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Okeahialam NA, Sultan AH, Thakar R. The prevention of perineal trauma during vaginal birth. Am J Obstet Gynecol 2024; 230:S991-S1004. [PMID: 37635056 DOI: 10.1016/j.ajog.2022.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/08/2022] [Accepted: 06/12/2022] [Indexed: 08/29/2023]
Abstract
Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%. The incidence of obstetrical anal sphincter injury is approximately 3%, with a significantly higher rate in primiparous than in multiparous women (6% vs 2%). Obstetrical anal sphincter injury is a significant risk factor for the development of anal incontinence, with approximately 10% of women developing symptoms within a year following vaginal birth. Obstetrical anal sphincter injuries have significant medicolegal implications and contribute greatly to healthcare costs. For example, in 2013 and 2014, the economic burden of obstetrical anal sphincter injuries in the United Kingdom ranged between £3.7 million (with assisted vaginal birth) and £9.8 million (with spontaneous vaginal birth). In the United States, complications associated with trauma to the perineum incurred costs of approximately $83 million between 2007 and 2011. It is therefore crucial to focus on improvements in clinical care to reduce this risk and minimize the development of perineal trauma, particularly obstetrical anal sphincter injuries. Identification of risk factors allows modification of obstetrical practice with the aim of reducing the rate of perineal trauma and its attendant associated morbidity. Risk factors associated with second-degree perineal trauma include increased fetal birthweight, operative vaginal birth, prolonged second stage of labor, maternal birth position, and advanced maternal age. With obstetrical anal sphincter injury, risk factors include induction of labor, augmentation of labor, epidural, increased fetal birthweight, fetal malposition (occiput posterior), midline episiotomy, operative vaginal birth, Asian ethnicity, and primiparity. Obstetrical practice can be modified both antenatally and intrapartum. The evidence suggests that in the antenatal period, perineal massage can be commenced in the third trimester of pregnancy to increase muscle elasticity and allow stretching of the perineum during birth, thereby reducing the risk of tearing or need for episiotomy. With regard to the intrapartum period, there is a growing body of evidence from the United Kingdom, Norway, and Denmark suggesting that the implementation of quality improvement initiatives including the training of clinicians in manual perineal protection and mediolateral episiotomy can reduce the incidence of obstetrical anal sphincter injury. With episiotomy, the International Federation of Gynecology and Obstetrics recommends restrictive rather than routine use of episiotomy. This is particularly the case with unassisted vaginal births. However, there is a role for episiotomy, specifically mediolateral or lateral, with assisted vaginal births. This is specifically the case with nulliparous vacuum and forceps births, given that the use of mediolateral or lateral episiotomy has been shown to significantly reduce the incidence of obstetrical anal sphincter injury in these groups by 43% and 68%, respectively. However, the complications associated with episiotomy including perineal pain, dyspareunia, and sexual dysfunction should be acknowledged. Despite considerable research, interventions for reducing the risk of perineal trauma remain a subject of controversy. In this review article, we present the available data on the prevention of perineal trauma by describing the risk factors associated with perineal trauma and interventions that can be implemented to prevent perineal trauma, in particular obstetrical anal sphincter injury.
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Affiliation(s)
| | - Abdul H Sultan
- Croydon University Hospital, London, United Kingdom; St George's University of London
| | - Ranee Thakar
- Croydon University Hospital, London, United Kingdom; St George's University of London.
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Eggebø TM, Rygh AB, von Brandis P, Skjeldestad FE. Prevention of obstetric anal sphincter injuries with perineal support and lateral episiotomy: A historical cohort study. Acta Obstet Gynecol Scand 2024; 103:488-497. [PMID: 38053429 PMCID: PMC10867358 DOI: 10.1111/aogs.14742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 12/07/2023]
Abstract
INTRODUCTION There are many risk factors for obstetric anal sphincter injury (OASIS) and the interaction between these risk factors is complex and understudied. The many observational studies that have shown a reduction of OASIS rates after implementation of perineal support have short follow-up time. We aimed to study the effect of integration of active perineal support and lateral episiotomy on OASIS rates over a 15-year period and to study interactions between risk factors known before delivery. MATERIAL AND METHODS We performed a historical cohort study over the periods 1999-2006 and 2007-2021 at Stavanger University Hospital, Norway. The main outcome was OASIS rates. Women without a previous cesarean section and a live singleton fetus in cephalic presentation at term were eligible. The department implemented in 2007 the Finnish concept of active perineal protection, which includes support of perineum, control of fetal expulsion, good communication with the mother and observation of perineal stretching. The practice of mediolateral episiotomy was replaced with lateral episiotomy when indicated. We analyzed the OASIS rates in groups with and without episiotomy stratified for delivery mode, fetal position at delivery and for parity, and adjusted for possible confounders (maternal age, gestational age, oxytocin augmentation and epidural analgesia). RESULTS We observed a long-lasting reduction in OASIS rates from 4.9% to 1.9% and an increase in episiotomy rates from 14.4% to 21.8%. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with instrumental vaginal deliveries and occiput anterior (OA) position; 3.4% vs 10.1% (OR 0.31; 95% CI: 0.24-0.40) and 6.1 vs 13.9% (OR 0.40; 95% CI: 0.19-0.82) in women with occiput posterior (OP) position. Lateral episiotomy was also associated with lower OASIS rates in nulliparous women with spontaneous deliveries and OA position; 2.1% vs 3.2% (OR 0.62; 95% CI: 0.49-0.80). The possible confounders had little confounding effects on the risk of OASIS in groups with and without episiotomy. CONCLUSIONS We observed a long-lasting reduction in OASIS rates after implementation of preventive procedures. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with an instrumental delivery. Special attention should be paid to deliveries with persistent OP position.
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Affiliation(s)
- Torbjørn M. Eggebø
- Department of Clinical and Molecular MedicineNorwegian University of Science and TechnologyTrondheimNorway
- Department of Obstetrics and GynecologyStavanger University HospitalStavangerNorway
| | - Astrid Betten Rygh
- Department of Obstetrics and GynecologyStavanger University HospitalStavangerNorway
| | - Phillip von Brandis
- Department of Obstetrics and GynecologyStavanger University HospitalStavangerNorway
| | - Finn Egil Skjeldestad
- Research Group Epidemiology of Chronic Diseases, Institute of Community MedicineUiT the Arctic University of NorwayTromsøNorway
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DeLancey JOL, Masteling M, Pipitone F, LaCross J, Mastrovito S, Ashton-Miller JA. Pelvic floor injury during vaginal birth is life-altering and preventable: what can we do about it? Am J Obstet Gynecol 2024; 230:279-294.e2. [PMID: 38168908 DOI: 10.1016/j.ajog.2023.11.1253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/20/2023] [Accepted: 11/20/2023] [Indexed: 01/05/2024]
Abstract
Pelvic floor disorders after childbirth have distressing lifelong consequences for women, requiring more than 300,000 women to have surgery annually. This represents approximately 10% of the 3 million women who give birth vaginally each year. Vaginal birth is the largest modifiable risk factor for prolapse, the pelvic floor disorder most strongly associated with birth, and is an important contributor to stress incontinence. These disorders require 10 times as many operations as anal sphincter injuries. Imaging shows that injuries of the levator ani muscle, perineal body, and membrane occur in up to 19% of primiparous women. During birth, the levator muscle and birth canal tissues must stretch to more than 3 times their original length; it is this overstretching that is responsible for the muscle tear visible on imaging rather than compression or neuropathy. The injury is present in 55% of women with prolapse later in life, with an odds ratio of 7.3, compared with women with normal support. In addition, levator damage can affect other aspects of hiatal closure, such as the perineal body and membrane. These injuries are associated with an enlarged urogenital hiatus, now known as antedate prolapse, and with prolapse surgery failure. Risk factors for levator injury are multifactorial and include forceps delivery, occiput posterior birth, older maternal age, long second stage of labor, and birthweight of >4000 g. Delivery with a vacuum device is associated with reduced levator damage. Other steps that might logically reduce injuries include manual rotation from occiput posterior to occiput anterior, slow gradual delivery, perineal massage or compresses, and early induction of labor, but these require study to document protection. In addition, teaching women to avoid pushing against a contracted levator muscle would likely decrease injury risk by decreasing tension on the vulnerable muscle origin. Providing care for women who have experienced difficult deliveries can be enhanced with early recognition, physical therapy, and attention to recovery. It is only right that women be made aware of these risks during pregnancy. Educating women on the long-term pelvic floor sequelae of childbirth should be performed antenatally so that they can be empowered to make informed decisions about management decisions during labor.
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Affiliation(s)
- John O L DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI.
| | - Mariana Masteling
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI
| | - Fernanda Pipitone
- Faculty of Medicine, Hospital das Clinicas of the University of São Paulo, São Paulo, Brazil
| | - Jennifer LaCross
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Sara Mastrovito
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - James A Ashton-Miller
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
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Simmelink R, Moll E, Verhoeven C. The influence of the attending midwife on the occurrence of episiotomy: A retrospective cohort study. Midwifery 2023; 125:103773. [PMID: 37453396 DOI: 10.1016/j.midw.2023.103773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 05/23/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Episiotomy at the time of vaginal birth can result in short- and long-term complications for women. Therefore, it is important to study factors that influence the occurrence of episiotomy. AIM To examine to what extent the individual factors of clinical midwives in the same working conditions contribute to variations in episiotomy. METHODS A retrospective cohort study was performed at a secondary care hospital in Amsterdam, the Netherlands, using data from women who were assisted by a clinical midwife during birth in 2016. The clinical midwives filled out a questionnaire to determine individual factors. The predictive value of the individual factors of the clinical midwives was examined in a multiple logistic regression model on episiotomy. RESULTS A total of 1302 births attended by 27 midwives were included. The mean episiotomy rate was 12.7%, with a range from 3.2% to 30.8% among midwives (p = 0.001). When stratified for parity, within the primipara group there was a significant variation in episiotomy among midwives with a range from 7.9% to 47.8% (p = 0.006). No significant variation was found in the occurrence of third/fourth degree tears or intact perineum. There was a significant difference in episiotomy for maternal indication among midwives (p = 0.041). Predictors for an episiotomy were number of years since graduation and place of bachelor education of the clinical midwife. CONCLUSION This study shows that individual factors of clinical midwives influence the rate of episiotomy. Predictors for an episiotomy were the number of years since graduation and place of bachelor education. This shows that continuous training of clinical midwives could contribute to reducing the number of unnecessary episiotomies. Since suspected fetal distress is the only evidence based indication to perform an episiotomy, there is room for improvement given the variation in the number of episiotomies performed for maternal indication.
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Affiliation(s)
- Renate Simmelink
- Amsterdam UMC location Vrije Universiteit Amsterdam, Midwifery Science, De Boelelaan 1117, Amsterdam, the Netherlands; Department of Obstetrics and Gynaecology, OLVG-West Hospital, Jan Tooropstraat 164, Amsterdam, the Netherlands.
| | - Etelka Moll
- Department of Obstetrics and Gynaecology, OLVG-West Hospital, Jan Tooropstraat 164, Amsterdam, the Netherlands
| | - Corine Verhoeven
- Amsterdam UMC location Vrije Universiteit Amsterdam, Midwifery Science, De Boelelaan 1117, Amsterdam, the Netherlands; Division of Midwifery, School of Health Sciences, University of Nottingham, Nottingham NG7 2RD, United Kingdom; Department of Obstetrics and Gynaecology, Maxima Medical Centre, De Run 4600, Veldhoven, the Netherlands
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Lucena da Silva M, Andressa Bastos Primo de Sousa Santos T, Wane Carvalho Leite L, Emanoel Chaves da Silva C, Oliveira do Nascimento A, Teixeira Alves A, Driusso P, da Costa Cunha K. The effectiveness of interventions in the prevention of perineal trauma in parturients: A systematic review with meta-analysis. Eur J Obstet Gynecol Reprod Biol 2023; 283:100-111. [PMID: 36827751 DOI: 10.1016/j.ejogrb.2023.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/07/2023] [Accepted: 02/11/2023] [Indexed: 02/19/2023]
Abstract
AIM To investigate the effectiveness of interventions to prevent the occurrence of perineal trauma in parturients. METHODS A bibliographic search was carried out in Cochrane Library, MEDLINE via PUBMED, LILACS via Virtual Health Library (VHL), Embase, Scopus, CINAHL, Scielo, Web of Science, and PEDro databases. Randomized clinical trials evaluating the effects of any intervention to prevent perineal trauma during pregnancy and/or childbirth were included. There were no temporal or language restrictions. The risk of bias assessment was performed using the Revised Cochrane Risk-of-bias Tool for Randomized Trials. RESULTS Fifty studies, with a total of 17,221 participants, were included in this meta-analysis. No intervention during childbirth was effective for the prevention of perineal trauma (RR = 1.07, 95% CI [0.98.1.18], p < 0.01, I2 = 83%) when compared to no intervention. However, a lower risk of perineal laceration was verified with techniques performed during pregnancy, when compared to no intervention (RR = 0.81, 95% CI [0.71, 0.93], p = 0.05, I2 = 47%). Among them, highlight the effects of perineal massage in preventing lacerations (RR = 0.69, 95% CI [0.54, 0.87], p < 0.01) when compared to no intervention. CONCLUSIONS The techniques performed during pregnancy, especially perineal massage, are associated with a lower risk of perineal laceration.
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Affiliation(s)
- Marianne Lucena da Silva
- Universidade Federal de Jataí, UFJ - Campus Riachuelo, Rua Riachuelo n° 1530 - Setor - Samuel Grahan, Jataí - GO, 75804-020, Jataí, Goiás, Brazil
| | | | - Lindely Wane Carvalho Leite
- Universidade do Estado do Pará, Avenida Hiléia, s/n° - Agrópolis do Incra - Bairro Amapá CEP: 68502-100, Marabá, Pará, Brazil
| | - Carlos Emanoel Chaves da Silva
- Universidade do Estado do Pará, Avenida Hiléia, s/n° - Agrópolis do Incra - Bairro Amapá CEP: 68502-100, Marabá, Pará, Brazil
| | - Alef Oliveira do Nascimento
- Universidade do Estado do Pará, Avenida Hiléia, s/n° - Agrópolis do Incra - Bairro Amapá CEP: 68502-100, Marabá, Pará, Brazil
| | - Aline Teixeira Alves
- Universidade de Brasília, Universidade de Brasília, Faculdade de Ceilândia, Campus Universitário - Centro Metropolitano, Ceilândia Sul, Brasília-DF. CEP: 72220-275, Brazil.
| | - Patrícia Driusso
- Universidade Federal de São Carlos, Rodovia Washington Luís, km 235 - SP-310. São Carlos, CEP 13565-905, São Paulo, Brazil
| | - Katiane da Costa Cunha
- Universidade do Estado do Pará, Avenida Hiléia, s/n° - Agrópolis do Incra - Bairro Amapá CEP: 68502-100, Marabá, Pará, Brazil
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Kropshofer S, Aigmüller T, Beilecke K, Frudinger A, Krögler-Halpern K, Hanzal E, Helmer H, Hölbfer S, Huemer H, Van MK, Kronberger I, Kuhn A, Pfeifer J, Reisenauer C, Tamussino K, Umek W, Kölle D, Abou-Dakn M, Gabriel B, Schwandner O, Pristauz-Telsnigg G, Welskop P, Bader W. Management of Third and Fourth-Degree Perineal Tears After Vaginal Birth. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015/079, December
2020). Geburtshilfe Frauenheilkd 2022; 83:165-183. [PMID: 37151735 PMCID: PMC10155200 DOI: 10.1055/a-1933-2647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 08/23/2022] [Indexed: 12/12/2022] Open
Abstract
Abstract
Purpose This guideline provides recommendations for the diagnosis, treatment and follow-up care of 3rd and 4th degree perineal tears which occur during vaginal birth. The aim is to
improve the management of 3rd and 4th degree perineal tears and reduce the immediate and long-term damage. The guideline is intended for midwives, obstetricians and physicians involved in
caring for high-grade perineal tears.
Methods A selective search of the literature was carried out. Consensus about the recommendations and statements was achieved as part of a structured process during a consensus
conference with neutral moderation.
Recommendations After every vaginal birth, a careful inspection and/or palpation by the obstetrician and/or the midwife must be carried out to exclude a 3rd or 4th degree perineal
tear. Vaginal and anorectal palpation is essential to assess the extent of birth trauma. The surgical team must also include a specialist physician with the appropriate expertise (preferably
an obstetrician or a gynecologist or a specialist for coloproctology) who must be on call. In exceptional cases, treatment may also be delayed for up to 12 hours postpartum to ensure that a
specialist is available to treat the individual layers affected by trauma. As neither the end-to-end technique nor the overlapping technique have been found to offer better results for the
management of tears of the external anal sphincter, the surgeon must use the method with which he/she is most familiar. Creation of a bowel stoma during primary management of a perineal tear
is not indicated. Daily cleaning of the area under running water is recommended, particularly after bowel movements. Cleaning may be carried out either by rinsing or alternate cold and warm
water douches. Therapy should also include the postoperative use of laxatives over a period of at least 2 weeks. The patient must be informed about the impact of the injury on subsequent
births as well as the possibility of anal incontinence.
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Affiliation(s)
- Stephan Kropshofer
- Frauenheilkunde und Geburtshilfe, Tirol Kliniken GmbH, Innsbruck, Austria
| | | | - Kathrin Beilecke
- Klinik für Urogynäkologie, Alexianer Sankt Hedwig Kliniken Berlin GmbH, Berlin, Germany
| | - Andrea Frudinger
- Department of Gynecology, Medical University of Graz, Graz, Austria
| | | | - Engelbert Hanzal
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Hanns Helmer
- Department of Obstetrics and Maternal-fetal Medicine, Medical University of Vienna, Vienna, Austria
| | | | | | | | | | - Annette Kuhn
- Urogynaecology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Johann Pfeifer
- Department of Surgery, Medical University of Graz, Graz, Austria
| | | | - Karl Tamussino
- Department of Gynecology, Medical University of Graz, Graz, Austria
| | - Wolfgang Umek
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Dieter Kölle
- Abteilung Gynäkologie, Sanatorium Hera, Vienna, Austria
| | - Michael Abou-Dakn
- Klinik für Gynäkologie, St Joseph Krankenhaus Berlin-Tempelhof, Berlin, Germany
| | - Boris Gabriel
- Klinik für Gynäkologie und Geburtshilfe, Josefs Hospital Wiesbaden, Wiesbaden, Germany
| | | | - Gunda Pristauz-Telsnigg
- Abteilung Frauenheilkunde und Geburtshilfe, Landeskrankenhaus Feldbach Fürstenfeld, Feldbach, Austria
| | - Petra Welskop
- Österreichisches Hebammengremium, Innsbruck, Austria
| | - Werner Bader
- Gynäkologie und Geburtshilfe, Klinikum Bielefeld, Bielefeld, Germany
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Erickson E, Tabari K, Bovbjerg M, Cheyney M. Patterns in Second Stage Labor Care Practices Associated With Genital Tract Injury and Postpartum Hemorrhage During Physiologic Birth: A Latent Mixture Model Analysis. INTERNATIONAL JOURNAL OF CHILDBIRTH 2022. [DOI: 10.1891/ijc-2021-0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTIONGenital tract injury during childbirth contributes to short and long-term problems, including postpartum hemorrhage, incontinence, and pelvic organ prolapse. The purpose of this study was to examine which sets of second stage management techniques employed by midwives attending births in the community setting are associated with genital tract injury and subsequent postpartum hemorrhage.METHODSData from primiparous individuals within the Midwives Alliance of North America (MANA) Stats 2.0 (2004–2009) database were used for this analysis. Latent mixture modeling identified classes (groups) within the sample that are most similar based on 11 different characteristics of second stage management as noted by midwives in their birth notes, including hands-on management techniques during birth, maternal positioning at birth, and water birth.RESULTSThree classes of second stage management techniques best fit this complex dataset. The patterns of techniques used by midwives were only marginally associated with better or worse genital tract outcomes independent of other factors. Two covariables, however, advanced maternal age (OR1.60, 95% CI 1.09–2.34) and births with low fetal heart rate during second stage (OR2.82, 95% CI 1.93–4.10)—were associated with severe genital tract injury. Postpartum hemorrhage was more likely for the two classes where midwives used more hands-on management during second stage, even when considering presence of genital tract injury (OR1.33, 95% CI 1.09–1.63). This study highlights the complex second stage circumstances that interact with management techniques, which together shape or contribute to both genital tissue and hemorrhage outcomes.
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Burns E, Feeley C, Hall PJ, Vanderlaan J. Systematic review and meta-analysis to examine intrapartum interventions, and maternal and neonatal outcomes following immersion in water during labour and waterbirth. BMJ Open 2022; 12:e056517. [PMID: 35790327 PMCID: PMC9315919 DOI: 10.1136/bmjopen-2021-056517] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Water immersion during labour using a birth pool to achieve relaxation and pain relief during the first and possibly part of the second stage of labour is an increasingly popular care option in several countries. It is used particularly by healthy women who experience a straightforward pregnancy, labour spontaneously at term gestation and plan to give birth in a midwifery led care setting. More women are also choosing to give birth in water. There is debate about the safety of intrapartum water immersion, particularly waterbirth. We synthesised the evidence that compared the effect of water immersion during labour or waterbirth on intrapartum interventions and outcomes to standard care with no water immersion. A secondary objective was to synthesise data relating to clinical care practices and birth settings that women experience who immerse in water and women who do not. DESIGN Systematic review and meta-analysis. DATA SOURCES A search was conducted using CINAHL, Medline, Embase, BioMed Central and PsycINFO during March 2020 and was replicated in May 2021. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Primary quantitative studies published in 2000 or later, examining maternal or neonatal interventions and outcomes using the birthing pool for labour and/or birth. DATA EXTRACTION AND SYNTHESIS Full-text screening was undertaken independently against inclusion/exclusion criteria in two pairs. Risk of bias assessment included review of seven domains based on the Robbins-I Risk of Bias Tool. All outcomes were summarised using an OR and 95% CI. All calculations were conducted in Comprehensive Meta-Analysis V.3, using the inverse variance method. Results of individual studies were converted to log OR and SE for synthesis. Fixed effects models were used when I2 was less than 50%, otherwise random effects models were used. The fail-safe N estimates were calculated to determine the number of studies necessary to change the estimates. Begg's test and Egger's regression risk assessed risk of bias across studies. Trim-and-fill analysis was used to estimate the magnitude of effect of the bias. Meta-regression was completed when at least 10 studies provided data for an outcome. RESULTS We included 36 studies in the review, (N=157 546 participants). Thirty-one studies were conducted in an obstetric unit setting (n=70 393), four studies were conducted in midwife led settings (n=61 385) and one study was a mixed setting (OU and homebirth) (n=25 768). Midwife led settings included planned home and freestanding midwifery unit (k=1), alongside midwifery units (k=1), planned homebirth (k=1), a freestanding midwifery unit and an alongside midwifery unit (k=1) and an alongside midwifery unit (k=1). For water immersion, 25 studies involved women who planned to have/had a waterbirth (n=151 742), seven involved water immersion for labour only (1901), three studies reported on water immersion during labour and waterbirth (n=3688) and one study was unclear about the timing of water immersion (n=215).Water immersion significantly reduced use of epidural (k=7, n=10 993; OR 0.17 95% CI 0.05 to 0.56), injected opioids (k=8, n=27 391; OR 0.22 95% CI 0.13 to 0.38), episiotomy (k=15, n=36 558; OR 0.16; 95% CI 0.10 to 0.27), maternal pain (k=8, n=1200; OR 0.24 95% CI 0.12 to 0.51) and postpartum haemorrhage (k=15, n=63 891; OR 0.69 95% CI 0.51 to 0.95). There was an increase in maternal satisfaction (k=6, n=4144; OR 1.95 95% CI 1.28 to 2.96) and odds of an intact perineum (k=17, n=59 070; OR 1.48; 95% CI 1.21 to 1.79) with water immersion. Waterbirth was associated with increased odds of cord avulsion (OR 1.94 95% CI 1.30 to 2.88), although the absolute risk remained low (4.3 per 1000 vs 1.3 per 1000). There were no differences in any other identified neonatal outcomes. CONCLUSIONS This review endorses previous reviews showing clear benefits resulting from intrapartum water immersion for healthy women and their newborns. While most included studies were conducted in obstetric units, to enable the identification of best practice regarding water immersion, future birthing pool research should integrate factors that are known to influence intrapartum interventions and outcomes. These include maternal parity, the care model, care practices and birth setting. PROSPERO REGISTRATION NUMBER CRD42019147001.
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Affiliation(s)
- Ethel Burns
- Faculty of Health and Life Sciences, Oxford Brookes University Faculty of Health and Life Sciences, Oxford, UK
| | - Claire Feeley
- Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
| | - Priscilla J Hall
- VA School of Nursing Academic Partnership, Emory University, Atlanta, Georgia, USA
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Karaca SY, Adıyeke M, İleri A, Vural T, Şenkaya AR, İleri H, Özeren M. Obstetric Perineal Tears in Pregnant Adolescents and the Influencing Factors. J Pediatr Adolesc Gynecol 2022; 35:323-328. [PMID: 34748916 DOI: 10.1016/j.jpag.2021.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 10/02/2021] [Accepted: 10/25/2021] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE The incidence and risk factors of obstetric perineal tear occurrence in vaginal delivery of adolescent pregnant patients are not well established. We aimed to describe the incidence of obstetric perineal tears in adolescents and the maternal obstetric risk factors associated with this situation. DESIGN Retrospective cohort study SETTING: Department of Obstetrics and Gynecology, Tepecik Education and Research Hospital, Izmir, Turkey PARTICIPANTS: Adolescent pregnant patients (≤19 years) who delivered vaginally in our institution between January 2014 and January 2021 INTERVENTIONS AND MAIN OUTCOME MEASURES: The main outcome measures were the incidence of perineal tears, the degree of perineal tears, and the risk factors associated with severe perineal tears in adolescents. Severe perineal tears include third- and fourth-degree lacerations. A third-degree tear is defined as partial or complete disruption of the anal sphincter muscles, and a fourth-degree tear is defined as lacerations involving the rectal mucosa. RESULTS A total of 3441 adolescents who had a vaginal delivery were included in the study. The rate of severe perineal tear was 5.8% (200/3441). Risk factors associated with obstetric laceration in adolescents in multivariate analysis were nulliparity (OR = 1.72; 95% CI, 1.14-2.41; P = 0.007), high birth weight (OR = 4.1; 95% CI, 2.71-6.21; P < 0.001), and labor induction (OR = 1.36; 95% CI, 1.01-1.85; P = 0.02). Spontaneous onset of labor and previous delivery reduced the risk of severe perineal tear in adolescent pregnant patients (respectively, OR = 0.68; 95% CI, 0.51-0.94; P = 0.02 and OR = 0.51; 95% CI, 0.33-0.79; P = 0.007). CONCLUSIONS In adolescents, the risk of severe perineal tear was associated with nulliparity, birth weight, and labor induction. The only possible modifiable risk factor was labor induction.
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Affiliation(s)
- Suna Yıldırım Karaca
- Health Sciences University Tepecik Education and Research Hospital, Department of Obstetrics and Gynaecology, Izmir, Turkey; Ege University, Institute of Health Sciences, Department of Stem Cell, Izmir, Turkey
| | - Mehmet Adıyeke
- Health Sciences University Tepecik Education and Research Hospital, Department of Obstetrics and Gynaecology, Izmir, Turkey
| | - Alper İleri
- Health Sciences University Tepecik Education and Research Hospital, Department of Obstetrics and Gynaecology, Izmir, Turkey.
| | - Tayfun Vural
- Health Sciences University Tepecik Education and Research Hospital, Department of Obstetrics and Gynaecology, Izmir, Turkey
| | - Ayşe Rabia Şenkaya
- Health Sciences University Tepecik Education and Research Hospital, Department of Obstetrics and Gynaecology, Izmir, Turkey
| | - Hande İleri
- Alsancak State Hospital, Department of Family Medicine, İzmir, Turkey
| | - Mehmet Özeren
- Ege University, Institute of Health Sciences, Department of Stem Cell, Izmir, Turkey
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10
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Hübner M, Rothe C, Plappert C, Baeßler K. Aspects of Pelvic Floor Protection in Spontaneous Delivery - a Review. Geburtshilfe Frauenheilkd 2022; 82:400-409. [PMID: 35392067 PMCID: PMC8983111 DOI: 10.1055/a-1515-2622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/17/2021] [Indexed: 11/17/2022] Open
Abstract
The necessity of increasingly addressing aspects of pelvic floor protection, i.e., prevention of the most frequent female pelvic floor disorders, such as urinary incontinence, faecal incontinence and pelvic organ prolapse, is the result of the steadily improving understanding of the association of pregnancy and delivery with the prevalence of these disorders. About a quarter of all women experience one or more such symptoms during their life. Apart from age and weight, pregnancies and births play an important part. While initial discussion of pelvic floor protection often focused very rapidly on the mode of delivery and elective caesarean section as a possible protective intervention, it has become apparent in the last few decades how varied and wide-ranging the options are that can be used to protect against pelvic floor disorders. The mode of delivery as such is "only" one element among numerous other considerations and has diminished markedly in importance. Interprofessionality and interdisciplinarity undoubtedly represent an important development as resulting recommendations must always be incorporated in an overall context that considers mother and child at the same time. Considering the pelvic floor only certainly does not make sense. This review article will analyze in greater detail important pre-, intra- and postpartum aspects that in their entirety can provide insight into the various aspects of pelvic floor protection. The authors regard the following article as an additional basis for discussion on achieving a sustained reduction in the incidence and prevalence of female pelvic floor disorders.
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Affiliation(s)
- Markus Hübner
- Klinik für Frauenheilkunde, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Germany
- Medizinische Fakultät der Universität Tübingen, Tübingen, Germany
| | | | - Claudia Plappert
- Institut für Gesundheitswissenschaften, Abt. Hebammenwissenschaft, Universität Tübingen, Tübingen, Germany
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11
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Ulfsdottir H, Saltvedt S, Edqvist M, Georgsson S. Management of the active second stage of labor in waterbirths compared with conventional births – a prospective cohort study. Midwifery 2022; 107:103283. [DOI: 10.1016/j.midw.2022.103283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 01/11/2022] [Accepted: 02/06/2022] [Indexed: 11/28/2022]
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12
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Which elements were significant in reducing obstetric anal sphincter injury? A prospective follow-up study. BMC Pregnancy Childbirth 2021; 21:781. [PMID: 34794417 PMCID: PMC8600779 DOI: 10.1186/s12884-021-04260-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 11/09/2021] [Indexed: 11/14/2022] Open
Abstract
Background To examine which elements of an obstetric anal sphincter injury (OASI) care bundle were protective for OASI. Several interventional trials showed that application of a care bundle involving a hands-on approach to perineal protection may reduce the risk of OASI. Previously, we found that only the element “hand on the fetal head” in itself was protective, although the risk of a type 2 error was calculated to be 50%. Methods A prospective follow-up study in an obstetric department in Denmark with 3200 deliveries per year. We included a cohort of 10,383 women giving birth vaginally from gestational week 22 + 0 from 2016 through 2019. We documented on a person-level the five elements of the care bundle together with maternal and obstetrical characteristics. The elements were 1) communication, 2) visible perineum, 3) hand on fetal head, 4) perineal support and 5) certification. Regression analysis was used for analysis of associations. The primary outcome measure was OASI. Results The total rate of OASI in vaginally delivering women was 1.9%. The incidence was 3.2% in nulliparous women giving birth vaginally. The rate of cesarean section was 16.5% and for episiotomy 2.4%. The reduction in the incidence of OASI was sustained since 2013. Hand on the fetal head and perineal support both were protective factors for OASI. In case of a nulliparous woman with a neonate weighing 3500 g giving birth spontaneously, the relative risk (RR) for OASI was 0.50 (95% CI 0.49- 0.51) with use of hand on the fetal head together with perineal support against no use. Similarly, with a nulliparous woman giving birth to a neonate of 3500 g by vacuum extraction, the RR for OASI was 0.65 (95% CI 0.62-0.68) against no use. Conclusions Both hand on the fetal head and perineal support were associated with a reduced risk of OASI.
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13
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Pizzagalli F. [Normal childbirth: physiologic labor support and medical procedures. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynaecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF) - Maternal postures during the second stage of labour, delivery techniques and perineal protection]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2020; 48:931-943. [PMID: 33011376 DOI: 10.1016/j.gofs.2020.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess maternal postures during the second stage of labour on course of labour, mode of delivery and maternal and neonatal morbidity. To describe the different techniques of spontaneous vaginal delivery and their influence on maternal and neonatal morbidity. To describe the different perineal protection techniques. METHOD Systematic review of the literature through consultation of Medline, Cochrane databases and international recommendations. RESULTS There is no particular posture that has demonstrated its superiority (Level of Evidence (LE) 2). In case of no contraindication and permanent maternal and fetal monitoring, it is recommended to encourage women to adopt the postures they consider most comfortable during the second stage of labour (Consensus agreement). There is insufficient evidence in the literature to recommend a technique for fetal head and shoulders delivery. There is not enough data in the literature to recommend the use of Ritgen maneuver (grade B), perineal massage (gradeC) or hot compresses (Consensus agreement). The abdominal expression must be abandoned (grade B). CONCLUSION The second stage of labour is a crucial time in labour that can lead to significant maternal and neonatal morbidity. It is necessary to take the greatest possible care in the supervision and management of women, especially for the perineal protection. The influence of non-medicinal techniques on the course of the second stage of labour should be studied.
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Affiliation(s)
- F Pizzagalli
- Service de gynécologie-obstétrique, hôpital Antoine-Béclère, AP-HP, 92140 Clamart, France.
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14
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Bidwell P, Thakar R, Gurol-Urganci I, Harris JM, Silverton L, Hellyer A, Freeman R, Morris E, Novis V, Sevdalis N. Exploring clinicians' perspectives on the 'Obstetric Anal Sphincter Injury Care Bundle' national quality improvement programme: a qualitative study. BMJ Open 2020; 10:e035674. [PMID: 32907894 PMCID: PMC7482496 DOI: 10.1136/bmjopen-2019-035674] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 05/07/2020] [Accepted: 06/30/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Obstetric anal sphincter injuries (OASI) can have severe debilitating consequences to women and health systems. The OASI Care Bundle quality improvement programme was introduced in 16 maternity units across England, Scotland and Wales (January 2017 to March 2018) to address increasing OASI rates. OBJECTIVES To explore clinicians' (midwives' and obstetricians') perspectives of the OASI Care Bundle with respect to (1) acceptability, (2) feasibility, and (3) sustainability. DESIGN A qualitative exploratory study using focus groups methodology. SETTING A total of 16 focus groups were conducted in 16 maternity units in England, Scotland and Wales where the OASI Care Bundle was implemented. Focus groups took place approximately 3 months following initial implementation of the care bundle in each unit. PARTICIPANTS A total of 101 clinicians participated, with an average of six per focus group. Participants volunteered to take part and compromised of 37 obstetricians and 64 midwives (including eight students). The majority were female and the mean age was 36.5 years. RESULTS Four main themes emerged: 'Implementation strategies', 'Opportunities to use the OASI Care Bundle', 'Does current practice need to change?' and 'Perceptions of what women want'. Midwives were more likely than obstetricians to report themes alluding to 'what women want' and variations in intrapartum perineal protection techniques. Both professional groups reported similar views of other themes, in particular regarding the supporting clinical evidence. Gaps were identified in clinicians' knowledge and experience of intrapartum perineal management. CONCLUSIONS Adoption of the OASI Care Bundle was associated with a number of cognitive and interpersonal factors, such as personal values, interprofessional working and how the intervention was launched; which both facilitated and impeded adoption. The 'what women want' theme has implications for maternal autonomy and needs further exploration. Our findings can be used by similar initiatives to reduce perineal trauma both nationally and internationally. TRIAL REGISTRATION NUMBER ISCTRN 12143325; https://doi.org/10.1186/ISRCTN12143325.
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Affiliation(s)
- Posy Bidwell
- Royal College of Obstetricians and Gynaecologists, London, UK
| | | | - Ipek Gurol-Urganci
- Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - James M Harris
- Centre for Nursing, Midwifery and Allied Health Professional Research, University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | | | - Edward Morris
- Royal College of Obstetricians and Gynaecologists, London, UK
| | - Vivienne Novis
- Royal College of Obstetricians and Gynaecologists, London, UK
| | - Nick Sevdalis
- Centre for Implementation Science, King's College London, London, UK
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15
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Manresa M, Kalis V, de Tayrac R, de Leeuw JW, Laine K, Räisänen S, Ismail KM. Hands up if you do not understand hands on. Midwifery 2020; 90:102836. [PMID: 32907704 DOI: 10.1016/j.midw.2020.102836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/02/2020] [Indexed: 11/18/2022]
Affiliation(s)
- M Manresa
- Department of Maternal Fetal Medicine, Hospital Clinic of Barcelona, Spain.
| | - V Kalis
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Czech Republic; Department of Obstetrics and Gynecology, University Hospital, Pilsen, Czech Republic
| | - R de Tayrac
- Department of Obstetrics and Gynecology, Nîmes University Hospital, University of Montpellier, France
| | - J W de Leeuw
- Department of Obstetrics and Gynaecology, Ikazia Hospital, Rotterdam, the Netherlands
| | - K Laine
- Oslo University Hospital, University of Oslo, Norway
| | - S Räisänen
- Tampere University of Applied Sciences, Tampere, Finland
| | - K M Ismail
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Czech Republic; Department of Gynecology and Obstetrics, Faculty of Medicine in Pilsen, Charles University, Czech Republic
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16
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Gurol-Urganci I, Bidwell P, Sevdalis N, Silverton L, Novis V, Freeman R, Hellyer A, van der Meulen J, Thakar R. Impact of a quality improvement project to reduce the rate of obstetric anal sphincter injury: a multicentre study with a stepped-wedge design. BJOG 2020; 128:584-592. [PMID: 33426798 PMCID: PMC7818460 DOI: 10.1111/1471-0528.16396] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2020] [Indexed: 11/29/2022]
Abstract
Objective To evaluate the impact of a care bundle (antenatal information to women, manual perineal protection and mediolateral episiotomy when indicated) on obstetric anal sphincter injury (OASI) rates. Design Multicentre stepped‐wedge cluster design. Setting Sixteen maternity units located in four regions across England, Scotland and Wales. Population Women with singleton live births between October 2016 and March 2018. Methods Stepwise region by region roll‐out every 3 months starting January 2017. The four maternity units in a region started at the same time. Multi‐level logistic regression was used to estimate the impact of the care bundle, adjusting for time trend and case‐mix factors (age, ethnicity, body mass index, parity, birthweight and mode of birth). Main outcome measures Obstetric anal sphincter injury in singleton live vaginal births. Results A total of 55 060 singleton live vaginal births were included (79% spontaneous and 21% operative). Median maternal age was 30 years (interquartile range 26–34 years) and 46% of women were primiparous. The OASI rate decreased from 3.3% before to 3.0% after care bundle implementation (adjusted odds ratio 0.80, 95% CI 0.65–0.98, P = 0.03). There was no evidence that the effect of the care bundle differed according to parity (P = 0.77) or mode of birth (P = 0.31). There were no significant changes in caesarean section (P = 0.19) or episiotomy rates (P = 0.16) during the study period. Conclusions The implementation of this care bundle reduced OASI rates without affecting caesarean section rates or episiotomy use. These findings demonstrate its potential for reducing perineal trauma during childbirth. Tweetable abstract OASI Care Bundle reduced severe perineal tear rates without affecting caesarean section rates or episiotomy use. OASI Care Bundle reduced severe perineal tear rates without affecting caesarean section rates or episiotomy use.
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Affiliation(s)
- I Gurol-Urganci
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.,RCOG Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians and Gynaecologists, London, UK
| | - P Bidwell
- RCOG Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians and Gynaecologists, London, UK
| | - N Sevdalis
- Health Service & Population Research Department, Centre for Implementation Science, King's College London, London, UK
| | | | - V Novis
- RCOG Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians and Gynaecologists, London, UK
| | - R Freeman
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - A Hellyer
- RCOG Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians and Gynaecologists, London, UK.,UCLPartners, London, UK
| | - J van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - R Thakar
- Croydon Health Services NHS Trust, Croydon, UK
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17
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The effects of hands on and hands off/poised techniques on maternal outcomes: A systematic review and meta-analysis. Midwifery 2020; 87:102712. [DOI: 10.1016/j.midw.2020.102712] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 03/09/2020] [Accepted: 03/27/2020] [Indexed: 11/23/2022]
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18
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Thornton JG, Dahlen HG. The UK Obstetric Anal Sphincter Injury (OASI) Care Bundle: A critical review. Midwifery 2020; 90:102801. [PMID: 32721637 DOI: 10.1016/j.midw.2020.102801] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Jim G Thornton
- Professor of obstetrics and gynaecology, School of Clinical Sciences, University of Nottingham, Division of obstetrics and gynaecology, Maternity Department, City Hospital, NG5 1PB, Hucknall Road, Nottingham.
| | - Hannah G Dahlen
- Professor of Midwifery, Associate Dean Research and HDR, Midwifery Discipline Lead, School of Nursing and Midwifery, Building EB/LG Room 34, Parramatta South Campus, Western Sydney University, Sydney, Australia.
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19
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Thakar R, Gurol-Urganci I, Bidwell P, Sevdalis N, Silverton L, Freeman R, van der Meulen J. Obstetric Anal Sphincter Injury (OASI) Care Bundle: Response to a critical review. Midwifery 2020; 90:102802. [PMID: 32721636 DOI: 10.1016/j.midw.2020.102802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Ranee Thakar
- Croydon Health Services NHS Trust, 530 London Road, Croydon CR7 7YE, United Kingdom.
| | - Ipek Gurol-Urganci
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom; RCOG Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians and Gynaecologists, 27 Sussex Pl, Marylebone, London NW1 4RG, United Kingdom
| | - Posy Bidwell
- RCOG Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians and Gynaecologists, 27 Sussex Pl, Marylebone, London NW1 4RG, United Kingdom
| | - Nick Sevdalis
- Health Service & Population Research Department, King's College London, David Goldberg Centre, De Crespigny Park, London SE5 8AF, United Kingdom
| | - Louise Silverton
- Royal College of Midwives, 15 Mansfield St, Marylebone, London W1G 9NH, United Kingdom
| | - Robert Freeman
- University Hospitals Plymouth NHS Trust, Derriford Road, Crownhill, Devon PL6 8DH, United Kingdom
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
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20
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Kalis V, Rusavy Z, Havelkova L, Zitka T, Tolar D, Ismail KM. Metrics of perineal support (MOPS) study. BMC Pregnancy Childbirth 2020; 20:361. [PMID: 32527247 PMCID: PMC7291533 DOI: 10.1186/s12884-020-03042-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 06/01/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Manual perineal protection (MPP) is an intrapartum intervention suggested to protect perineal integrity during childbirth. Proper execution of MPP is complex and evaluation of its true contribution is difficult in the clinical setting because of the large number of obstetric variables, some of which are hardly quantifiable. In this study we aimed to gather initial data on the forces executed by the accoucheur's thumb, index and middle fingers during MPP at the time of fetal head expulsion, quantify the duration of the intervention and investigate the timely interaction of the different components of MPP. METHODS Two bespoke right-handed measurement gloves (MG), with built in sensors, were designed and produced. The MG allowed the electronic real-time measurement of applied forces during MPP and transferred this data wirelessly to an integrated computer system. Sterile gloves were worn over the MG when used at the time of birth. The study was undertaken between January and December 2019. Singleton, term pregnant women having their first vaginal birth who provided a valid written consent were enrolled into this prospective pilot study. All deliveries were undertaken by one of two obstetricians experienced in MPP. RESULTS Twenty women were enrolled. The mean duration of execution of MPP during the last contraction was 13.6 s. In 20% it lasted < 5 s. The overall mean values of the average and maximum forces of the thumb, index and middle fingers were 26.7 N; 25.5 N; 20.2 N and 34.3 N; 32.6 N; and 27.6 N respectively. The onset of fingers and thumb activity was simultaneous in 13 cases (65%), while in seven (35%) deliveries the middle finger's force activity was initiated later. CONCLUSIONS MPP during fetal head expulsion happens over a short period of time. In the majority of cases the thumb and fingers actions started simultaneously. There were differences in the duration of application and the forces executed by the fingers and thumb between the two practitioners, however this was only significant for thumb measurements. The results obtained will aid in improving further MPP modeling studies to optimize the technique.
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Affiliation(s)
- Vladimir Kalis
- Department of Gynecology and Obstetrics, University Hospital, alej Svobody 76, 304 60, Pilsen, Czech Republic.,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Zdenek Rusavy
- Department of Gynecology and Obstetrics, University Hospital, alej Svobody 76, 304 60, Pilsen, Czech Republic.,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Linda Havelkova
- New Technologies - Research Centre, University of West Bohemia, Pilsen, Czech Republic
| | - Tomas Zitka
- New Technologies - Research Centre, University of West Bohemia, Pilsen, Czech Republic
| | - David Tolar
- New Technologies - Research Centre, University of West Bohemia, Pilsen, Czech Republic
| | - Khaled M Ismail
- Department of Gynecology and Obstetrics, University Hospital, alej Svobody 76, 304 60, Pilsen, Czech Republic. .,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.
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21
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Risk Factors for Obstetric Anal Sphincter Injuries among Women Delivering at a Tertiary Hospital in Southwestern Uganda. Obstet Gynecol Int 2020; 2020:6035974. [PMID: 32508928 PMCID: PMC7244954 DOI: 10.1155/2020/6035974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/28/2020] [Indexed: 11/20/2022] Open
Abstract
Background Obstetric anal sphincter injuries (OASIS) arise from perineal trauma during vaginal delivery and are associated with poor maternal health outcomes. Most OASIS occur in unattended deliveries in resource-limited settings. However, even in facilities where deliveries are attended by skilled personnel, a number of women still get OASIS. Objectives To determine the incidence and risk factors for obstetric anal sphincter injuries among women delivering at Mbarara Regional Referral Hospital (MRRH). Methods We conducted an unmatched hospital-based case control study, with the ratio of cases to controls of 1 : 2 (80 cases and 160 controls). We defined a case as a mother who got a third- or fourth-degree perineal tear after vaginal delivery while the controls recruited were the next two mothers who delivered vaginally without a third- or fourth-degree perineal tear. A questionnaire and participants' medical records review were used to obtain sociodemographic and clinical data. We estimated the incidence of OASIS and performed univariable and multivariable logistic regression to identify the associated risk factors. Results The cumulative incidence for OASIS during the study period was 6.6%. The risk factors for OASIS were 2nd stage of labour ≥1 hour (aOR 6.07, 95%CI 1.86–19.82, p=0.003), having episiotomy performed during labour (aOR 2.57, 95%CI 1.07–6.17, p=0.035), perineum support during delivery (aOR 0.03, 95%CI 0.01–0.12, p < 0.001), and monthly income of >50,000 shillings (aOR 0.09, 95%CI 0.03–0.28, p < 0.001). Conclusions and Recommendations. The risk factors for obstetric anal sphincter injury were prolonged second stage of labour and performing episiotomies during deliveries while higher monthly income and perineum support during delivery were protective. We recommend routine support to the perineum during delivery. Care should be taken in mothers with episiotomies, as they can extend and cause OASIS.
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22
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van Bavel J, Ravelli A, Abu-Hanna A, Roovers J, Mol BW, de Leeuw JW. Risk factors for the recurrence of obstetrical anal sphincter injury and the role of a mediolateral episiotomy: an analysis of a national registry. BJOG 2020; 127:951-956. [PMID: 32285571 DOI: 10.1111/1471-0528.16263] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The assessment of risk factors, including mediolateral episiotomy (MLE), for the recurrence of obstetric anal sphincter injury (rOASI). DESIGN Population-based cohort study. SETTING Data from the nationwide database of the Dutch Perinatal Registry (Perined). POPULATION A cohort of 391 026 women at term, of whom 9943 had an OASI in their first delivery and had a second vaginal delivery of a liveborn infant in cephalic position. METHODS Possible risk factors were tested for statistical significance using univariate and multivariate logistic regression analysis. MAIN OUTCOME MEASURES Rate of rOASI. RESULTS The rate of rOASI was 5.8%. Multivariate analysis identified a birthweight of ≥4000 g (adjusted OR, aOR, 2.1, 95% CI 1.6-2.6) and a duration of second stage of ≥30 minutes (aOR 1.8, 95% CI 1.4-2.3) as statistically significant risk factors for rOASI. Mediolateral episiotomy was associated with a statistically significant lower rate of rOASI in spontaneous vaginal delivery (SVD) (aOR 0.4, 95% CI 0.3-0.5) and in operative vaginal delivery (OVD) (aOR 0.2, 95% CI 0.1-0.5). CONCLUSIONS Women with a history of OASI have a higher rate of OASI in their next delivery. Duration of the second stage of ≥30 minutes and a birthweight of ≥4000 g are significantly associated with an increased rate of rOASI. Mediolateral episiotomy is associated with a significantly lower rate of rOASI in both SVD and OVD. TWEETABLE ABSTRACT Mediolateral episiotomy is associated with a significant lower recurrence rate of OASI in women with an OASI in their first delivery.
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Affiliation(s)
- J van Bavel
- Department of Obstetrics and Gynaecology, Amphia Hospital Breda, Breda, the Netherlands
| | - Acj Ravelli
- Department of Medical Informatics, Academic Medical Centre, Amsterdam, the Netherlands
| | - A Abu-Hanna
- Department of Medical Informatics, Academic Medical Centre, Amsterdam, the Netherlands
| | - Jpwr Roovers
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, the Netherlands
| | - B W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - J W de Leeuw
- Department of Obstetrics and Gynaecology, Ikazia Hospital, Rotterdam, the Netherlands
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23
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Kleprlikova H, Kalis V, Lucovnik M, Rusavy Z, Blaganje M, Thakar R, Ismail KM. Manual perineal protection: The know‐how and the know‐why. Acta Obstet Gynecol Scand 2020; 99:445-450. [DOI: 10.1111/aogs.13781] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/19/2019] [Accepted: 11/20/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Hana Kleprlikova
- Department of Obstetrics and Gynecology Croydon University Hospital London UK
- Department of General Anthropology Faculty of Humanities Charles University Prague Czech Republic
| | - Vladimir Kalis
- Biomedical Center Faculty of Medicine in Pilsen Charles University Pilsen Czech Republic
- Department of Obstetrics and Gynecology University Hospital Pilsen Czech Republic
| | - Miha Lucovnik
- National Department of Perinatology Division of Obstetrics and Gynecology University Medical Center Ljubljana Slovenia
- Medical Faculty University of Ljubljana Ljubljana Slovenia
| | - Zdenek Rusavy
- Biomedical Center Faculty of Medicine in Pilsen Charles University Pilsen Czech Republic
- Department of Obstetrics and Gynecology University Hospital Pilsen Czech Republic
| | - Mija Blaganje
- National Department of Perinatology Division of Obstetrics and Gynecology University Medical Center Ljubljana Slovenia
- Medical Faculty University of Ljubljana Ljubljana Slovenia
| | - Ranee Thakar
- Department of Obstetrics and Gynecology Croydon University Hospital London UK
| | - Khaled M. Ismail
- Biomedical Center Faculty of Medicine in Pilsen Charles University Pilsen Czech Republic
- Department of Gynecology and Obstetrics Faculty of Medicine in Pilsen Charles University Pilsen Czech Republic
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24
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Myriknas SE, Papadakis K, Hinshaw K. Optimising non‐rotational forceps: the anterior ninety‐degree elevation forceps (ANEF) approach. ACTA ACUST UNITED AC 2020. [DOI: 10.1111/tog.12649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Stylianos E Myriknas
- Clinical Fellow in Obstetrics and Gynaecology Chelsea and Westminster Hospital NHS Foundation Trust 369 Fulham Road Chelsea, London SW10 9NH UK
| | - Konstantinos Papadakis
- Specialist Trainee in Obstetrics and Gynaecology, West of Scotland Deanery Queen Elizabeth University Hospital 1345 Govan Rd Glasgow G51 4TF UK
| | - Kim Hinshaw
- Consultant Obstetrician and Gynaecologist, Director of Research and Innovation, South Tyneside and Sunderland NHS Foundation Trust Sunderland Royal Hospital Kayll Road Sunderland SR4 7TP UK
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25
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Abstract
The second stage of labor is defined as the time from complete dilation of the cervix to delivery of the fetus. The objective of this seminar is to provide a contemporary, evidence-based approach to management of the second stage of labor. This seminar reviews background maternal and fetal characteristics that impact the duration of the second stage of labor, the recommended evidence-based management (e.g. immediate pushing, manual rotation, operative vaginal delivery), and the maternal/neonatal morbidity clinicians must consider when deciding between operative delivery and a prolonged second stage of labor.
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Affiliation(s)
- Brock E Polnaszek
- Department of Obstetrics and Gynecology, Washington University in Saint Louis School of Medicine, 901 Forest Park Avenue, Saint Louis, MO 63108, United States.
| | - Alison G Cahill
- Department of Women's Health, Division of Maternal Fetal Medicine, The University of Texas at Austin, Dell Medical School
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26
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Wilson AN, Homer CSE. Third- and fourth-degree tears: A review of the current evidence for prevention and management. Aust N Z J Obstet Gynaecol 2020; 60:175-182. [PMID: 32065386 DOI: 10.1111/ajo.13127] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 01/12/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Third- and fourth-degree tears are associated with significant pain, discomfort and impact on quality of life and intimate relationships. Australian women experience comparatively higher rates of third- and fourth-degree tears relative to countries of similar economic development. AIMS We aimed to conduct a comprehensive review of the literature, published over the past five years, to identify the best ways to prevent and manage third- and fourth-degree perineal tears in Australian maternity centres. MATERIALS AND METHODS We searched the literature using the Cochrane Database of Systematic Reviews, EMBASE, MEDLINE, Maternity and Infant Care Database and Google Scholar for articles published since 2013 using key search terms. A review of reviews was undertaken given the extensive amount of literature on this topic. RESULTS Twenty-six systematic reviews were identified. The most common risk factors reported in the literature for third- and fourth-degree tears included primiparity, mother's ethnicity, large for gestational age infants and certain interventions used in labour and birth, such as instrumental deliveries. Preventive practices with varying degrees of effectiveness and often dependant on parity included: antenatal perineal massage, different maternal birthing positions, water births, warm compresses, protection of the perineum and episiotomy for instrumental births. CONCLUSIONS Third- and fourth-degree perineal tears are associated with immediate and long-term implications for women and health systems. Evidence-based approaches can reduce the number of women who sustain a severe perineal tear and alleviate the associated disease burden for those who do.
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Affiliation(s)
- Alyce N Wilson
- Maternal and Child Health Program, Burnet Institute, Melbourne, Victoria, Australia.,Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Caroline S E Homer
- Maternal and Child Health Program, Burnet Institute, Melbourne, Victoria, Australia.,Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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27
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Kleprlikova H, Kalis V, Lucovnik M, Rusavy Z, Blaganje M, Thakar R, Ismail KM. Slowing of fetal head descent is an integral component of manual perineal protection. Acta Obstet Gynecol Scand 2020; 99:558-559. [PMID: 31891186 DOI: 10.1111/aogs.13799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 12/29/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Hana Kleprlikova
- Department of Obstetrics and Gynecology, Croydon University Hospital, London, UK.,Department of General Anthropology, Faculty of Humanities, Charles University, Prague, Czech Republic
| | - Vladimir Kalis
- Biomedical Center, Faculty of Medicine in Pilsen Charles University, Pilsen, Czech Republic.,Department of Obstetrics and Gynecology, University Hospital, Pilsen, Czech Republic
| | - Miha Lucovnik
- National Department of Perinatology, Division of Obstetrics and Gynaecology, University Medical Center, Ljubljana, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Zdenek Rusavy
- Biomedical Center, Faculty of Medicine in Pilsen Charles University, Pilsen, Czech Republic.,Department of Obstetrics and Gynecology, University Hospital, Pilsen, Czech Republic
| | - Mija Blaganje
- National Department of Perinatology, Division of Obstetrics and Gynaecology, University Medical Center, Ljubljana, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Ranee Thakar
- Department of Obstetrics and Gynecology, Croydon University Hospital, London, UK
| | - Khaled M Ismail
- Biomedical Center, Faculty of Medicine in Pilsen Charles University, Pilsen, Czech Republic.,Department of Gynecology and Obstetrics, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
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28
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Camargo JDCSD, Varela V, Ferreira FM, Chofakian CBDN, Osava RH, Araújo NM, Narchi N, Santos ME, Nené M, Grande C. Perineal outcomes and its associated variables of water births versus non-water births: a cross-sectional study. REVISTA BRASILEIRA DE SAÚDE MATERNO INFANTIL 2019. [DOI: 10.1590/1806-93042019000400003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Abstract Objectives: to describe the perineal outcomes of women who had delivered in water and out of water. Methods: a cross-sectional and quantitative study developed in a public hospital in Setúbal, Portugal. The population was of women who participated in the "Water Birth Project" in the period from 2011 to 2014, which gave birth in water and out of water. 104 women were selected according to established inclusion criteria. The groups were compared according to the following variables: demographics, obstetric information, delivery care and perineal outcomes. The data were analyzed in the Stata(r) software, with descriptive and bivariate statistics (chi-square and Fisher's test). Results: the medical records of 73 women who gave birth in water and 31 women who gave birth out of water were studied. Water deliveries were significantly associated with fewer perineal lacerations, lower rates of episiotomy, and shorter delivery time. Conclusions: the results of the study suggest that childbirth in water has a protective effect against severe third or fourth degree perineal tears, during fetal expulsion in water.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Manuela Nené
- School of Health of the Portuguese Red Cross, Portugal
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29
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ACOG Practice Bulletin No. 198: Prevention and Management of Obstetric Lacerations at Vaginal Delivery. Obstet Gynecol 2019; 132:e87-e102. [PMID: 30134424 DOI: 10.1097/aog.0000000000002841] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Lacerations are common after vaginal birth. Trauma can occur on the cervix, vagina, and vulva, including the labial, periclitoral, and periurethral regions, and the perineum. Most of these lacerations do not result in adverse functional outcomes. Severe perineal lacerations, extending into or through the anal sphincter complex, although less frequent, are more commonly associated with increased risk of pelvic floor injury, fecal and urinary incontinence, pain, and sexual dysfunction with symptoms that may persist or be present many years after giving birth. The purpose of this document is to provide evidence-based guidelines for the prevention, identification, and repair of obstetric lacerations and for episiotomy.
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30
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Jangö H, Westergaard HB, Kjærbye‐Thygesen A, Langhoff‐Roos J, Lauenborg J. Changing incidence of obstetric anal sphincter injuries—A result of formal prevention programs? Acta Obstet Gynecol Scand 2019; 98:1455-1463. [DOI: 10.1111/aogs.13672] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/27/2019] [Accepted: 05/29/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Hanna Jangö
- Department of Obstetrics and Gynecology Copenhagen University Hospital Hillerød Denmark
- Department of Obstetrics and Gynecology Copenhagen University Hospital Herlev Denmark
| | - Hanne B. Westergaard
- Department of Obstetrics and Gynecology Copenhagen University Hospital Hillerød Denmark
| | | | - Jens Langhoff‐Roos
- Department of Obstetrics Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Jeannet Lauenborg
- Department of Obstetrics and Gynecology Copenhagen University Hospital Herlev Denmark
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31
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Huang J, Zang Y, Ren LH, Li FJ, Lu H. A review and comparison of common maternal positions during the second-stage of labor. Int J Nurs Sci 2019; 6:460-467. [PMID: 31728401 PMCID: PMC6839002 DOI: 10.1016/j.ijnss.2019.06.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 05/28/2019] [Accepted: 06/17/2019] [Indexed: 01/05/2023] Open
Abstract
The second-stage of labor is the most stressful part of childbirth process and the proper maternal position during this period is paramount for women's safe vaginal birth. Midwives play a pivotal role in managing maternal positions during the second-stage of labor. However, there is limited evidence to support an ideal maternal position during the second-stage of labor. Further, the difference between different maternal positions might not be apparent. This paper aims to review and compare the benefits and risks of common maternal positions during the second-stage of labor, thereby to provide midwives evidence-based practical guidelines.
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Affiliation(s)
- Jing Huang
- School of Nursing, Peking University, Beijing, China
| | - Yu Zang
- School of Nursing, Peking University, Beijing, China
| | - Li-Hua Ren
- School of Nursing, Peking University, Beijing, China
| | - Feng-Juan Li
- Maternal and Child Health Hospital of Xinjiang Uyghur Autonomous Region, Uyghur, China
| | - Hong Lu
- School of Nursing, Peking University, Beijing, China
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32
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Pierce-Williams RAM, Saccone G, Berghella V. Hands-on versus hands-off techniques for the prevention of perineal trauma during vaginal delivery: a systematic review and meta-analysis of randomized controlled trials. J Matern Fetal Neonatal Med 2019; 34:993-1001. [PMID: 31092083 DOI: 10.1080/14767058.2019.1619686] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Perineal trauma at the time of vaginal delivery is common, and when the anal sphincter is included, these injuries can be associated with additional morbidity including incontinence, pelvic pain, and sexual dysfunction. OBJECTIVE The aim of this systematic review with meta-analysis was to evaluate whether a hands-on technique during vaginal delivery results in less incidence of perineal trauma than a hands-off technique. METHODS Electronic databases were searched from their inception until June 2018. No restrictions for language or geographic location were applied. The reference lists of identified articles were examined to identify studies not captured by electronic searches. Randomized controlled trials comparing a hands-on technique of perineal support during vaginal delivery (i.e. intervention group) with a hands-off technique (i.e. control group) were included in the meta-analysis. Hands-on was defined as involving one hand on the fetal head, applying pressure to control expulsion, with the other hand applying pressure on the maternal perineum. The primary outcome was severe perineal trauma, defined as either third- or fourth-degree lacerations. The meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of relative risk (RR) with 95% confidence interval (CI). RESULTS Five trials, including 7287 women, were analyzed. All studies included singleton gestations with cephalic presentation at term undergoing spontaneous vaginal delivery. Women randomized to the hands-on technique had similar incidence of severe perineal trauma (1.5 versus 1.3%; RR 2.00, 95% CI 0.56-7.15). There was no significant between-group difference in the incidence of intact perineum, first-, second- and fourth-degree laceration. Hands-on technique was associated with increased risk of third-degree lacerations (2.6 versus 0.7%; RR 3.41, 95% CI 1.39-8.37) and of episiotomy (13.6 versus 9.8%, RR 1.59, 95% CI 1.14-2.22) compared to the hands-off technique. CONCLUSIONS Hands-on technique during spontaneous vaginal delivery of singleton gestations results in similar incidence of several perineal traumas compared to a hands-off technique. The incidence of third-degree lacerations and of episiotomy increases with the hands-on technique. Key Message A hands-on technique during vaginal delivery results in similar incidence of severe lacerations compared to hands-off.
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Affiliation(s)
- Rebecca A M Pierce-Williams
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
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33
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Elvander C, Ahlberg M, Edqvist M, Stephansson O. Severe perineal trauma among women undergoing vaginal birth after cesarean delivery: A population-based cohort study. Birth 2019; 46:379-386. [PMID: 30350424 DOI: 10.1111/birt.12402] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 09/18/2018] [Accepted: 09/20/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND To examine risk of severe perineal trauma among nulliparous women and those undergoing vaginal birth after cesarean delivery (VBAC). METHODS This is a population-based cohort study of all births to women with their two first consecutive singleton pregnancies in Stockholm-Gotland Sweden between 2008 and 2014. Risk of severe perineal trauma was compared between nulliparous women and those undergoing VBAC with severe perineal trauma being the main outcome measure. Associations between indication and timing of primary cesarean delivery and risk of severe perineal trauma in subsequent vaginal birth were analyzed using Poisson regression analysis. RESULTS The rate of severe perineal trauma among nulliparous women and those undergoing VBAC was 7.0% and 12.3%, respectively. Compared with nulliparous women, those undergoing VBAC were significantly older, had a shorter stature, and gave birth in a non-upright position to heavier infants with larger head circumferences. The rate of instrumental vaginal delivery among nulliparous women and those undergoing VBAC was 19.3% and 20.2%, respectively (P = 0.331). An increased risk of severe perineal trauma remained after adjustments among those undergoing VBAC (adjusted risk ratio 1.42, 95% CI 1.23-1.63). Level of risk was not associated with indication (dystocia or signs of fetal distress) of primary cesarean delivery, nor how far the woman had progressed in labor (fully dilated versus planned cesarean delivery) before delivering by cesarean. CONCLUSIONS Compared with nulliparous women, those undergoing VBAC are at increased risk of severe perineal trauma, irrespective of indication and timing of primary cesarean delivery.
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Affiliation(s)
- Charlotte Elvander
- Clinical Epidemiology Unit, Department of Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Mia Ahlberg
- Clinical Epidemiology Unit, Department of Medicine, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Malin Edqvist
- Department of Health Science, Faculty of Medicine, Lund University, Lund, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Unit, Department of Medicine, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska University Hospital Solna, Stockholm, Sweden
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34
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Sveinsdottir E, Gottfredsdottir H, Vernhardsdottir AS, Tryggvadottir GB, Geirsson RT. Effects of an intervention program for reducing severe perineal trauma during the second stage of labor. Birth 2019; 46:371-378. [PMID: 30444289 DOI: 10.1111/birt.12409] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 10/20/2018] [Accepted: 10/20/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Obstetric anal sphincter injuries lead frequently to short- and long-term consequences for the mother, including perineal pain, genital prolapse, and sexual problems. The aim of the study was to evaluate whether the implementation of an intervention program in the second stage of labor involving altered perineal support techniques reduced severe perineal trauma. METHODS All women reaching the second stage of labor and giving birth vaginally to singleton babies at Landspítali University Hospital (comprising 76% of births in Iceland in 2013) were enrolled in a cohort study. Data were recorded retrospectively for 2008-2010 and prospectively in 2012-2014, for a total of 16 336 births. During 2011, an intervention program was implemented, involving all midwives and obstetricians working in the labor wards. Two professionals assessed and agreed on classification of every perineal tear. RESULTS The prevalence of obstetric anal sphincter injuries decreased from 5.9% to 3.7% after the implementation (P < 0.001). Third-degree tears decreased by 40%, and fourth-degree tears decreased by 56% (P < 0.001). The prevalence of first-degree tears increased from 25.8% to 33.1%, whereas second-degree tears decreased from 44.7% to 36.6% between the before and after study periods. Severe perineal trauma was linked to birthweight, and this did not change despite the new intervention. CONCLUSIONS Active intervention to reduce perineal trauma was associated with an overall significant decrease in obstetric anal sphincter injuries. Good perineal visualization, manual perineal support, and controlled delivery of the fetal head were essential components for reducing perineal trauma.
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Affiliation(s)
- Edda Sveinsdottir
- Midwifery Division, Faculty of Nursing, University of Iceland, Reykjavik, Iceland.,Department of Obstetrics and Gynecology, Women's Clinic, Landspítali University Hospital, Reykjavik, Iceland
| | - Helga Gottfredsdottir
- Midwifery Division, Faculty of Nursing, University of Iceland, Reykjavik, Iceland.,Department of Obstetrics and Gynecology, Women's Clinic, Landspítali University Hospital, Reykjavik, Iceland
| | - Anna S Vernhardsdottir
- Midwifery Division, Faculty of Nursing, University of Iceland, Reykjavik, Iceland.,Department of Obstetrics and Gynecology, Women's Clinic, Landspítali University Hospital, Reykjavik, Iceland
| | | | - Reynir T Geirsson
- Department of Obstetrics and Gynecology, Women's Clinic, Landspítali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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35
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Zhou X, Ma D, Wang F, Tian Y, Xu X. 'Hands‐off/poised' or 'Hands‐on' method among Chinese midwives: A cross‐sectional survey. J Clin Nurs 2019; 28:2889-2898. [PMID: 30938878 DOI: 10.1111/jocn.14879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 02/20/2019] [Accepted: 03/23/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Xuan Zhou
- Women's Hospital School of Medicine Zhejiang University Hangzhou China
| | - Dong‐Mei Ma
- Women's Hospital School of Medicine Zhejiang University Hangzhou China
| | - Fang Wang
- Women's Hospital School of Medicine Zhejiang University Hangzhou China
| | - Yanping Tian
- Women's Hospital School of Medicine Zhejiang University Hangzhou China
| | - Xinfen Xu
- Women's Hospital School of Medicine Zhejiang University Hangzhou China
- Haining Maternal and Child Health Hospital Jiaxing China
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36
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Obstetric Anal Sphincter Injuries at Vaginal Delivery: A Review of Recently Published National Guidelines. Obstet Gynecol Surv 2019; 73:695-702. [PMID: 30572346 DOI: 10.1097/ogx.0000000000000622] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Importance Obstetric anal sphincter injuries (OASISs) complicate approximately 1 in 10 deliveries. Objective The aims of this study were to review and compare recommendations from recently published national guidelines regarding OASISs at vaginal delivery. Evidence Acquisition Three national guidelines on OASISs at vaginal delivery are presented through a descriptive review: Royal College of Obstetricians and Gynaecologists on "The Management of Third- and Fourth-Degree Perineal Tears," American College of Obstetricians and Gynecologists on "Prevention and Management of Obstetric Lacerations at Vaginal Delivery," and Society of Obstetricians and Gynaecologists of Canada on "Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair." These guidelines were summarized and compared in terms of prevention and management of OASISs. Quality of evidence was also reviewed based on method of reporting for each guideline. Results This published evidence reflects the differences between the national recommendations on the prevention and management of OASISs. Especially, as for the prevention of OASIS, routine use of episiotomy is not recommended, whereas warm perineal compresses and perineal massage during the second stage of labor seem to have a protective role. In the management of OASIS, special care is needed during the repair process of the torn anorectal mucosa and the internal and external anal sphincter. The postoperative use of broad-spectrum antibiotics, oral laxatives, and analgesia is also recommended. Conclusions Summarized guidelines can have an impact on special care in prevention and management of OASIS; this may support the reduction of morbidity associated with that entity.
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37
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Masenga GG, Shayo BC, Msuya S, Rasch V. Urinary incontinence and its relation to delivery circumstances: A population-based study from rural Kilimanjaro, Tanzania. PLoS One 2019; 14:e0208733. [PMID: 30673696 PMCID: PMC6343883 DOI: 10.1371/journal.pone.0208733] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 11/22/2018] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To investigate the prevalence and risk factors of urinary incontinence (UI), the different UI subtypes and the association between UI and delivery circumstances. DESIGN Cross-sectional population-based study conducted in Kilimanjaro Region, Tanzania. PARTICIPANTS AND SETTINGS 1048 women aged 18-90 women living in rural Kilimanjaro. Simple random sampling was done to select villages, households and participants. Community health workers helped in identifying eligible women and trained nurses/midwives conducted face-to-face interviews. Data were analysed using descriptive statistics and Univariate and Multivariate logistic regression modelling. RESULTS The overall prevalence rate of UI was 42%. When focusing on the different types of UI, 17% of the women had stress UI, 9% had urge UI and 16% had mixed UI. Only one woman (0.1%) with vesico-vaginal fistula was identified. UI was found to be significantly associated with increasing parity (OR = 2.41 (1.55-3.74). In addition, women who in relation to their first delivery had delivered at home or had been in labour for more than 24 hours, had increased adjusted ORs of 1.70(1.08-2.68) and 2.10(1.08-4.10), respectively, for having UI. CONCLUSION UI is common in rural Tanzania and of the subtypes of UI, Stress Urinary Incontinence (SUI) is the commonest followed by Mixed Urinary Incontinence (MUI). Home delivery, prolonged labour and increasing parity especially having 5 or more deliveries are associated with increased risk for developing UI.
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Affiliation(s)
- Gileard G. Masenga
- Kilimanjaro Christian Medical University College, Moshi, Klimanjaro, Tanzania
- Department of Obstetrics and Gynecology, Kilimanjaro Christian Medical Centre, Moshi, Kilimanjaro, Tanzania
- * E-mail:
| | - Benjamin C. Shayo
- Department of Obstetrics and Gynecology, Kilimanjaro Christian Medical Centre, Moshi, Kilimanjaro, Tanzania
| | - Sia Msuya
- Kilimanjaro Christian Medical University College, Moshi, Klimanjaro, Tanzania
| | - Vibeke Rasch
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Ali-Masri H, Hassan S, Fosse E, Zimmo KM, Zimmo M, Ismail KMK, Vikanes Å, Laine K. Impact of electronic and blended learning programs for manual perineal support on incidence of obstetric anal sphincter injuries: a prospective interventional study. BMC MEDICAL EDUCATION 2018; 18:258. [PMID: 30419884 PMCID: PMC6233260 DOI: 10.1186/s12909-018-1363-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 10/29/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Obstetric anal sphincter injuries (OASIS) are associated with anal incontinence, dyspareunia and perineal pain. Bimanual perineal support technique (bPST) prevents OASIS. The aim of this study was to assess the effect of two different bPST training-methods on OASIS incidence. METHODS This is a prospective-interventional quality improvement study conducted in two Palestinian maternity units between June 1 2015 and December 31 2016. Women having spontaneous or operative vaginal-delivery at ≥24 gestational-weeks or a birthweight of ≥1000 g (n = 1694) were recruited and examined vaginally and rectally immediately after vaginal birth by a trained assessor. Data on baseline OASIS incidence were collected during Phase-1 of the study. Subsequently, birth attendants in both maternity units were trained in bPST using two training modalities. A self-directed electronic-learning (e-learning) using an animated video was launched in phase-2 followed by a blended learning method (the animated e-learning video+ structured face-to-face training) in phase-3. OASIS incidence was monitored during phases-2 and 3. Variations in OASIS incidence between the three phases were assessed using Pearson-χ2-test (or Fisher's-Exact-test). The impact of each training-method on OASIS incidence was assessed using logistic-regression analysis. RESULTS A total of 1694 women were included; 376 in phase-1, 626 in phase-2 and 692 in phase-3. Compared to Phase-1, OASIS incidence was reduced by 45% (12.2 to 6.7%, aOR: 0.56, CI; 0.35-0.91, p = 0.018) and 74% (12.2 to 3.2%, aOR, 0.29, CI; 0.17-0.50, p < 0.001) in phases-2 and 3, respectively. There was also a significant reduction in OASIS incidence by 52% from phase-2 to phase-3 (6.7% (42/626) to 3.2% (22/692), p = 0.003). These reductions reached statistical significance among parous-women only (aOR: 0.18, CI; 0.07-0.49, p = 0.001) after the first training method tested in phase-2. However, the reduction was significant among both primiparous (aOR: 0.39, CI; 0.21-0.74, p = 0.004) and parous-women (aOR: 0.11, CI; 0.04-0.32, p < 0.001) after implementing the blended learning method in phase-3. CONCLUSION The animated e-learning video had a positive impact on reducing OASIS incidence. However, this reduction was enhanced by the use of a blended learning program combining both e- learning and face-to-face training modalities. STUDY REGISTRATION NUMBER ClinicalTrialo.gov identifier: NCT02427854 , date: 28 April 2015.
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Affiliation(s)
- Hadil Ali-Masri
- Department of Obstetrics, Palestine Medical Complex, Ramallah, Palestine
- The Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Sahar Hassan
- Faculty of Pharmacy, Nursing and Health Professions, Birzeit University, Ramallah, Palestine
| | - Erik Fosse
- The Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kaled M. Zimmo
- The Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Obstetrics, Al Aqsa Martyrs Hospital, Gaza, Palestine
| | - Mohammed Zimmo
- The Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Obstetrics, Al Shifa Hospital, Gaza, Palestine
| | | | - Åse Vikanes
- The Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Katariina Laine
- Department of Obstetrics, Oslo University Hospital, Ullevål, Oslo, Norway
- Department of Health Management and Health Economics, Institute for Health and Society, University of Oslo, Oslo, Norway
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De Meutter L, D van Heesewijk A, van der Woerdt-Eltink I, de Leeuw JW. Implementation of a perineal support programme for reduction of the incidence of obstetric anal sphincter injuries and the effect of non-compliance. Eur J Obstet Gynecol Reprod Biol 2018; 230:119-123. [DOI: 10.1016/j.ejogrb.2018.09.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 09/11/2018] [Indexed: 10/28/2022]
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Rasmussen OB, Yding A, Lauszus F, Andersen CS, Anhøj J, Boris J. Importance of Individual Elements for Perineal Protection in Childbirth: An Interventional, Prospective Trial. AJP Rep 2018; 8:e289-e294. [PMID: 30377553 PMCID: PMC6205860 DOI: 10.1055/s-0038-1675352] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 09/14/2018] [Indexed: 12/18/2022] Open
Abstract
Objective To analyze the association between each element of a hands-on intervention in childbirth and the incidence of obstetric anal sphincter injuries (OASIS). Study Design We conducted a prospective, interventional quality improvement project and implemented a care bundle with five elements at an obstetric department in Denmark with 3,000 deliveries annually. We aimed at reducing the incidence of OASIS. In the preintervention period, 355 vaginally delivering nulliparous women were included. Similarly, 1,622 nulliparous women were included in the intervention period. The association of each element with the outcome was estimated using a regression analysis. Results The incidence of OASIS went down from 7.0 to 3.4% among nulliparous women delivering vaginally ( p = 0.003; relative risk = 0.48; 95% confidence interval [CI]: 0.30-0.76). Number needed to treat was 28. Logistic regression analysis showed that using hand on the head of the child significantly reduced the risk of OASIS (odds ratio = 0.28; 95% CI: 0.14-0.58). Conclusion Using a quality improvement framework, we documented the individual elements of the intervention. Hand on the infant's head reduced the risk of OASIS.
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Affiliation(s)
- Ole Bredahl Rasmussen
- Department of Obstetrics and Gynaecology, Herning Regional Hospital, Herning, Denmark
| | - Annika Yding
- Department of Obstetrics and Gynaecology, Herning Regional Hospital, Herning, Denmark
| | - Finn Lauszus
- Department of Obstetrics and Gynaecology, Herning Regional Hospital, Herning, Denmark
| | | | - Jacob Anhøj
- Centre of Diagnostic Investigation, University of Copenhagen, Copenhagen, Denmark
| | - Jane Boris
- Department of Obstetrics and Gynaecology, Herning Regional Hospital, Herning, Denmark
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Affiliation(s)
- Mary Steen
- Professor of Midwifery, School of Nursing and Midwifery, University of South Australia
| | - Monica Diaz
- Research and clinical midwife, School of Nursing and Midwifery, University of South Australia and Women and Children's Hospital, Adelaide
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Zimmo KM, Laine K, Fosse E, Zimmo M, Ali-Masri H, Böttcher B, Zucknick M, Vikanes Å, Hassan S. Impact of animated instruction on tablets and hands-on training in applying bimanual perineal support on episiotomy rates: an intervention study. Int Urogynecol J 2018; 30:1343-1350. [PMID: 30008080 PMCID: PMC6647226 DOI: 10.1007/s00192-018-3711-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/20/2018] [Indexed: 11/27/2022]
Abstract
Introduction and hypothesis In Palestine, episiotomy is frequently used among primiparous women.This study assesses the effect of training birth attendants in applying bimanual perineal support during delivery by either animated instruction on tablets or hands-on training on episiotomy rates among primiparous women. Methods An interventional cohort study was performed from 15 October 2015 to 31 January 2017, including all primiparous women with singletons and noninstrumental vaginal deliveries at six Palestinian hospitals. Intervention 1 (animated instructions on tablets) was conducted in Hospitals 1, 2, 3, and 4. Intervention 2 (bedside hands-on training) was applied in Hospitals 1 and 2 only. Hospitals 5 and 6 did not receive interventions. Differences in episiotomy rates in intervention and nonintervention hospitals were assessed before and after the interventions and presented as p values using chi-square test, and odds ratios (OR) with 95% confidence intervals (CI). Differences in the demographic and obstetric characteristics were presented as p values using the Kruskal–Wallis test. Results Of 46,709 women, 12,841 were included. The overall episiotomy rate in the intervention hospitals did not change significantly after intervention 1, from 63.1 to 62.1% (OR = 0.96, 95% CI 0.84–1.08), but did so after intervention 2, from 61.1 to 38.1% (OR = 0.39, 95% CI 0.33–0.47). Rates after Intervention 2 changed from 65.0 to 47.3% (OR = 0.52, 95% CI 0.40–0.67) in Hospital 1 and from 39.4 to 25.1% (OR = 0.49, 95% CI 0.35–0.68) in Hospital 2. Conclusions Hands-on training of bimanual perineal support during delivery of primiparous women was significantly more effective in reducing episiotomy rates than animated instruction videos alone. Electronic supplementary material The online version of this article (10.1007/s00192-018-3711-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kaled Mikki Zimmo
- Department of Obstetrics, Al Aqsa Hospital, Gaza, Palestine.
- The Intervention Centre, Oslo University Hospital, Rikshospitalet, 4950 Nydalen, 0424, Oslo, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Katariina Laine
- Department of Health Management and Health Economics, Institute for Health and Society, University of Oslo, Oslo, Norway
- Department of Obstetrics, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Erik Fosse
- The Intervention Centre, Oslo University Hospital, Rikshospitalet, 4950 Nydalen, 0424, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Mohammed Zimmo
- The Intervention Centre, Oslo University Hospital, Rikshospitalet, 4950 Nydalen, 0424, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Obstetrics, Al Shifa Hospital, Gaza, Palestine
| | - Hadil Ali-Masri
- The Intervention Centre, Oslo University Hospital, Rikshospitalet, 4950 Nydalen, 0424, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Obstetrics, Palestine Medical Complex, Ramallah, Palestine
| | - Bettina Böttcher
- Faculty of Medicine, Islamic University of Gaza, Gaza, Palestine
| | - Manuela Zucknick
- Department of Biostatistics, Oslo Centre for Biostatistics and Epidemiology, University of Oslo, Oslo, Norway
| | - Åse Vikanes
- The Intervention Centre, Oslo University Hospital, Rikshospitalet, 4950 Nydalen, 0424, Oslo, Norway
| | - Sahar Hassan
- Departement of Nursing, Faculty of Pharmacy, Nursing and Health Professions, Birzeit University, Birzeit, Palestine
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Basu M, Smith D. Long-term outcomes of the Stop Traumatic OASI Morbidity Project (STOMP). Int J Gynaecol Obstet 2018; 142:295-299. [PMID: 29885253 DOI: 10.1002/ijgo.12565] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 04/07/2018] [Accepted: 06/08/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate long-term sustainability of the Stop Traumatic OASI Morbidity Project (STOMP) in reducing the incidence of obstetric anal sphincter injury (OASI). METHODS A prospective observational study of women undergoing vaginal delivery at a UK district general hospital between September 1, 2014, and February 28, 2017. The principles of STOMP involve encouraging upright positioning, verbal coaching to avoid expulsive pushing and to slow down delivery, and tactile support to the vertex to judge speed and slow down delivery. After a training period, STOMP was implemented for all vaginal deliveries. Clinical and demographic data on women affected by OASI were collected across a 30-month period. The primary outcome measure was the incidence of OASI. RESULTS There were 8782 vaginal deliveries during the 30-month period after implementation of STOMP. There was a significant decrease in the mean incidence of OASI relative to the 9 months before implementation (P<0.001). There was a significant decrease in the incidence of OASI for both spontaneous vaginal and instrumental deliveries (both P<0.05). There was no change in the frequency of episiotomy. CONCLUSIONS Implementation of STOMP led to a significant decrease in OASI, confirming the sustainability of this approach to improve outcomes.
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Affiliation(s)
- Maya Basu
- Department of Obstetrics and Gynaecology, Medway NHS Foundation Trust, Gillingham, UK
| | - Dot Smith
- Department of Obstetrics and Gynaecology, Medway NHS Foundation Trust, Gillingham, UK
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Lee N, Firmin M, Gao Y, Kildea S. Perineal injury associated with hands on/hands poised and directed/undirected pushing: A retrospective cross-sectional study of non-operative vaginal births, 2011–2016. Int J Nurs Stud 2018; 83:11-17. [DOI: 10.1016/j.ijnurstu.2018.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 04/03/2018] [Accepted: 04/03/2018] [Indexed: 10/17/2022]
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Begley C, Guilliland K, Dixon L, Reilly M, Keegan C, McCann C, Smith V. A qualitative exploration of techniques used by expert midwives to preserve the perineum intact. Women Birth 2018; 32:87-97. [PMID: 29730096 DOI: 10.1016/j.wombi.2018.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 03/29/2018] [Accepted: 04/18/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND The perineum stretches during birth to allow passage of the baby, but 85% of women sustain some degree of perineal trauma during childbirth, which is painful post-partum. Episiotomy rates vary significantly, with some countries having rates of >60%. Recent Irish and New Zealand studies showed lower severe perineal trauma and episiotomy rates than other countries. AIM To explore expert Irish and New Zealand midwives' views of the skills that they employ in preserving the perineum intact during spontaneous vaginal birth. METHODS Following ethical approval a qualitative, descriptive study was undertaken. Semi-structured, recorded, interviews were transcribed and analysed using the constant comparative method. Expert midwives employed in New Zealand and one setting in Ireland, were invited to join the study. "Expert" was defined as achieving, in the preceding 3.5 years, an episiotomy rate for nulliparous women of <11.8%, a 'no suture' rate of 40% or greater, and a severe perineal tear rate of <3.2%. Twenty-one midwives consented to join the study. RESULTS Four core themes emerged: 'Calm, controlled birth', 'Position and techniques in early second stage', 'Hands on or off?' and 'Slow, blow and breathe the baby out.' Using the techniques described enabled these midwives to achieve rates, in nulliparous women, of 3.91% for episiotomy, 59.24% for 'no sutures', and 1.08% for serious lacerations. CONCLUSIONS This study provides further understanding of the techniques used by expert midwives at birth. These findings, combined with existing quantitative research, increases the evidence on how to preserve the perineum intact during spontaneous birth.
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Affiliation(s)
- C Begley
- School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin D02 T283, Ireland; Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - K Guilliland
- New Zealand College of Midwives, Christchurch, New Zealand
| | - L Dixon
- New Zealand College of Midwives, Christchurch, New Zealand
| | - M Reilly
- Midwife-Led Unit, Cavan General Hospital, Cavan, Ireland
| | - C Keegan
- Midwife-Led Unit, Our Lady of Lourdes Hospital, Drogheda, Ireland
| | - C McCann
- Our Lady of Lourdes Hospital, Drogheda, Ireland
| | - V Smith
- School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin D02 T283, Ireland
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Jefford E, Jomeen J, Guy F, Newcombe B, Martin C. Applying a Midwifery-Specific Decision-Making Tool to Midwives’ Clinical Reasoning and Midwifery Practice When Managing a Woman’s Perineum in Labor: An Exploratory Study. INTERNATIONAL JOURNAL OF CHILDBIRTH 2018. [DOI: 10.1891/2156-5287.8.1.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Introduction: Many of the risk factors for perineal trauma are modifiable, and midwives are in an ideal position to mitigate such risks. To date, no investigation using a midwifery-specific decision-making tool has sought to determine how midwives make decisions within a midwifery philosophy/context or identify the factors that may contribute to that decision making about perineal management. We sought to apply such a tool to midwives’ narratives and explore their clinical reasoning and midwifery practice when managing a woman’s perineum in labor. Methods: A qualitative interview-based study with practicing midwives in one regional Australian maternity unit was conducted. The decision-making matrix specified by a psychometrically robust and validated measure of clinical decision making and midwifery practice-guided analysis. Results: Effective clinical decision making in response to perineal trauma is contingent on a heuristic and individualized “working hypothesis” that combines distinct elements of an optimal clinical decision-making process. Midwives’ narratives highlighted their ability to engage in some form of clinical reasoning. Some elements of midwifery practice was lacking within several midwives’ narratives, thus resulting in them abdicating their professional role.Conclusion: The manner and processes by which midwives engage effectively with perineal management are complex. However, a significant influence on this process appears to be recollections from original training in perineal management, which appears to be largely rote and taught by example. We recommend balance between practical experience and synthesis with current evidence within a midwifery philosophy to optimize perineal care and risk modification.
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Tunestveit JW, Baghestan E, Natvig GK, Eide GE, Nilsen ABV. Factors associated with obstetric anal sphincter injuries in midwife-led birth: A cross sectional study. Midwifery 2018; 62:264-272. [PMID: 29734121 DOI: 10.1016/j.midw.2018.04.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 01/29/2018] [Accepted: 04/03/2018] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Obstetric anal sphincter injurie (OASI) in vaginal births are a serious complication, and are associated with maternal morbidity. Focus on modifiable factors in midwives clinical skills and competences contributing to prevent the occurrence of OASI are essential. The objective of this study was to investigate the association between OASI and factors related to midwife-led birth such as manual support of perineum, active delivery of baby's shoulders, maternal birth position, and pushing and breathing techniques in second stage of labour. METHODS A prospective cross sectional study including primiparous (n = 129) and multiparous (n = 628) women in midwife-led non-instrumental deliveries with OASI (n = 96) or intact perineum (n = 661). Data were collected in a university hospital in Norway with two different birth settings: an alongside midwife-led unit with approximately 1500 births per year and an obstetrical unit with approximately 3500 births per year. In midwife-led births, there were a total of 2.6% OASI and 18.9% intact perineum. RESULTS The sample consisted of 757 women, 12.7% suffered OASI and 87.3% of participating women had an intact perineum. This selected sample compares the most serious outcome (OASI), and the optimal outcome (intact perineum).In primiparous women, 61 women suffered OASI and 68 women had intact perineum, while for multipara women, 35 women suffered OASI and 593 women had intact perineum. There was an increased risk of OASI if women actively pushed when the head was crowning compared to breathing the head out (adjusted OR: 3.10; 95% CI: 1.75 to 5.47). The maternal birth position associated with the lowest risk of OASI was kneeling position (adjusted OR: 0.15; 95% CI: 0.03 to 0.70), supine maternal birth position (adjusted OR: 2.52; 95% CI: 1.04 to 4.90) and oxytocin augmentation more than 30 min in second stage (OR: 1.93; 95% CI: 1.68 to 15.63) were associated with an increased risk of OASI, when adjusting for maternal, foetal, and obstetric factors. CONCLUSION Our study suggests that actively pushing when the baby's head is crowning, a supine maternal birth position and oxytocin augmentation more than 30 min in second stage, were associated with increased risk of OASI when compared to intact perineum. A kneeling maternal birth position was associated with a decreased risk of OASI.
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Affiliation(s)
- Jorunn Wik Tunestveit
- Department of Global Public Health and Primary Care, University of Bergen, Norway ; Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway.
| | - Elham Baghestan
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
| | - Gerd Karin Natvig
- Department of Global Public Health and Primary Care, University of Bergen, Norway
| | - Geir Egil Eide
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway ; Lifestyle Epidemiology Research Group, Department of Global Public Health and Primary Care, University of Bergen, Norway
| | - Anne Britt Vika Nilsen
- Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Norway
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Habek D, Tikvica Luetić A, Marton I, Prka M, Pavlović G, Kuljak Ž, Švanjug D, Mužina Z. Modified Ritgen Maneuver in Perineal Protection - Sixty-Year Experience. Acta Clin Croat 2018; 57:116-121. [PMID: 30256019 PMCID: PMC6400357 DOI: 10.20471/acc.2018.57.01.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
SUMMARY – The aim is to present the 60-year experience in modified Ritgen maneuver according to perineal injuries. This retrospective clinical observational study (1950-2010) analyzed the impact of modified Ritgen maneuver delivery technique (controlled fetal head deflexion with left hand and synchronous reduction of perineal strain with extended right hand thumb along the right side of the vulva and perineum without pushing) on peripartum perineal tears at the Maternity Ward, Bjelovar General Hospital in Bjelovar, Croatia, divided into five-year intervals. The rate of perineal tear in general was less than 5% until 2000. The rate of perineal tear grade I was very low until 1995, then increased to 8.6% in 2010, yet never exceeding 10%. The rate of perineal tear grade II never exceeded 2%, whereas perineal tear grade III was a sporadic event never exceeding 0.4% of the study material with a single case of grade IV tear. The rate of intact perineum in vaginal deliveries without episiotomy ranged from 96.2% to 100% in the 1950-1960 period, with a decrease to 46% in 2010. The study revealed the modification of Ritgen maneuver described to have resulted in significant reduction of all grades of perineal tear over decades.
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Affiliation(s)
| | - Ana Tikvica Luetić
- University Department of Obstetrics and Gynecology, Sveti Duh University Hospital, Croatian Catholic University, Zagreb, Croatia
| | - Ingrid Marton
- University Department of Obstetrics and Gynecology, Sveti Duh University Hospital, Croatian Catholic University, Zagreb, Croatia
| | - Matija Prka
- University Department of Obstetrics and Gynecology, Sveti Duh University Hospital, Croatian Catholic University, Zagreb, Croatia
| | - Goran Pavlović
- Department of Obstetrics and Gynecology, Bjelovar General Hospital, Bjelovar, Croatia
| | - Željka Kuljak
- University Department of Obstetrics and Gynecology, Sveti Duh University Hospital, Croatian Catholic University, Zagreb, Croatia
| | - Deana Švanjug
- University of Rijeka, Faculty od Health Sciences, Rijeka, Croatia
| | - Zdenka Mužina
- Department of Obstetrics and Gynecology, Bjelovar General Hospital, Bjelovar, Croatia
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[Anal incontinence and obstetrical anal sphincter injuries, epidemiology and prevention]. ACTA ACUST UNITED AC 2018; 46:419-426. [PMID: 29500142 DOI: 10.1016/j.gofs.2018.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Indexed: 12/11/2022]
Abstract
Our main objectives were to identify risk factors, methods for early diagnosis, and prevention of obstetric anal sphincter injuries (OASIs), using a literature review. The main risk factors for OASIs are nulliparity, instrumental delivery, posterior presentation, median episiotomy, prolonged second phase of labor and fetal macrosomia. Asian origin, short ano-vulvar distance, ligamentous hyperlaxity, lack of expulsion control, non-visualization of the perineum or maneuvers for shoulder dystocia also appear to be risk factors. There is a risk of under-diagnosis of OASIs in the labor ward. Experience of the accoucheur is a protective factor. Secondary prevention is based on the training of birth professionals in recognition and repair of OASIs. Primary prevention of OASIs is based on training in the maneuvers of the second phase of labor; if possible, instrumental extractions should be avoided. Mediolateral episiotomy may have a preventive role in high-risk OASIs deliveries. A robust predictive model is still lacking to allow a selective use of episiotomy.
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Vieira F, Guimarães JV, Souza MCS, Sousa PML, Santos RF, Cavalcante AMRZ. Scientific evidence on perineal trauma during labor: Integrative review. Eur J Obstet Gynecol Reprod Biol 2018; 223:18-25. [PMID: 29453137 DOI: 10.1016/j.ejogrb.2018.01.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 01/30/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To assess the scientific evidence for management and preservation of perineal integrity during the expulsive stage of labor. STUDY DESIGN Integrative review that employed the Population, Intervention, Comparison, Outcome strategy to formulate the research question: Which perineal measure(s) is(are) effective in maintaining perineal integrity during labor? The search was performed in the databases MEDLINE, LILACS, BDENF and SciELO. The ten selected studies were analyzed based on their level of evidence and grade of recommendation. RESULTS Four categories of measures were located: antenatal perineal care, perineal massage during the expulsive phase of labor, manual perineal support during the expulsive phase of labor and perineal hyaluronidase injection. CONCLUSION Based on its level of evidence, perineal massage with lubricants performed by the women or their partners at the end of pregnancy may be recommended as a measure favorable for perineal protection.
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Affiliation(s)
- Flaviana Vieira
- School of Nursing, Federal University of Goiás, Goiânia, Goiás, Brazil.
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