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Lallemant M, D'Antona A, Vidal C, Bourtembourg A, Toubin C, Chehab M, Vilchez M, Boiteux G, Ramanah R, Pazart L, Riethmuller D, Mottet N. Conservative management versus systematic suture of isolated vaginal or first-degree perineal tears after delivery: A preliminary randomized efficacy trial. Birth 2023; 50:513-524. [PMID: 35960611 DOI: 10.1111/birt.12671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The objective of this study was to assess the preliminary efficacy and safety of conservative management compared with systematic suture in isolated vaginal or first-degree perineal tears after birth. METHODS We conducted a preliminary efficacy, open-label, randomized, controlled, and prospective trial. This study implemented Simon's 2-step plan (interim analysis and final analysis) to test the success rate of the digital compression strategy group. Primiparous women aged ≥18 years with isolated vaginal or first-degree perineal tears after spontaneous vaginal birth of a cephalic presenting term (≥37 weeks) neonate were randomly allocated to the conservative management (CM) group (digital compression if bleeding followed by suture if persistent bleeding) or a systematic suture (SS) group. The primary outcome was the success of the intervention 10 days after delivery, defined by pain as evaluated using a visual analog scale < 3, satisfactory healing defined by a REEDA score ≤ 2, and no bleeding or infection. Sexual well-being was assessed at 2 and 6 months postpartum. RESULTS Among 861/2209 eligible women, 143 consenting women with a superficial perineal tear were randomized: 72 in the systematic suture group and 71 in the conservative management group. Success rate was 87.8% (90% CI [70.5-93.54]) (42/55) in the systematic suture group vs 90% (90% CI [78.3-93.8]) (53/61) in the conservative management group. The REEDA score was significantly higher in the systematic suture group (1.4 vs 0.9; P = 0.036). Perineal pain was significantly higher at day 1 in the systematic suture group (2.38 vs 1.69; P = 0.034). For the Female Sexual Functional Index score, no significant difference was found between the two groups at inclusion or at 2 and 6 months postpartum. CONCLUSIONS Conservative management of superficial perineal tears shows an efficacy rate ≥90%. Women in the conservative management group had less pain at the 1st day follow-up and lower REEDA scores at the 10th day follow-up.
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Affiliation(s)
- Marine Lallemant
- Department of Obstetrics and Gynecology, University Medical Center of Besancon, University of Franche-Comte, Besançon, France
- Applied Mechanics Department, FEMTO-ST Institute, University Bourgogne Franche-Comté, CNRS (UMR 6174), Besançon, France
| | - Aurélie D'Antona
- Department of Obstetrics and Gynecology, University Medical Center of Besancon, University of Franche-Comte, Besançon, France
| | - Chrystelle Vidal
- Centre d'investigation Clinique, INSERM CI 1431, University Medical Center of Besancon, Besançon, France
| | - Aude Bourtembourg
- Department of Obstetrics and Gynecology, University Medical Center of Besancon, University of Franche-Comte, Besançon, France
| | - Claire Toubin
- Department of Obstetrics and Gynecology, University Medical Center of Besancon, University of Franche-Comte, Besançon, France
| | - Malek Chehab
- Department of Obstetrics and Gynecology, University Medical Center of Besancon, University of Franche-Comte, Besançon, France
| | - Marie Vilchez
- Department of Obstetrics and Gynecology, University Medical Center of Besancon, University of Franche-Comte, Besançon, France
| | - Guillaume Boiteux
- Centre d'investigation Clinique, INSERM CI 1431, University Medical Center of Besancon, Besançon, France
| | - Rajeev Ramanah
- Department of Obstetrics and Gynecology, University Medical Center of Besancon, University of Franche-Comte, Besançon, France
- Nanomedecine Laboratory, INSERM EA4662, University of Franche-Comte, Besançon, France
| | - Lionel Pazart
- Centre d'investigation Clinique, INSERM CI 1431, University Medical Center of Besancon, Besançon, France
| | - Didier Riethmuller
- Department of Obstetrics and Gynecology, University Medical Center of Grenoble, Grenoble, France
| | - Nicolas Mottet
- Department of Obstetrics and Gynecology, University Medical Center of Besancon, University of Franche-Comte, Besançon, France
- Nanomedecine Laboratory, INSERM EA4662, University of Franche-Comte, Besançon, France
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Zhou M, Shui W, Bai W, Wu X, Ying T. Ultrasonographic study of female perineal body and its supportive function on pelvic floor. Front Med (Lausanne) 2023; 10:1176360. [PMID: 37564038 PMCID: PMC10410282 DOI: 10.3389/fmed.2023.1176360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/12/2023] [Indexed: 08/12/2023] Open
Abstract
Objectives The study aimed to observe, measure the size and elastic value of perineal body (PB) and assess its association with levator hiatus. Methods Datasets were acquired in 45 nulliparous, 66 POP women and 70 postpartum women using ultrasound. The PB was measured in depth, height, and Young's modulus. The datasets were compared to assess whether there are some differences in the morphology, dimension and elastography modulus of PB among women. Pearson correlation analysis was used to evaluate the association between the morphology measurements (ΔValsalva-rest[v-r]), tissue mechanical properties (ΔValsalva-rest[v-r]) of the PB and levator hiatus area (ΔValsalva-rest[v-r]) to preliminarily explore whether PB can influence levator hiatus. Results Four representative manifestations of PB were presented in our study. Nulliparous women had smaller diameters and bigger Young's modulus while postpartum women had bigger diameters and smaller Young's modulus. POP and postpartum women had bigger levator hiatal distensibility and PB extensibility. There was no statistical association between PB measurements and levator hiatal area. Conclusion It is feasible to observe the morphology of PB and assess the dimension and elastography modulus by high-frequency ultrasound. The manifestations and measurements of PB are influenced by parity and long-term increased abdominal pressure. Our study preliminarily shows that PB has little effect on levator hiatus area.
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Affiliation(s)
| | | | | | | | - Tao Ying
- Department of Ultrasound in Medicine, Shanghai Institute of Ultrasound in Medicine, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Boudry T, Lallemant M, Ramanah R, Mottet N. Influence of in utero fetal death on perineal tears in vaginal deliveries. Sci Rep 2023; 13:7484. [PMID: 37160998 PMCID: PMC10170066 DOI: 10.1038/s41598-023-34185-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 04/25/2023] [Indexed: 05/11/2023] Open
Abstract
The aim of this work was to evaluate and compare the incidence of perineal tears and Obstetrical anal sphincter injuries (OASIS) after vaginal delivery following a in utero fetal death (IUFD) compared with those with a live-birth. We conducted a single-center, retrospective cohort study using a database of all women who underwent a spontaneous vaginal delivery in the level III maternity ward. Exclusion criteria were breech presentation, cesarean section birth, instrumental delivery, multiple pregnancy, delivery before 24 + 6 weeks of gestation (WG) and termination of pregnancy for medical reasons. Women from the database were divided into two groups: an "in utero fetal death" (IUFD) group and a control group. Women were included in the IUFD group if they had a spontaneous vaginal delivery following a fetal demise after 24 + 6 WG in cephalic presentation between January 2006 and June 2020. Women in the "control" group were selected from the same database and were included if they underwent a spontaneous vaginal delivery of a live fetus in cephalic presentation, after 24 + 6 WG, during the same period. Each woman in the "IUFD" group was matched to two women (ratio 1:2) in the control group for parity, maternal age, body mass index, gestation and birth weight. The primary outcome was the presence of a sutured or unsutured perineal tear. During the study period, 31,208 patients delivered at a level III maternity hospital. Among them, 215 and 430 women were included in the IUFD group and the control group respectively. The two groups were comparable for all demographic and clinical characteristics except for an epidural analgesia (92% versus 70% in the control group, p < 0.01) and labor induction (86% versus 17% in the control group, p < 0.01). The incidence of any perineal tears was 13% (28/15) in the IUFD group versus 16% (70/430) in the control group. Relative risk of any perineal tears was non significative (RR = 0.8 IC95% [0.5-1.2]). The incidence of first-degree perineal tears was 10% in the IUFD group and 11% in the control group. The incidence of second-degree perineal tears was 18% in the IUFD group and 28% in the control group. Relative risk of first-degree perineal tears (RR = 0.88 95% CI [0.5-1.4]) and second-degree tears (RR = 0.51 95% CI [0.2-1.4]) were non significative. No obstetrical anal sphincter injury was found in either group. Vaginal delivery following a fetal demise did not appear to be either a risk factor or a protective factor for perineal tears. But there as a trend toward a lower incidence of second degree perineal tears in this context.
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Affiliation(s)
- Thibaud Boudry
- Department of Obstetrics and Gynecology, University Medical Center of Besancon, University of Franche-Comte, Alexander Fleming Boulevard, 25000, Besançon, France
| | - Marine Lallemant
- Department of Obstetrics and Gynecology, University Medical Center of Besancon, University of Franche-Comte, Alexander Fleming Boulevard, 25000, Besançon, France
- Université de Franche-Comté, FEMTO-ST Institute, UMR CNRS 6174, Department of Applied Mechanics, Besançon, France
| | - Rajeev Ramanah
- Department of Obstetrics and Gynecology, University Medical Center of Besancon, University of Franche-Comte, Alexander Fleming Boulevard, 25000, Besançon, France
- Nanomedicine Laboratory, INSERM EA4662, University of Franche-Comte, 25000, Besancon, France
| | - Nicolas Mottet
- Department of Obstetrics and Gynecology, University Medical Center of Besancon, University of Franche-Comte, Alexander Fleming Boulevard, 25000, Besançon, France.
- Nanomedicine Laboratory, INSERM EA4662, University of Franche-Comte, 25000, Besancon, France.
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Peroz M, Ghesquière L, Pouypoudat L, Lehembre V, Debarge V, Rakza T, Garabedian C, Subtil D. [Couder's maneuver. Knowledge and practices in a French university maternity hospital]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:35-40. [PMID: 36243297 DOI: 10.1016/j.gofs.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/02/2022] [Accepted: 10/06/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND During childbirth, the performance of a systematic Couder's maneuver could be linked to a reduction in the risk of perineal tear. OBJECTIVE To know the practices and knowledge of childbirth professionals regarding the Couder's maneuver. To measure the effect of a training program for juniors. MATERIALS AND METHODS Single-center questionnaire survey of senior and junior obstetricians and midwives. Before-and-after study in juniors to evaluate maneuver training. RESULTS One hundred and twenty-five caregivers responded to the questionnaire: (19 physicians and 46 senior midwives; 21 residents and 39 midwifery students). Only one third of the respondents said they practiced the Couder's maneuver "always or almost always" (41/125, 32.8%) and less than one third felt "very comfortable" with the maneuver (34/125, 27.2%), with large differences according to profession and senior vs junior status. Being a doctor (vs midwife) was significantly related to systematic or frequent practice of the maneuver (70.0 vs 15.3%, ORMH=42.7 [9.4; 192.3]) as was being a senior (vs junior) (46.2 vs 18.3%, ORMH=15.9 [3.5; 72.9]). Less than half of the seniors surveyed had received education in maneuvering. Of those who did not practice the maneuver, the majority did not consider its systematic practice to be useful (19/26, 73.1%), and one third considered it potentially harmful (8/26, 30.8%). Theoretical and practical training of the juniors significantly improved their knowledge. CONCLUSION There are great differences in the practice of the Couder's maneuver. It deserves to be better known, practiced and evaluated.
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Affiliation(s)
- M Peroz
- Pôle Femme-Mère-Nouveau-né, university Lille, hôpital Jeanne-de-Flandre, CHU de Lille, 1, rue Eugène-Avinée, 59037 Lille cedex, France.
| | - L Ghesquière
- Pôle Femme-Mère-Nouveau-né, university Lille, hôpital Jeanne-de-Flandre, CHU de Lille, 1, rue Eugène-Avinée, 59037 Lille cedex, France; University Lille, EA 2694, METRICS, évaluation des technologies de santé et des pratiques médicales, hôpital Jeanne-de-Flandre, CHU de Lille, 59000 Lille, France
| | - L Pouypoudat
- Pôle Femme-Mère-Nouveau-né, university Lille, hôpital Jeanne-de-Flandre, CHU de Lille, 1, rue Eugène-Avinée, 59037 Lille cedex, France
| | - V Lehembre
- University Lille, école de Sages-Femmes, institut Gernez-Rieux, CHU de Lille, 59000 Lille, France
| | - V Debarge
- Pôle Femme-Mère-Nouveau-né, university Lille, hôpital Jeanne-de-Flandre, CHU de Lille, 1, rue Eugène-Avinée, 59037 Lille cedex, France; University Lille, EA 2694, METRICS, évaluation des technologies de santé et des pratiques médicales, hôpital Jeanne-de-Flandre, CHU de Lille, 59000 Lille, France
| | - T Rakza
- Pôle Femme-Mère-Nouveau-né, university Lille, hôpital Jeanne-de-Flandre, CHU de Lille, 1, rue Eugène-Avinée, 59037 Lille cedex, France
| | - C Garabedian
- Pôle Femme-Mère-Nouveau-né, university Lille, hôpital Jeanne-de-Flandre, CHU de Lille, 1, rue Eugène-Avinée, 59037 Lille cedex, France; University Lille, EA 2694, METRICS, évaluation des technologies de santé et des pratiques médicales, hôpital Jeanne-de-Flandre, CHU de Lille, 59000 Lille, France
| | - D Subtil
- Pôle Femme-Mère-Nouveau-né, university Lille, hôpital Jeanne-de-Flandre, CHU de Lille, 1, rue Eugène-Avinée, 59037 Lille cedex, France; University Lille, EA 2694, METRICS, évaluation des technologies de santé et des pratiques médicales, hôpital Jeanne-de-Flandre, CHU de Lille, 59000 Lille, France
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Forey PL, Soulier C, Curtelin C, Curto L, Préaubert L, Hoffmann P, Riethmuller D. [Introduction of the Couder manoeuvre and perineal injuries]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:645-649. [PMID: 34896636 DOI: 10.1016/j.gofs.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 12/02/2021] [Accepted: 12/02/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To analyse the introduction of the Couder manoeuvre in our level 3 maternity unit shortly after its introduction in 2019. Then, to evaluate and compare the rate of perineal injuries between 2017, when the manoeuvre was not performed at all, and 2020. MATERIALS AND METHOD A single-centre retrospective study of patients who delivered a singleton eutociously at term from 1 January to 31 December 2017 and 2020. RESULTS In total, 2930 records were analysed. The Couder manoeuvre rate was 32.12% in 2020. A change in the distribution of perineal lesions was observed: the rate of intact perineum increased (P<0.001), while 2nd degree lesions decreased between 2017 and 2020 (P<0.05). The 1st degree perineum and obstetric anal sphincter injuries remained stable. The rate of episiotomy decreased significantly by almost a factor of 7. CONCLUSION The practice of the Couder manoeuvre can be implemented fairly quickly after training of the actors with nearly a third of normal deliveries at term concerned one year after its introduction. This manoeuvre seems, in our practice, to have contributed to the reduction, as previously reported, of the rate of second degree perineal injuries.
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Affiliation(s)
- P-L Forey
- Département de gynécologie-obstétrique et médecine de la reproduction, CHU d'Alpes-Grenoble, Grenoble, France
| | - C Soulier
- Département de gynécologie-obstétrique et médecine de la reproduction, CHU d'Alpes-Grenoble, Grenoble, France
| | - C Curtelin
- Département de gynécologie-obstétrique et médecine de la reproduction, CHU d'Alpes-Grenoble, Grenoble, France
| | - L Curto
- Département de gynécologie-obstétrique et médecine de la reproduction, CHU d'Alpes-Grenoble, Grenoble, France
| | - L Préaubert
- Département de gynécologie-obstétrique et médecine de la reproduction, CHU d'Alpes-Grenoble, Grenoble, France
| | - P Hoffmann
- Département de gynécologie-obstétrique et médecine de la reproduction, CHU d'Alpes-Grenoble, Grenoble, France
| | - D Riethmuller
- Département de gynécologie-obstétrique et médecine de la reproduction, CHU d'Alpes-Grenoble, Grenoble, France.
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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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Dole C, Metz JP, Formet J, Riethmuller D, Ramanah R, Mottet N. Intra pelvic spontaneous rotation of persistent occiput posterior position in case of operative vaginal delivery with spatulas. J Gynecol Obstet Hum Reprod 2020; 50:101943. [PMID: 33069912 DOI: 10.1016/j.jogoh.2020.101943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 10/05/2020] [Accepted: 10/09/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVES In 5 % of vaginal deliveries in case of cephalic presentation there is a persistent occipital posterior position known to be associated with a higher maternal and neonatal morbidity. In these situations, vacuum extractor seems to be the best choice for assisted delivery but it also has limits and contraindications, for example an important caput succadenum or premature birth. The aim of our study was to evaluate the rate of intra-pelvic rotation of persistent occipital posterior position without instrumental rotation in case of operative delivery with spatulas. METHODS This is a retrospective, monocentric and descriptive study evaluating the rate of spontaneous intra-pelvic rotation of persistent occipital posterior position in case of assisted delivery with spatulas among all live births at the Besançon University Medical Center between 2010 and 2017. RESULTS There were 20 205 births during the study and 81(0,4 %) operative deliveries by spatulas in case of persistent occipital posterior position. Delivery in occiput anterior (OA) position was obtained in 36 cases (44.4 %). There was no significant difference in maternal or neonatal morbidity between both groups and perineum injuries were less severe in case of OA delivery. CONCLUSION Operative deliveries by spatulas without instrumental rotation in case of persistent occipital-posterior position seem to be a relevant alternative to vacuum extractor, especially in case of premature birth or important caput succedaneum without altering the maternal or neonatal prognostic.
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Affiliation(s)
- Chloé Dole
- Besançon University Medical Center, Department of Obstetrics and Gynaecology, Alexander Fleming Boulevard, 25000, Besançon, France.
| | - Jean Patrick Metz
- Besançon University Medical Center, Department of Obstetrics and Gynaecology, Alexander Fleming Boulevard, 25000, Besançon, France
| | - Justine Formet
- Besançon University Medical Center, Department of Obstetrics and Gynaecology, Alexander Fleming Boulevard, 25000, Besançon, France
| | - Didier Riethmuller
- Besançon University Medical Center, Department of Obstetrics and Gynaecology, Alexander Fleming Boulevard, 25000, Besançon, France
| | - Rajeev Ramanah
- Besançon University Medical Center, Department of Obstetrics and Gynaecology, Alexander Fleming Boulevard, 25000, Besançon, France
| | - Nicolas Mottet
- Besançon University Medical Center, Department of Obstetrics and Gynaecology, Alexander Fleming Boulevard, 25000, Besançon, France
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Forey PL, Lallemant M, Bourtembourg-Matras A, Eckman-Lacroix A, Ramanah R, Riethmuller D, Mottet N. Impact of a selective use of episiotomy combined with Couder's maneuver for the perineal protection. Arch Gynecol Obstet 2020; 302:77-83. [PMID: 32388778 DOI: 10.1007/s00404-020-05572-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 04/25/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the impact of a selective use of episiotomy combined with Couder's maneuver on the incidence of perineal tears in spontaneous term deliveries. METHODS A comparative, retrospective, mono-centric study in a university maternity unit was designed and included all primiparous women who delivered spontaneously after 37 weeks of gestation in cephalic presentation. Two cohorts were studied, before and after the practice of Couder's maneuver. In the first cohort, the ''OSE cohort'' only selective episiotomies were performed from January 2009 to December 2010. In the second cohort, from January 2016 to December 2017, the ''SEC cohort'' selective episiotomies combined with Couder's maneuver were performed by midwives and obstetricians. The primary outcome was the type of perineal tears, according to the Royal College of Obstetricians and Gynaecologists (RCOG) classification. RESULTS A total of 2081 patients were included: 909 patients in the OSE cohort and 1172 patients in the SEC cohort. Couder's maneuver was performed in 59% of the SEC cohort. In the SEC cohort, there were an increase in the number of intact perinea (55% versus 63%, p < 0.001), a decrease in second-degree perineal tears (18% versus 11%, p < 0.001) and a decrease in labia minora tears (48% versus 37%, p < 0.001). The rate of obstetrical anal sphincter injuries was less than 1% in both cohorts (0.3% versus 0.5%, p = 0.7). CONCLUSION A selective use of episiotomy combined with Couder's maneuver could reduce the incidence of perineal tears, particularly second-degree perineal tears, without increasing the rate of obstetrical anal sphincter injuries.
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Affiliation(s)
- Pierre-Louis Forey
- Department of Obstetrics and Gynecology, University Hospital Jean Minjoz, University of Franche-Comté, 25000, Besançon, France
| | - Marine Lallemant
- Department of Obstetrics and Gynecology, University Hospital Jean Minjoz, University of Franche-Comté, 25000, Besançon, France
| | - Aude Bourtembourg-Matras
- Department of Obstetrics and Gynecology, University Hospital Jean Minjoz, University of Franche-Comté, 25000, Besançon, France
| | - Astrid Eckman-Lacroix
- Department of Obstetrics and Gynecology, University Hospital Jean Minjoz, University of Franche-Comté, 25000, Besançon, France
| | - Rajeev Ramanah
- Department of Obstetrics and Gynecology, University Hospital Jean Minjoz, University of Franche-Comté, 25000, Besançon, France
- Nanomedecine Laboratory, Imagery and Therapeutics, INSERM EA 4662, University of Franche-Comté, 25000, Besançon, France
| | - Didier Riethmuller
- Department of Obstetrics and Gynecology, University Hospital Jean Minjoz, University of Franche-Comté, 25000, Besançon, France
| | - Nicolas Mottet
- Department of Obstetrics and Gynecology, University Hospital Jean Minjoz, University of Franche-Comté, 25000, Besançon, France.
- Nanomedecine Laboratory, Imagery and Therapeutics, INSERM EA 4662, University of Franche-Comté, 25000, Besançon, France.
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Paschoal A, Uchiyama Nakamara M, Araujo Júnior E, Petricelli CD, Alexandre SM, Zanetti MRD. Device to predict pelvic floor integrity during vaginal delivery: an intra- and interrater reliability study of the Epi-no distensibility measurement. J Matern Fetal Neonatal Med 2019; 34:3481-3487. [PMID: 31718332 DOI: 10.1080/14767058.2019.1685970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To determine the test-retest reliability of the pelvic floor distensibility evaluation with Epi-no® device.Methods: Prospective, blinded observational study with 32 women pregnant from 35 gestational weeks. An Epi-no® balloon was inflated within the pregnant woman's vagina and the maximum circumference achieved was measured using a standard metric measuring tape. Measurements were performed twice in a day by two physiotherapists in a randomized order. Intraobserver reproducibility was obtained with another evaluation 7-14 d after the initial examination. The intraclass correlation coefficient (ICC) was used to determine the intra and interrater reliability and the respective 95% confidence intervals with an alpha level of 0.05.Results: From a total of 32 included pregnant women, 28 were analyzed; they were 29.3 (±5.97) years old, were at 37 (±1.3) weeks' gestation and presented a mean Epi-no® circumference of 20.4 (±2.4) cm. Regarding the intraobserver analysis, examiner 1 observed a maximum circumference of 20.6 (±2.6) cm in the first evaluation and 20.2 (±2.4) cm in the second evaluation, with good reliability (ICC = 0.85). Examiner 2 observed 19.7 (±2.4) cm in the first evaluation and 21.0 (±2.0) cm in the second one, with moderate reliability (ICC = 0.58). Regarding the interobserver analysis, there was good reliability on two evaluation days, with an ICC of 0.76 and 0.82, respectively.Conclusions: Epi-no® device is a reliable device for physiotherapists to measure pelvic floor distention during pregnancy.
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Affiliation(s)
- Aline Paschoal
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Mary Uchiyama Nakamara
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Carla Dellabarba Petricelli
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Sandra Maria Alexandre
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Miriam Raquel Diniz Zanetti
- Department of Science of Human Movement, Physical Therapy Course, Federal University of São Paulo (UNIFESP), Santos, Brazil
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Hulot G, Ramanah R, Riethmuller D, Mottet N. The impact of active delivery of the anterior arm during vacuum-assisted vaginal delivery on perineal tears: a clinical practice evaluation. J Matern Fetal Neonatal Med 2019; 33:3308-3312. [PMID: 30714443 DOI: 10.1080/14767058.2019.1571573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Objective: Our purpose was to evaluate the impact of active delivery of the anterior arm with Couder's Maneuver (CM) during vacuum-assisted vaginal delivery (VAVD) on perineal tears. This maneuver can be beneficial because it has the advantage of reducing fetal biacromial diameter.Methods: This monocentric retrospective study compared two non-concurrent cohorts of nulliparous women before and after implementation of a systematic CM during VAVD: Cohort 1 from 1 January to 31 December 2006 without CM and Cohort 2 from 1 January to 31 December 2016 with systematic CM. This study reviewed all births during these two periods. All live-born singleton pregnancies where VAVD occurred after 37 weeks of gestation were included. The principal endpoint was the type of perineal tear.Results: In total, there were 179 VAVD in the Cohort 1 and 267 VAVD in the Cohort 2. In the Cohort 2, 233 VAVD (87.3%) were performed with systematic CM. No episiotomy was performed in both cohorts. There was a significant decrease in the rate of second-degree perineal tears between the two cohorts (42.4 versus 15%, p < .001) and a significant increase in the rate of intact perineum (34.1 versus 54.7%, p < .001). There was no influence of CM on the rate of obstetrical anal sphincter injury (3.9 versus 2.6%, p = .44).Conclusions: Practicing this maneuver could improve the perineal prognosis during VAVD in nulliparous women.
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Affiliation(s)
- Ghislain Hulot
- Department of Obstetrics and Gynecology, Besançon University Medical Center, Besançon, France
| | - Rajeev Ramanah
- Department of Obstetrics and Gynecology, Besançon University Medical Center, Besançon, France
| | - Didier Riethmuller
- Department of Obstetrics and Gynecology, Besançon University Medical Center, Besançon, France
| | - Nicolas Mottet
- Department of Obstetrics and Gynecology, Besançon University Medical Center, Besançon, France
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Abstract
Shoulder dystocia can lead to death or brain damage for the baby. Traction on the head can damage the brachial plexus. The diagnosis should be made when the mother cannot push the shoulders out with her own efforts with the next contraction after delivery of the head. There should be no traction on the head to diagnose shoulder dystocia. McRoberts’ position is acceptable but it should not be accompanied by any traction on the head. If the posterior shoulder is in the sacral hollow then the best approach is to use posterior axillary traction to deliver the posterior shoulder and arm. If both shoulders are above the pelvic brim, the posterior arm should be brought down with Jacquemier’s maneuver. If that fails, cephalic replacement or symphysiotomy is the next step. After shoulder dystocia is resolved, one should wait 1 minute or so to allow placental blood to return to the baby before cutting the umbilical cord.
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Affiliation(s)
- Savas Menticoglou
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Canada,
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12
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Riethmuller D, Ramanah R, Mottet N. [Fetal expulsion: Which interventions for perineal prevention? CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]. ACTA ACUST UNITED AC 2018; 46:937-947. [PMID: 30377094 DOI: 10.1016/j.gofs.2018.10.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The objective for all obstetricians and midwifes who intervene during the release of the fetal presentation is to prevent at best the perineal lesions. This work consisted in analyzing the literature, researching and evaluating interventions that reduce this perineal risk during the release. METHODS A keyword search for each medical intervention during the expulsion phase was conducted by selecting studies assessing perineal risk. Interventions during pregnancy and during delivery before the expulsion phase were specifically addressed in other sections of the recommendations. RESULTS Firstly, the degree of perineal stretching during the second stage of labour does not appear to be a risk factor for OASIS, postpartum incontinence, or sexual disorders (LE3) and that a substantial stretching of the perineum is not an indication of episiotomy (Professional consensus). Then, manual control of the expulsion of the fetus at the end of the second stage of labour and support of the posterior perineum during this time appear to reduce the rate of OASIS (LE3). The crowning of the baby's head should be manually controlled and the posterior perineum manually supported manually to reduce the risk of OASIS (GradeC). There is no recognised benefit to episiotomy in normal deliveries (LE1); the liberal practice of episiotomy results in fewer intact perineums than its restrictive practice, and the latter does not result in increasing the number of cases of OASIS. No evidence indicates that an episiotomy for women with a breech presentation, twin pregnancy, or posterior position prevents OASIS (LE3). Indication for episiotomy during delivery depends on individual risk factors and obstetric conditions (Professional consensus). It is recommended that the indication for episiotomy be explained and the woman's consent received before its performance. The performance of an episiotomy during normal deliveries is not recommended to reduce the risk of OASIS (Grade A). The liberal practice of episiotomy to prevent OASIS is not recommended for women with a breech presentation, twin pregnancy, or posterior position (GradeC). Episiotomy during an instrumental delivery appears to be associated with a reduction of the risk of OASIS (LE3). The vacuum extractor appears to induce fewer cases of OASIS than other instruments (LE3). Episiotomy may be indicated in instrumental deliveries to avoid OASIS (GradeC). Training in perineal protection in obstetrics is recommended (Grade B). In operative vaginal deliveries when several instruments can be used, a vacuum extractor is preferentially recommended to reduce the risk of OASIS (GradeC). When forceps or spatulas are used, it is preferable that they be withdrawn just before cephalic deflexion so that the fetal head is not "capped" with these instruments at birth (Professional consensus). Couder's maneuver, which consists of lowering the forearm during the release of the fetal shoulders, appears to decrease the rate of second-degree perineal tears and increase the rate of intact perineum (LE3). CONCLUSION Manual control of the expulsion and perineal support reduce the risk of perineal injury. There is no benefit to episiotomy in normal delivery, nor in special cases such the breech presentation for example. On the other hand, in case of instrumental delivery, an episiotomy may be indicated to avoid OASIS (GradeC), and it is recommended if it is possible to use the ventouse preferentially. The Couder's maneuver seems to reduce the rate of 2nd degree perineal lesions (LE3). Finally, training in perineal obstetric protection is recommended (Grade B).
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Affiliation(s)
- D Riethmuller
- Pôle Mère-Femme, CHRU Besançon, 3, boulevard Fleming, 25000 Besançon, France.
| | - R Ramanah
- Pôle Mère-Femme, CHRU Besançon, 3, boulevard Fleming, 25000 Besançon, France
| | - N Mottet
- Pôle Mère-Femme, CHRU Besançon, 3, boulevard Fleming, 25000 Besançon, France
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Bourgon N, Mottet N, Bourtembourg A, Pugin A, Ramanah R, Riethmuller D. [Obstetrical anal sphincter injuries and vacuum-assisted delivery at term in primiparas]. ACTA ACUST UNITED AC 2018; 46:686-691. [PMID: 30293947 DOI: 10.1016/j.gofs.2018.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Operative Vaginal Delivery (OVD) is subject to a risk of perineal tears especially of Obstetrical Anal Sphincter Injuries (OASIS) that are associated with more complications and impaired quality of life. The main objective of this study was to compare the rate of OASIS in primipara at term with fetus in cephalic presentation depending on the type of delivery: OVD using vacuum extractor and spontaneous delivery. METHODS This is a single-center retrospective study between 01/01/2010 and 12/31/2014 including all primipara who delivered vaginally at term, a single and living fetus in cephalic presentation. Perineal lesions were classified according to the WHO classification. The primary endpoint was the proportion of OASIS. RESULTS 3552 patients were included: 2496 spontaneous deliveries (SD) and 1056 OVD (29.72 %). There were twenty sphincter tears (0.56 %): 7 in SD group (0.28 %) and 13 in OVD (1.23 %), P<0.0001, OR=5.10 [2.00; 12.99]. Other risk factors associated with OASIS in univariable analysis were: maternal age (≥30 years), duration of expulsive efforts (≥20min) and a birth weight≥4000g. CONCLUSION In these patients, the risk of OASIS in case of AI increases by a factor of 5;10. The high rate of AI in these patients exposes them to a real risk of OASIS. However, the proportion of OASIS in this group remains lower than those reported in the literature and is barely higher than the national overall rate, despite a very restrictive policy of the use of episiotomy.
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Affiliation(s)
- N Bourgon
- Pôle Mère-Femme, CHRU Besançon, 3, boulevard Fleming, 25000 Besançon, France
| | - N Mottet
- Pôle Mère-Femme, CHRU Besançon, 3, boulevard Fleming, 25000 Besançon, France
| | - A Bourtembourg
- Pôle Mère-Femme, CHRU Besançon, 3, boulevard Fleming, 25000 Besançon, France
| | - A Pugin
- Centre d'investigation clinique, CHRU Besançon, 3, boulevard Fleming, 25000 Besançon, France
| | - R Ramanah
- Pôle Mère-Femme, CHRU Besançon, 3, boulevard Fleming, 25000 Besançon, France
| | - D Riethmuller
- Pôle Mère-Femme, CHRU Besançon, 3, boulevard Fleming, 25000 Besançon, France.
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