalic fetus, at more than 34 weeks of gestation. We considered vacuum, forceps, and spatula deliveries. We proceeded to a comparative analysis between women with and without episiotomy. The main outcome was obstetric anal sphincter injury occurrence. We used composite criteria for both maternal and neonatal immediate morbidity.

RESULTS

The analyses pertained to 11,013 women. Overall prevalence of episiotomy was 23%: 17% for vacuum (N=7007), 37% for forceps (N=2378), and 29% in case of spatula-assisted (N=1628) delivery. Episiotomy was not associated with significantly decreased obstetric anal sphincter injury occurrence in vacuum delivery (from 5.2% without episiotomy to 3.8%, odds ratio=0.73 [0.48-1.03]) or forceps delivery (from 10.9% without episiotomy to 8.8%, odds ratio=0.81 [0.56-1.14]). In contrast, we observed significantly decreased obstetric anal sphincter injury occurrence (from 9.4% without episiotomy to 5.6%) in spatula delivery (odds ratio=0.60 [0.37-0.87]). Episiotomy was associated with increased maternal morbidity using forceps (from 13.6%-18.3%, odds ratio=1.35 [1.01-1.73]) and spatulas (from 9.0%-13.4%, odds ratio=1.51 [1.11-2.00]). We also observed increased neonatal morbidity in vacuum delivery associated with episiotomy (from 9.1%-13.6%, odds ratio=1.49 [1.21-1.79]), but a decrease in case of forceps delivery with episiotomy (from 12.6%-9.2%, odds ratio=0.74 [0.55-0.95]).

CONCLUSION

Episiotomy was not associated with a decreased risk of obstetric anal sphincter injury in vacuum or forceps delivery, and a marginal reduction was achieved using spatulas. Our results do not favor extensive episiotomy during instrumental delivery.

TRIAL REGISTRATION

ClinicalTrial NCT 04446780.

Influence of experimental conditions on some in-vitro biomechanical properties of the sow's perineum

The aim of this work was to develop an experimental protocol that takes into account the influence of experimental conditions on these perineal tissues, before determining their mechanical properties. Samples of each perineal tissue layer were obtained from the skin, the vagina, the external anal sphincter (EAS), the internal anal sphincter (IAS) and anal mucosa of freshly dead sows. They were tested in quasi-static uniaxial tension using the Mach-1 testing machine. Stress-strain curves of each perineal tissue layer before the first damage for each sow were obtained and modeled by hyperelastic laws described by three coefficients: C1, C2, and C3 (Yeoh model). The influence of sample preparation conditions such as tissue freezing, hygrometry and sample orientation were evaluated, and the conditions under which the tests were performed such as the displacement velocity during testing were also evaluated by analysing C1-coefficient. This study suggested that sample preparation conditions such as tissue freezing for 24 h, storage in cellophane paper for two hours and the strain rate did not statistically affect the C1-hyperelastic coefficient for each perineal layer (p > 0.05). Samples should not be stored in saline for 2 h (p < 0.05). Sample orientation did not influence C1-hyperelastic coefficient (p > 0.05). This experimental protocol could be used to study in vitro biomechanical properties of perineal tissues in order to better understand perineal tears during delivery.

Obstetric Perineal Tears, Birth Characteristics and the Association with Urinary Incontinence Among Primiparous Women 12 Months Postpartum: A Prospective Cohort Study

INTRODUCTION AND HYPOTHESIS

Postpartum urinary incontinence (UI) is common and a concern for many women, as UI leads to a lower quality of life and self-esteem. Perineal tears may be a risk factor for UI, yet few studies have investigated the association between the degree of perineal tear and risk of developing UI postpartum. The objective was to examine how the degree of perineal tear and selected obstetric risk factors were associated with any UI and stress ultrasound (SUI) 12 months postpartum among primiparous women.

METHODS

A prospective cohort study was conducted at four Danish hospitals. Baseline data were obtained at a clinical examination 2 weeks postpartum. Symptoms of UI were evaluated 12 months postpartum by the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form questionnaire (web-based). Multivariate regression analyses were performed to investigate the risk factors for UI.

RESULTS

A total of 603 primiparous women (203 with none/labia/first-degree tears, 200 with second-degree tears and 200 with third-/fourth-degree tears) were included between July 2015 and January 2018. Women with tears involving the perineal muscles reported any UI more often than women with no/labia or first-degree tears (spontaneous second-degree tear: RR 2.04, 95% CI 0.92-4.50; episiotomy: RR 2.22, 95% CI 0.99-4.96; third- or fourth-degree tear: RR 2.73, 95% CI 1.18-6.28). The same was found for SUI, but with wider confidence intervals.

CONCLUSIONS

A higher prevalence of any UI and SUI was found among women with perineal tears involving any perineal muscles, compared with women with no, labia, or first-degree tears.

Reproductive history of parous women and urinary incontinence in midlife: A National Birth Cohort follow-up study

OBJECTIVE

To investigate how reproductive history was associated with urinary incontinence in midlife.

DESIGN

A follow-up study.

SETTING

Denmark.

POPULATION

A total of 39 977 mothers who participated in the Maternal Follow up (2013-2014) in the Danish National Birth Cohort. National registries provided their reproductive history.

METHODS

How parity, mode of birth and obstetric tears associated with urinary incontinence were estimated with adjusted odds ratios (OR) and 95% CI using logistic regression.

MAIN OUTCOME MEASURES

Self-reported urinary incontinence including subtypes stress, urge and mixed urinary incontinence.

RESULTS

At an average age of 44 years, the prevalence of any urinary incontinence was 32% (21% stress, 2% urge, and 8% mixed urinary incontinence). Women with two births more often had urinary incontinence than women with one birth (OR 1.20, 95% CI 1.10-1.31). Compared with women with only spontaneous births, a history of only caesarean sections was associated with much lower odds of urinary incontinence (OR 0.39, 95% CI 0.35-0.42) and a history of instrumental births with slightly lower odds (OR 0.92, 95% CI 0.86-0.98). Compared with no tear/first-degree tear as the largest tear, episiotomy was associated with less urinary incontinence (OR 0.91, 95% CI 0.86-0.97) whereas third/fourth-degree tears were associated with more (OR 1.14, 95% CI 1.04-1.25). Findings were mainly explained by similar associations with stress and mixed urinary incontinence.

CONCLUSIONS

Vaginal birth was associated with a higher risk of long-term urinary incontinence, but our results indicate that this risk may be reduced by shortening the second stage of birth.

The Effect of Perineum Massage Applied With and Without an Instrument in the Active Phase of Labor Birth Outcomes: A Randomized Clinical Trial

INTRODUCTION AND HYPOTHESIS

Perineal massage during labor reduces the need for episiotomy and shortens the length of the episiotomy. Pregnant women should be offered instrumented (EPI-NO) or manual perineal massage in labor. This study was conducted to determine the effect of perineal massage applied with (EPI-NO) and without an instrument during the active phase of labor on episiotomy rate and episiotomy length in women who gave birth vaginally.

METHODS

The study included 101 pregnant women aged 18-35 years, with gestational ages between 38 and 42 weeks and indications for vaginal delivery. Participants were randomly assigned to one of three groups: EPI-NO massage, manual massage, and control. The perineal massage was administered during the active labor phase (4- to 8-cm dilation) for 20 min in the intervention groups. Postpartum episiotomy rates and lengths were recorded using standardized forms. The research data were collected using the Introductory Information Form and Birth Assessment Form.

RESULTS

The episiotomy rate was found to be 33.3% in group I, 75.0% in group II, and 74.4% in the Control group, and a statistically significant difference was found between the groups (p = 0.001; p < 0.01). The mean episiotomy length of the women was 1.5 cm (mean ± SD: 1.50 ± 1.20) for group I, 3 cm (mean ± SD 2.70 ± 1.50) for group II, and 3.5 cm (mean ± SD 3.10 ± 2.00) for the control group (p < 0.000).

CONCLUSION

Perineal massage with EPI-NO was the most effective method at decreasing the episiotomy rate and shortening the episiotomy length compared with other groups.

Obstetric anal sphincter injury in the second birth after perineal wound complication in the first birth: A nationwide register cohort study

OBJECTIVE

To investigate whether perineal wound complications in the first birth, alone or in conjunction with obstetric anal sphincter injury (OASI), is associated with an increased risk of OASI in the second birth.

DESIGN

Nationwide population-based cohort study.

SETTING

Sweden.

POPULATION

Women (n = 411 317) with first and second singleton vaginal births in Sweden, 2001-2019.

METHODS

Data on diagnostic codes and surgical procedures were retrieved from the Swedish Medical Birth Register and the Swedish Patient Register. A perineal wound complication was defined as wound infection, dehiscence or perineal haematoma within 2 months of childbirth.

MAIN OUTCOME MEASURES

Associations between wound complications in the first birth and OASI in the second birth were investigated with logistic regression and presented as adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs).

RESULTS

In total, 2619 (0.6%) women had a wound complication in the first birth, and 5318 (1.3%) had an OASI in the second birth. Women with a wound complication but no OASI in the first birth had more than doubled odds of OASI in the second birth (aOR 2.73, 95% CI 2.11-3.53). Women with OASI and a wound complication in the first birth had almost tenfold odds (aOR 9.97, 95% CI 6.53-15.24) of recurrent OASI.

CONCLUSIONS

Perineal wound complication in the first birth increases the likelihood of OASI in a subsequent birth.

Occurrence and risk factors for second-degree perineal tears: A prospective cohort study using a detailed classification system

BACKGROUND

The amount of tissue trauma within second-degree perineal tears varies widely. Therefore, subcategorization of second-degree tears and a better understanding of their occurrence and risk factors are needed. The aim of this study was to assess the occurrence of perineal tears when second-degree tears were subcategorized. Furthermore, we aimed to assess the association between variables related to perineal anatomy and other potential risk factors, with second-degree tear subcategories.

METHODS

This prospective cohort study included 880 primiparous and multiparous women giving birth to one child vaginally. Perineal tears were categorized using the classification system recommended by the Royal College of Obstetricians and Gynaecologists. In addition, second-degree tears were subcategorized as 2A, 2B, or 2C according to the percentage of damage to the perineal body. Selected variables related to perineal anatomy were as follows: length of genital hiatus; perineal body length; and previous perineal trauma. Risk factors for second-degree tear subcategories were analyzed using a multinominal regression model.

RESULTS

Perineal tears occurred as follows: first-degree: 35.6% (n = 313), 2A: 16.3% (n = 143), 2B: 9.1% (n = 80), 2C: 6.6% (n = 58), and third- or fourth-degree: 1.6% (n = 14). In total, 169/880 participants underwent an episiotomy. When episiotomies were excluded, the risk for 2B, or 2C tears increased with smaller genital hiatus, larger perineal body, previous perineal trauma, primiparity, higher gestational age, instrumental vaginal delivery and fetal presentation other than occiput anterior.

CONCLUSION

The occurrence of second-degree tear subcategories was 16.3% for 2A tears, 9.1% for 2B tears, and 6.6% for 2C tears. Factors related to perineal anatomy increased the odds for experiencing a second-degree tear in a more severe subcategory.

Midterm complications after primary obstetrical anal sphincter injury repair in France

BACKGROUND

Incidence of complications following obstetrical anal sphincter injury (OASI) during vaginal delivery are poorly defined. They are only studied in high level maternities, small cohorts, all stages of perineal tear or in low-income countries. The aim of our study was to describe complications after primary OASI repair following a vaginal delivery in all French maternity wards at short and midterm and to assess factors associated with complication occurrence.

METHODS

We conducted a historical cohort study using the French nationwide claim database (PMSI) from January 2013 to December 2021. All women who sustained an OASI repair following a vaginal delivery were included and virtually followed-up for 2 years. Then, we searched for OASIS complications. Finally, we evaluated factors associated with OASIS complication repaired or not and OASIS complication repairs.

RESULTS

Among the 61,833 included women, 2015 (2.8%) had an OASI complication and 842 (1.16%) underwent an OASI complication repair. Women were mainly primiparous (71.6%) and 44.3% underwent an instrumental delivery. During a follow-up of 2 years, 0.6% (n = 463), 0.3% (n = 240), 0.2% (n = 176), 0.1% (n = 84), 0.06% (n = 43) and 0.01% (n = 5) of patients underwent second surgery for a perineal repair, a fistula repair, a sphincteroplasty, a perineal infection, a colostomy and a sacral nervous anal stimulation, respectively. Only one case of artificial anal sphincter was noticed. Instrumental deliveries (OR = 1.56 CI95%[1.29;1.9]), private for-profit hospitals (OR = 1.42 [1.11;1.82], reference group "public hospital"), obesity (OR = 1.36 [1;1.84]), stage IV OASIS (OR = 2.98 [2.4;3.72]), perineal wound breakdown (OR = 2.8 [1.4;5.48]), ages between 25 and 29 years old (OR = 1.59 [1.17;2.18], refence group "age between 13 and 24 years old") and 30 and 34 years old (OR = 1.57 [1.14; 2.16], refence group "age between 13 and 24 years old") were factors associated with OASIS complication repairs.

CONCLUSIONS

Maternal age, stage IV OASIS, obesity, instrumental deliveries and private for-profit hospitals seemed to predict OASIS complications. Understanding factors associated with OASIS complications could be beneficial for the patient to inform them and to influence the patient's follow-up in order to prevent complications, repairs and maternal distress.

The REPAIR study: oral antibiotics to prevent infection and wound dehiscence after obstetric perineal tear-a double-blinded placebo controlled randomized trial

BACKGROUND

Approximately 85% of women experience an obstetric tear at delivery and up to 25% subsequently experience wound dehiscence and/or infection. Previous publications suggest that intravenous antibiotics administrated during delivery reduces this risk. We do not know if oral antibiotics given after delivery can reduce the risk of wound dehiscence or infection. Our aim is to investigate whether three doses of oral antibiotics (amoxicillin 500 mg/clavulanic acid 125 mg) given after delivery can reduce the risk of wound dehiscence and infection in patients with a second-degree obstetric tear or episiotomy.

METHODS

We will perform a randomized, controlled, double-blinded study including 221women in each arm with allocation 1:1 in relation to the randomization. The study is carried out at Department of Obstetrics & Gynecology, Herlev University Hospital, Copenhagen, Denmark. The women will be included after delivery if they have had a second-degree tear or episiotomy. After inclusion, the women will have a clinical follow-up visit after 1 week. The tear and healing will be evaluated regarding signs of infection and/or dehiscence. The women will again be invited for a 1-year clinical examination including ultrasound. Questionnaires exploring symptoms related to the obstetric tear and possible complications will be answered at both visits. Our primary outcome is wound dehiscence and/or wound infection, which will be calculated using χ2 tests to compare groups. Secondary outcomes are variables that relate to wound healing, as pain, use of painkillers and antibiotics, need for further follow-up, as well as outcomes that may be related to the birth or healing process, urinary or anal incontinence, symptoms of prolapse, female body image, and sexual problems.

DISCUSSION

Reducing the risk of wound dehiscence and/or infection would decrease the number of control visits, prevent the need for longer antibiotic treatment, and possibly also decrease both short-term and long-term symptoms. This would be of great importance so the mother, her partner, and the baby could establish and optimize their initial family relation.

TRIAL REGISTRATION

The conduction of this study is approved the 2/2-2023 with the EU-CT number: 2022-501930-49-00.

CLINICALTRIALS

gov Identifier: NCT05830162.

Retrospective Case-Control Study of Extended Birth Perineal Tears and Risk Factors

BACKGROUND

A perineal tear is a rupture of the skin or muscle between the vagina and anus (perineum). A third-degree tear is one type of extended perineal tear (EPT), and it involves the penetration of the anal sphincter muscle. Another type of EPT is a fourth-degree laceration, which penetrates deeper into the lining of the anus or rectum. The stretching of the perineum during childbirth may result in perineal trauma. Invasive surgical interventions are required for the treatment of EPTs. For this reason, the reduction of their incidence can be achieved by fully comprehending the risk aspects associated with them.

OBJECTIVE

The aim of this study is to contribute to the body of knowledge by providing insight into the various risk factors that are associated with extended perineal trauma. By following this path, this study aims to contribute to and advance Saudi Arabia's development of evidence-oriented obstetric care recommendations.

STUDY DESIGN

The current study is a case-control study where a review of 5000 vaginal delivery records was carried out between March 1, 2018, and March 19, 2023. For the study, cases (n = 71) were female patients who had documented greater than second-degree perineal injury. The control group (n = 238) was randomly chosen from women who had vaginal delivery but with less or equal to a second-degree perineal laceration. For each patient, we reviewed medical and obstetrics records for the following characteristics: age of diagnosis, gestational age, parity, labor induction, second-stage labor duration, mode of delivery, infant birth weight, epidural use and episiotomy indication, healthcare worker (HCW) experience, and APGAR (appearance, pulse, grimace, activity, and respiration) score.

RESULTS

From the 5000 births analyzed, the cases were 71 patients (1.42% of 5000 births). The mean age at diagnosis in our sample was (28.05 ± 4.66 years). The study's results showed that the following variables significantly affected the occurrence of EPTs: birth weight, labor durations, parity, HCW experience, and mode of delivery. The odds for tears were 3.69 (95% CI: 0.156-0.469) higher in nulliparous patients relative to multiparous patients. Instrumental deliveries resulted in more tears than non-instrumental deliveries with an odds ratio (OR) of 5.901 (95% CI: 2.443-14.525). This study also found that prolonged second-stage labor seems to be associated with an increased risk of perineal damage. HCW experience was looked at in relation to the increased incidence of EPTs, which showed that midwives had a lower incidence rate than physicians with an OR of 2.25 (95% CI: 1.169-4.366). Epidural usage has also been significantly associated with a lesser incidence of perineal tears, which indicates that using epidural could protect against the occurrence of EPTs.

CONCLUSION

In conclusion, the occurrence of perineal lacerations could be prevented during childbirth by taking preventative measures and having more precise judgments. Epidural was a protective factor in our study against the incidence of extensive perineal tearing. Furthermore, as compared to midwives, our study showed that the majority of EPTS occurred in cases of physicians (residents/consultants). Further research, proper documentation, and the development of evidence-based guidelines are needed to improve perineal care and reduce EPT incidence.

Complications 8 weeks after an obstetric second-degree perineal laceration in relation to body mass index

INTRODUCTION AND HYPOTHESIS

How body mass index (BMI) affects pelvic floor function after a second-degree perineal laceration is unknown. The hypothesis of this study is that pelvic floor dysfunction and complications after an obstetric second-degree perineal laceration are more common in women with a higher BMI 8 weeks postpartum.

METHODS

This register-based cohort study includes 10,876 primiparous women with an obstetric second-degree perineal laceration between 2014 and 2021. Data were retrieved from the Swedish Perineal Laceration Registry. Outcomes in relation to maternal BMI were urinary incontinence (UI), anal incontinence (AI) and common complications attributable to the laceration. Uni- and multivariate logistic regressions were used for comparison between normal weight (BMI < 24.9, reference), overweight (25.0-29.9) and obese (≥ 30) women.

RESULTS

Multivariate analyses showed an increased risk for UI in both overweight and obese women compared to normal-weight women 8 weeks after a second-degree perineal laceration with an adjusted odds ratio (aOR) of 1.21 (CI 1.02-1.44) and 1.27 (CI 1.13-1.58) respectively. Overweight and obese women had a decreased risk for AI (aOR 0.81, CI 0.68-0.96; aOR 0.72, CI 0.57-0.90 respectively) compared with normal-weight women. No significant differences were found in the univariate analyses over BMI strata concerning complications after perineal laceration.

CONCLUSIONS

Primiparous overweight and obese women report less AI and more UI than normal-weight women 8 weeks after a second-degree perineal laceration. No differences were found regarding complications. These findings are new and merit further study to find potential preventive factors and interventions after a second-degree perineal laceration.

Management of postpartum perineal wound complications

PURPOSE OF REVIEW

Perineal wound complications occur in up to 25% of postpartum patients. Wound complications are most common after obstetric anal sphincter injuries (OASIS) but can occur after any laceration. It is imperative that any provider caring for postpartum patients understand the best evidence-based practices to recognize and manage these complications. We present a review of the available literature on the management of postpartum perineal wound complications.

RECENT FINDINGS

There is a paucity of new publications on the management of postpartum perineal wound complications, despite an increased emphasis on postpartum recovery in women's health. The role of topical estrogen in healing of perineal wounds was investigated in a pilot study, demonstrating that granulation tissue does express estrogen receptors, and the use of estrogen increases cell proliferation. Progression of perineal wound healing by secondary intention was evaluated in an observational study. Wound healing was delayed in 30% of women, with the initial wound area, perimeter, bacterial colonization, and OASIS being associated with delayed healing.

SUMMARY

Evidence based practices on timing of follow-up, addressing wound care and analgesia, administrating antibiotics, timing secondary repair, and surgical technique all play a role in optimizing recovery and reducing morbidity in patients with postpartum perineal wound complications.

Incidence, temporal trends and risk factors of puerperal infection in Mainland China: a meta-analysis of epidemiological studies from recent decade (2010-2020)

BACKGROUND

Puerperal infection (PI) is a severe threat to maternal health. The incidence and risk of PI should be accurately quantified and conveyed for prior decision-making. This study aims to assess the quality of the published literature on the epidemiology of PI, and synthesize them to identify the temporal trends and risk factors of PI occurring in Mainland China.

METHODS

This review was registered in PROSPERO (CRD42021267399). Putting a time frame on 2010 to March 2022, we searched Cochrane library, Embase, Google Scholar, MEDLINE, Web of Science, China biology medicine, China national knowledge infrastructure and Chinese medical current contents, and performed a meta-analysis and meta-regression to pool the incidence of PI and the effects of risk factors on PI.

RESULTS

A total of 49 eligible studies with 133,938 participants from 17 provinces were included. The pooled incidence of PI was 4.95% (95%CIs, 4.46-5.43), and there was a statistical association between the incidence of PI following caesarean section and the median year of data collection. Gestational hypertension (OR = 2.14), Gestational diabetes mellitus (OR = 1.82), primipara (OR = 0.81), genital tract inflammation (OR = 2.51), anemia during pregnancy (OR = 2.28), caesarean section (OR = 2.03), episiotomy (OR = 2.64), premature rupture of membrane (OR = 2.54), prolonged labor (OR = 1.32), placenta remnant (OR = 2.59) and postpartum hemorrhage (OR = 2.43) have significant association with PI.

CONCLUSIONS

Maternal infection remains a crucial complication during puerperium in Mainland China, which showed a nationwide temporal rising following caesarean section in the past decade. The opportunity to prevent unnecessary PI exists in several simple but necessary measures and it's urgent for clinicians and policymakers to focus joint efforts on promoting the bundle of evidence-based practices.

Risk Factors for Perineal Wound Breakdown in Early Postpartum: A Retrospective Case-Control Study

We conducted a retrospective case-control study in patients presenting a perineal tear (second degree or higher) or episiotomy complicated by wound breakdown during maternity stay to identify risk factors associated with wound breakdown in early postpartum with a view to improving the quality of care. We collected ante- and intrapartum characteristics and outcomes at the postpartum visit. In all, 84 cases and 249 control subjects were included. In univariate analysis, primiparity, absence of history of vaginal delivery, a longer second phase of labour, instrumental delivery, and a higher degree of laceration emerged as risk factors for early perineal suture breakdown postpartum. Gestational diabetes, peripartum fever, streptococcus B, and suture technique did not emerge as risk factors for perineal breakdown. Multivariate analysis confirmed that instrumental delivery (OR = 2.18 [1.07; 4.41], p = 0.03) and a longer second phase of labour (OR = 1.72 [1.23; 2.42], p = 0.001) were risk factors for early perineal suture breakdown.

Factors associated with infection after operative vaginal birth-a secondary analysis of a randomized controlled trial of prophylactic antibiotics for the prevention of infection following operative vaginal birth

BACKGROUND

A recent randomized controlled trial of prophylactic antibiotics for the prevention of infection following operative vaginal birth showed that women allocated prophylactic intravenous amoxicillin and clavulanic acid had a significantly lower risk of developing confirmed or suspected infection within 6 weeks after operative vaginal birth (risk ratio [RR], 0.58; 95% confidence interval [CI], 0.49-0.69; P < .001). Some international and national guidelines have subsequently been updated to include prophylactic antibiotics after operative vaginal birth. However, the generalizability of the trial results may be limited in settings where the episiotomy rate is lower (89% of women in the trial had an episiotomy). In addition, there was a high burden of infection in the prophylactic antibiotics group despite the administration of prophylactic antibiotics. It is essential to identify modifiable risk factors for infection after operative vaginal birth, including the timing of antibiotic administration.

OBJECTIVE

This study aimed to evaluate if the effectiveness of the prophylactic antibiotic in reducing confirmed or suspected infection was independent of perineal trauma, identify risk factors for infection after operative vaginal birth, and investigate variation in efficacy with the timing of antibiotic administration.

STUDY DESIGN

This study was a secondary analysis of 3225 women with primary outcome data from the prophylactic antibiotics for the prevention of infection following operative vaginal birth randomized controlled trial. Women were divided into subgroups according to the perineal trauma experienced (episiotomy and/or perineal tear). The consistency of the prophylactic antibiotics in preventing infection across the subgroups was assessed using log-binomial regression and the likelihood ratio test. Multivariable log-binomial regression was used to investigate factors associated with infection. The multivariable risk factor model was subsequently fitted to the group of women who received amoxicillin and clavulanic acid to investigate the timing of antibiotic administration.

RESULTS

Of the 3225 women included in the secondary analysis, 2144 (66.5%) had an episiotomy alone, 726 (22.5%) had an episiotomy and a tear, 277 (8.6%) had a tear alone, and 78 (2.4%) had neither episiotomy nor tear. Among women who experienced perineal trauma, amoxicillin and clavulanic acid administration was protective against infection in all subgroups compared with placebo with no significant interaction between subgroup and trial allocation (P=.17). Moreover, 2925 women were included in the multivariable risk factor analysis. The following were associated with adjusted risk ratios of infection: episiotomy, 2.94 (95% confidence interval, 1.62-5.31); forceps, 1.37 (95% confidence interval, 1.12-1.69) compared to vacuum extraction; primiparity, 1.34 (95% confidence interval, 1.05-1.70); amoxicillin and clavulanic acid administration, 0.60 (95% confidence interval, 0.51-0.72); body mass index of 25.0 to 29.9 kg/m², 1.21 (95% confidence interval, 1.00-1.47), and body mass index of ≥30 kg/m², 1.22 (95% confidence interval, 0.98-1.52) compared to body mass index of <25 kg/m². Each 15-minute increment between birth and antibiotic administration was associated with a 3% higher risk of infection (adjusted risk ratio, 1.03; 95% confidence interval, 1.01-1.06).

CONCLUSION

Timely prophylactic antibiotics should be administered to all women after operative vaginal birth, irrespective of the type of perineal trauma. The use of episiotomy, forceps birth, primiparity, and overweight were associated with an increased risk of confirmed or suspected infection after operative vaginal birth.

The Skin Antiseptic agents at Vaginal dElivery (SAVE) trial: study protocol for a randomized controlled trial

BACKGROUND

Cleansing of the vulva and perineum is recommended during preparation for vaginal delivery, and special attention is paid to cleansing before episiotomy because episiotomy is known to increase the risk of perineal wound infection and/or dehiscence. However, the optimal method of perineal cleansing has not been established, including the choice of antiseptic agent. To address this issue, we designed a randomized controlled trial to examine whether skin preparation with chlorhexidine-alcohol is superior to povidone-iodine for the prevention of perineal wound infection after vaginal delivery.

METHODS

In this multicenter randomized controlled trial, term pregnant women who plan to deliver vaginally after episiotomy will be enrolled. The participants will be randomly assigned to use antiseptic agents for perineal cleansing (povidone-iodine or chlorhexidine-alcohol). The primary outcome is superficial or deep perineal wound infection within 30 days after vaginal delivery. The secondary outcomes are the length of hospital stay, physician office visits, or hospital readmission for infection-related complications, endometritis, skin irritations, and allergic reactions.

DISCUSSION

This study will be the first randomized controlled trial aiming to determine the optimal antiseptic agent for the prevention of perineal wound infections after vaginal delivery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05122169. First submitted date on 8 November 2021. First posted date on 16 November 2021.

Body mass index and complications after obstetric anal sphincter injury, 8 weeks postpartum

INTRODUCTION AND HYPOTHESIS

The impact of body mass index (BMI) on pelvic floor recovery after an obstetric anal sphincter injury (OASI) is unclear. The aim of this study was to evaluate the hypothesis that urinary incontinence (UI) and anal incontinence (AI) are more common in overweight and obese women than in normal-weight women 8 weeks postpartum in women with OASI.

METHODS

A population-based cohort study including 6,595 primiparous women, with an OASI, delivered between 2014 and 2019. Exposure and questionnaire data were retrieved from the Swedish Perineal Laceration Registry. Uni- and multivariate analyses were used to compare normal-weight (BMI ≤24.9, reference), overweight (25.0-29.9), and obese (≥ 30) women with regard to UI and AI at 8 weeks post-partum.

RESULTS

Multivariate analyses showed an increased risk for urinary incontinence (OR 1.54, 95% CI 1.27-1.87) among overweight women as well as among obese women (OR 1.72, 95% CI 1.32-2.24). In contrast to our hypothesis, both overweight women (OR 0.68, 95% CI 0.56-0.83) and obese women (OR 0.65, 95% CI 0.49-0.87) were at a decreased risk for any gas and/or faecal incontinence after adjustment to possible confounding factors. The absolute rate of AI was 40.1% among normal-weight women, 34.2% among overweight women, and 29.1% in the obese group.

CONCLUSIONS

Urinary incontinence is more common, whereas AI is less common among overweight and obese women than in primiparous women with a BMI <24.9, 8 weeks after an OASI. The new finding, that overweight women report less AI than normal-weight women, merits further study.

Use of Autologous Platelet Rich Plasma (A-PRP) for Postpartum Perineal Repair Failure: A Case Report

Perineal wound dehiscence is an uncommon but important postpartum complication. In many cases, it leads to extreme pain and urinary and defecation problems. For up to several weeks, it can interfere with the mother’s daily activity, affecting psychosexual health and body image. The best way to manage perineal wound breakdown (resuturing vs. spontaneous closure) after childbirth remains controversial. A-PRP is the autologous human plasma containing an increased platelet concentration, rich in growth factors, and mediators with hemostatic, anti-inflammatory, and antimicrobial properties. It accelerates the natural healing process. Even though A-PRP is widely used in orthopedics and dermatology, its use in gynecological injuries is limited. We describe here a case of a woman with postpartum perineal dehiscence treated with A-PRP with positive outcomes.

Düşük riskli kadınlarda enfekte epizyotomi riskini öngören bir model

Purpose: Infected episiotomy (IE) is a rare complication of vaginal delivery. However, the practical use of the risk factors involved in the development of IE is unclear. The aim of this study is to create a risk scoring model to be applied in clinical practice with the risk factors we will determine so as to predict the development of IE. Materials and Methods: All women who were delivered vaginally with mediolateral episiotomy within a 1-year period were included in this retrospective study. While 42 women (cases) with the diagnosis of IE were eligible for inclusion in the study and formed the case group, randomly selected 168 women in whom IE was not detected formed the control group. Possible risk factors for the development of IE were evaluated by multivariate regression analysis. Results: The analysis revealed 5 significant independent factors related to IE. Among these factors, 5 points were given to current smoking presence, 4 points to weight gain during pregnancy ≥11.5 kg, 3 points to postpartum neutrophil to lymphocyte ratio ≥10.4, 2 points to presence of diabetes mellitus, and 1 point to presence of hospitalization before active phase of labor. And a cut-off value of 5.5 was found to be moderately effective in predicting IE. Conclusion: Consequently, this five-variable model can predict the presence of IE with significant efficiency. In the presence of these variables, the clinician can identificate the patients at risk of IE. In this way, individualized patient risk assessment and situation-specific counseling can be made.

The incidence of wound complications following primary repair of obstetric anal sphincter injury: a systematic review and meta-analysis

OBJECTIVE

We aimed to systematically determine the incidences of wound infection and dehiscence after primary obstetric anal sphincter injury repair.

DATA SOURCES

MEDLINE, Embase, CINAHL, EmCare, the Cochrane Library, and Trip Pro databases were searched from inception to February 2021.

STUDY ELIGIBILITY CRITERIA

We included observational clinical studies reporting the incidences of wound infection and dehiscence after primary obstetric anal sphincter injury repair. Case series and reports were excluded. Conference articles and observational study abstracts were included if they contained enough information regarding study design and outcome data.

METHODS

Data were analyzed as incidence (percentage) with 95% confidence intervals. Moreover, the prediction intervals were calculated to provide a predicted range for the potential incidence of wound complications when applied to an individual study setting. Study quality and risk of bias were assessed using the relevant tool from the Joanna Briggs Institute.

RESULTS

Of 956 studies found, 39 were selected for full-text review. Moreover, 10 studies (n=4767 women) were eligible and included in the meta-analysis. All 10 studies were conducted in high-income countries (Denmark [n=1], the United Kingdom [n=3], and the United States [n=6]). The incidences of wound infection (n=4593 women) and wound dehiscence (n=3866 women) after primary obstetric anal sphincter injury repair ranged between 0.1% to 19.8% and 1.9% to 24.6%, respectively. The overall incidences were 4.4% (95% confidence interval, 0.4-8.4) for wound infection and 6.9% (95% confidence interval, 1.6-12.2) for wound dehiscence. The prediction intervals were wide and suggested that the true incidences of wound infection and dehiscence in future studies could lie between 0.0% to 11.7% and 0.0% to 16.4%, respectively. Overall, 8 studies had a high or unclear risk of bias across ≥1 assessed element. None of the studies used the same set of clinical parameters to define wound infection or dehiscence. Furthermore, microbiological confirmation with wound swabs was never used as a diagnostic measure.

CONCLUSION

This was a systematic review and meta-analysis of wound infection and dehiscence incidences after primary obstetric anal sphincter injury repair. The incidence estimates from this review will be useful for clinicians when counseling women with obstetric anal sphincter injury and when consenting them for primary surgical repair.

Antibiotic Prescribing in Connection to Childbirth: An Observational Study in Two Districts in Lao PDR

Overuse and misuse of antibiotics has frequently been reported for obstetric conditions and procedures, which may impact both the mother and the unborn baby and increase antibiotic resistance. This study aimed to investigate the antibiotic prescribing pattern in connection to childbirth in two districts in Lao PDR. It is a cross-sectional observational study. Antibiotic prescription data related to childbirth was collected via reviews of medical records in two district hospitals and five health centers in Lao PDR from September 2019 to November 2020. In total, antibiotic prescription data for 1777 women were extracted from their medical records. It was found that all women received antibiotics during in-patient care irrespective of delivery mode. When in hospital, 85.5% of the women who underwent a caesarean section got antibiotic treatment for 5 days and women who had a vaginal delivery usually had antibiotic treatment for one day or less. All the women got oral antibiotics for an additional 4–5 days upon discharge. Antibiotic prescription rate in connection to childbirth was very high in comparison with the WHO guidelines, and antibiotics were used extensively in the participating health facilities. Interventions to guide appropriate prescribing behavior in relation to childbirth are urgently needed in Lao PDR.

Healing of disrupted perineal wounds after vaginal delivery: a poorly understood condition

Perineal injury following childbirth can result in complications such as wound infection and dehiscence. The reported incidence of these complications in the literature range between 0.1-23.6% and 0.2-24.6%, respectively. However, the healing of disrupted perineal wounds is poorly understood. In addition, it is a neglected area in maternity services. In this review, the authors explore the process of wound healing in the context of infected perineal wounds following childbirth. In addition, the authors describe the management of complications including hypergranulation, perineal pain and dyspareunia.

Risk analysis of poor wound healing in forceps delivery

AIM

This study aims to explore the risk factors leading to poor wound healing after forceps delivery.

METHOD

In this retrospective study, 74 patients undergoing forceps delivery with poor wound healing were compared with contemporary randomly selected 74 patients undergoing forceps delivery but with normal wound healing.

RESULTS

Compared to the normal healing group, the poor healing group had larger birthweight (p = 0.01), longer labor length (805.9 ± 356.4 min vs. 572.9 ± 306.3 min, p < 0.001), more virginal checks (4.0 ± 1.5 vs. 3.4 ± 1.7, p = 0.029), and more contaminated amniotic fluid (p = 0.043). More patients in poor healing group suffered from postpartum fever (52.7% vs. 21.6%, p < 0.001), postpartum hemorrhage (p < 0.001), and anemia after delivery (p < 0.001). Labor length (odds ratio (OR) 1.125, 95% confidence interval [CI] = 1.033-1.226), anemia after delivery (OR 3.621, 95% CI = 2.077-6.314), postpartum fever (OR 7.100, 95% CI = 2.505-20.124), and degree of laceration (OR 3.067, 95% CI = 1.258-7.479) were the risk factors of poor healing of perineal wound after forceps delivery, while postpartum antibiotics (OR 0.303, 95% CI = 0.098-0.937) and suture removal days (OR 0.272, 95% CI = 0.133-0.556) were the protective factors.

CONCLUSION

To promote the wound healing from the forceps delivery, obstetricians may consider to control the patient's labor length and degree of laceration, increase patient's nutrition, apply prophylactic antibiotics, and prolong the suture removal days.

Risk Factors in Third and Fourth Degree Perineal Tears in Women in a Tertiary Centre: An Observational Ambispective Cohort Study

Objectives: To analyze the main risk factors associated with third and fourth degree postpartum perineal tears in women attended to in our obstetrics service. Methods: An observational, retrospective, hospital cohort study was carried out in women whose deliveries were attended to in the obstetrics service of the Hospital General Universitario Gregorio Marañón de Madrid (HGUGM), during the period from January 2010 to April 2017. Results: During the study period, a total of 33,026 patients were included in the study. For maternal variables, the associated increased risk of severe perineal tearing in nulliparous women is OR = 3.48, for induced labor OR = 1.29, and for instrumental delivery by forceps OR = 4.52 or spatulas OR = 4.35; for the obstetric variable of episiotomy, it is OR = 3.41. For the neonatal variables, the weight of the newborns has a directly proportional relationship with the risk of severe tears, and for birth weights of 3000 g (OR = 2.41), 3500 g (OR = 1.97), and 4000 g (OR = 2.17), statistically significant differences were found in each of the groups (p < 0.05). Conclusion: Primiparity, induction of labor, episiotomy, instrumental delivery with forceps or spatula, and a birth weight of 3000 g or more are significantly associated with an increased risk of third and fourth degree perineal tears.

Outcome of abdominal binder in midline abdominal wound Dehiscence in terms of pain, psychological satisfaction and need for reclosure

Objective

To assess the role of abdominal binder in patients with midline wound dehiscence after elective or emergency laparotomy in terms of pain, psychological satisfaction and need for reclosure.

Methods

It was a comparative study done at EAST Surgical Ward of Mayo Hospital, Lahore from 1^st January 2018 to 31^st December 2019. One hundred and sixty-two (162) patients were included in this study with post-operative midline abdominal wound dehiscence and after informed consent by consecutive non probability sampling technique. Patients were divided into two groups by lottery method into eighty-one patients each. Group-A included patients where abdominal binder was applied and Group-B included patients without abdominal binder. In both groups pain score, psychological satisfaction and need for reclosure was assessed and compared.

Results

Patients with abdominal binder shows significantly less pain (P value =0.000) and more psychological satisfaction (P value = 0.000) as compared to the patients where abdominal binder was not used. However, there was no difference in reducing the need for reclosure in patients who use abdominal binder (P value = 0.063).

Conclusion

Although abdominal binder helps in reducing the pain and improving the psychological satisfaction in patients with midline abdominal wound dehiscence yet it doesn't help in healing of wound and reclosure of the dehisced abdominal wound is needed.

Immune Regulation, Maternal Infection, Vaccination, and Pregnancy Outcome

About 12.5% of all maternal deaths in the United States are due to infectious causes. This proportion, although stable during the past three decades, represents an increase in infectious causes of mortality, as the overall mortality rate in U.S. pregnant women had increased steadily during that same period. During healthy pregnancies, a delicate immunological balance-in which a mother's immune system tolerates the semi-allogeneic fetus yet maintains immune competency against infectious agents-is achieved and maintained. This immunological paradigm, however, results in increased susceptibility to infectious diseases during pregnancy, particularly in later stages and during the early postpartum period. The inflammatory process induced by these infectious insults, as well as some noninfectious insults, occurring during pregnancy can disrupt this carefully achieved balance and, in turn, lead to a state of rampant inflammation, immune activation, and dysregulation with deleterious health outcomes for the mother and fetus. Elucidating mechanisms contributing to the disruption of this immunologic homeostasis, and its disruption by infectious pathogens, might offer opportunities for interventions to reduce maternal and fetal morbidity and mortality.

The use of non-surgical glue to repair perineal first-degree lacerations in normal birth: A non-inferiority randomised trial

BACKGROUND AND PROBLEM

Surgical glue has been indicated for uncomplicated operatory wounds; however, it has a considerable cost. Non-surgical glue, a commercially available and cheaper product, has not been studied for repairing postpartum lacerations.

AIM

To compare non-surgical glue to traditional sutures on perineal first-degree lacerations after normal birth.

METHODS

In a prospective, open-label, non-inferiority, randomised controlled trial, we selected childbearing women who were admitted for normal term births and in whom skin lacerations occurred. They were assigned to laceration repair using either non-surgical glue (ethyl 2-cyanoacrylate; Glue group) or catgut sutures (Suture group). The primary endpoint was the occurrence of dehiscence >3mm. Secondary endpoints were procedure runtime, pain score, satisfaction level, and aspects of perineal repair by the REEDA score (hyperaemia, oedema, ecchymosis, exudation, and coaptation) immediately (T0), 24-48h (T1), and 7-10 days (T2) after childbirth.

FINDINGS

We included 126 women, 63 in each group, and found a non-inferiority dehiscence rate in the Glue Group compared to the Control group (T1=1.6% vs. 1.6%, P=0.999 and P<0.001 for non-inferiority; and T2=2.2% vs. 4.3%, P=0.557). In the Glue Group, the procedure runtime was shorter, pain score was lower, and women's satisfaction was greater. No women had any allergic reaction in the study.

CONCLUSIONS

Non-surgical glue was not inferior to traditional sutures to repair postpartum first-degree lacerations. In addition, non-surgical glue was associated with less pain and greater satisfaction. Brazilian Clinical Trials Registry (www.ensaiosclinicos.gov.br/rg/RBR-5Z8MKC).

Early re-suturing of dehisced obstetric perineal wounds: A 13-year experience

OBJECTIVES

To describe post-operative outcomes following early re-suturing of obstetric perineal wound dehiscence.

STUDY DESIGN

This was a retrospective series of 72 women who underwent re- suturing of a dehisced perineal wound at a tertiary urogynaecology department during a 13-year period (December 2006 - December 2019).

RESULTS

Seventy-two women with complete perineal wound dehiscence opted for secondary re-suturing. Other accompanying symptoms included purulent discharge from the wound (22.2 %), perineal pain (23.6 %) and both purulent discharge and pain (26.4 %). The median time taken for the wound to heal completely following re-suturing was 28 days (IQR 14.0-52.0); 49.2 % had healed completely by four weeks, 63.5 % by six weeks and 76.2 % by eight weeks. The median number of out-patient follow-up appointments required was 2 (IQR 1.0-3.0). No post-operative complications were experienced in 63.6 % of women, one complication occurred in 25.8 % and two complications in 10.6 %. Complications included skin dehiscence (33.3 %), granuloma (33.3 %), scar tissue (17.6 %), perineal pain (5.9 %) and sinus formation (5.9 %). Of the women who developed two complications, four developed skin dehiscence with granulation tissue and one had skin sinus formation. One developed granulation tissue with perineal pain. All complications were managed conservatively in an outpatient setting or surgically under local anaesthetic, without further complication. There was no significant difference (p = 0.443) in complication rates between the group (n = 10) with dehisced wounds with signs of wound infection (purulent discharge or the presence of both purulent discharge and pain) pre-operatively versus the group (n = 14) without signs of infection.

CONCLUSIONS

This study demonstrates the positive outcomes of early re-suturing of perineal wound dehiscence with faster healing, reduced follow-up requirements and few major complications. It provides information to clinicians who are uncertain about the effects of early re-suturing of perineal wounds which can be used to help counsel mothers with wound dehiscence on their management options.

Still No Substantial Evidence to Use Prophylactic Antibiotic at Operative Vaginal Delivery: Systematic Review and Meta-Analysis

Background

Postpartum maternal infection is still a common problem worldwide, mainly due to obstetric risk factors. The use of prophylactic antibiotic at operative vaginal delivery (OVD), taking it as a standalone risk factor, has been controversial. The purpose of this review was to rigorously evaluate the association of OVD with postpartum infection and shed light on such highly controversial issue.

Methods

A computer-based literature search was done mainly in the databases of PUBMED, HINARI health research, and the Cochrane library. Systematic review and meta-analysis were done by including 14 articles published between 1990 and August 2019.

Results

The average absolute risk of postpartum infection at OVD from seven large cohort studies was 1%. Few studies showed a weak association of OVD with postpartum infection without being adjusted to perineal wound, but the pooled meta-analysis showed statistically significant association with non-OVD. In the included randomized trial, 97% of the study participants had perineal wound for whom repairs were performed; the risks of maternal infection and perineal wound breakdown were comparable, and maternal infections other than perineal wound infection did not show significant difference between prophylactic antibiotic and placebo groups. The majority of included studies demonstrated a strong association of postpartum infection and perineal wound dehiscence with episiotomy and perineal tear.

Conclusion

Both the relative and absolute risks of postpartum infection at OVD are extremely low unless accompanied by episiotomy and 3^rd/4^tht degree perineal tear. From previous studies, there is no substantial evidence to use prophylactic antibiotic at OVD, but episiotomy and perineal tear.

The role of fetal head circumference in the formation of obstetric anal sphincter injuries following vacuum deliveries among primiparous women

PURPOSE

To evaluate the association of sonographic fetal head circumference (HC) with obstetric anal sphincter injury (OASIS) occurrence among primiparous women who underwent vacuum-assisted delivery (VAD).

METHODS

A retrospective study of all primiparous women who delivered at term by VAD between 2011 and 2019 and underwent ultrasound with fetal biometry within 1 week prior to delivery. Women who suffered OASIS were compared to women without OASIS.

RESULTS

Overall, 74 of 3222 (2.3%) primiparous women suffered an OASIS. As compared with control, women with OASIS were younger (median 28 vs. 30 years, p = 0.001), had higher BMI (median 28.2 vs. 26.9 kg/m², p = 0.03), and had a longer second stage of labor (median 190 vs. 168 min, p = 0.01). Fetal head circumference was larger in the OASIS group (mean 334 vs. 330 mm, p = 0.03), occiput posterior fetal head position was more prevalent (12 (16%) vs. 232 (7.4%), OR [95% CI]: 2.43 (1.29-4.57), p = 0.004), and the rate of mediolateral episiotomy performed was lower (58 (78.0%) vs. 2777 (88.2%), OR [95% CI]: 0.48 (0.27-0.85), p = 0.01). Multivariate regression modeling identified higher fetal HC (aOR [95% CI] 1.03 (1.001-1.06), p = 0.04) and occiput posterior (aOR [95% CI] 2.5 (1.16-5.71), p = 0.01) as independently positively associated with OASIS. Mediolateral episiotomy and maternal age were independently negatively associated with an OASIS (aOR [95% CI] 0.39 (0.18-0.85), p = 0.01); aOR [95% CI] 0.4 (0.17-0.60), p = 0.001).

CONCLUSIONS

Sonographic large fetal HC is associated with OASIS occurrence during VAD. The only modifiable predictor of OASIS detected was mediolateral episiotomy, found to be protective against OASIS.

Risk factors for severe perineal trauma during childbirth: An updated meta-analysis

Several studies have investigated the importance of maternal, fetal factors and intrapartum characteristics in predicting severe perineal lacerations. The purpose of the present systematic review is to accumulate current evidence and provide estimated effect sizes for the various risk factors described. We reviewed Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar for published studies in the field for observational studies as well as randomized controlled trials. Two researchers independently assessed the included studies and documented outcomes. Data extraction was performed using a modified data form that was based in Cochrane`s data collection form for intervention reviews for RCTs and non-RCTs. Forty-three articles were selected for inclusion in the present systematic review. The analyzed population reached 716,031 parturient of whom 22,280 (3,1%) sustained third- and fourth-degree perineal lacerations. Several risk factors were identified. Instrumental delivery [RR 3.38 (2.21, 5.18)], midline episiotomy [RR 2.88 (1.79, 4.65)] and a persistent occiput posterior position [RR 2.73 (2.08, 3.58)] were associated with the higher risk of developing severe perineal lacerations. Mediolateral episiotomy did not increase, but was also not protective against perineal lacerations [RR 1.55 (0.95, 2.53)]. Several factors contribute to the development of severe perineal lacerations. The present meta-analysis presents accumulated data that may help physicians estimate risks and provide appropriate patient counseling.

Obstetric perineal tears, sexual function and dyspareunia among primiparous women 12 months postpartum: a prospective cohort study

OBJECTIVE

Sexuality is an important aspect of human identity and contributes significantly to the quality of life in women as well as in men. Impairment in sexual health after vaginal delivery is a major concern for many women. We aimed to examine the association between degree of perineal tear and sexual function 12 months postpartum.

DESIGN

A prospective cohort study SETTING: Four Danish hospitals between July 2015 and January 2019 PARTICIPANTS: A total of 554 primiparous women: 191 with no/labia/first-degree tears, 189 with second-degree tears and 174 with third-degree/fourth-degree tears. Baseline data were obtained 2 weeks postpartum by a questionnaire and a clinical examination. Sexual function was evaluated 12 months postpartum by an electronic questionnaire (Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12)) and a clinical examination.

PRIMARY OUTCOME MEASURES

Total PISQ-12 score and dyspareunia RESULTS: Episiotomy was performed in 54 cases and 95 women had an operative vaginal delivery. The proportion of women with dyspareunia was 25%, 38% and 53% of women with no/labia/first-degree, second-degree or third-degree/fourth-degree tears, respectively.Compared with women with no/labia/first-degree tears, women with second-degree or third-degree/fourth-degree tears had a higher risk of dyspareunia (adjusted relative risk (aRR) 2.05; 95% CI 1.51 to 2.78 and aRR 2.09; 95% CI 1.55 to 2.81, respectively). Women with third-degree/fourth-degree tears had a higher mean PISQ-12 score (12.2) than women with no/labia/first-degree tears (10.4).

CONCLUSIONS

Impairment of sexual health is common among primiparous women after vaginal delivery. At 12 months postpartum, more than half of the women with a third-degree/fourth-degree tear experienced dyspareunia. Women delivering with no/labia/first-degree tears reported the best outcomes overall. Thus, it is important to minimise the extent of perineal trauma and to counsel about sexuality during and after pregnancy.