A novel obstetrical surgical intervention - New episiotomy: Case series study

OBJECTIVES

To establish anatomical structures responsible for creating a resistance force on a fetal head during vaginal delivery at term; to develop a new episiotomy to widen the vaginal outlet.

DESIGN

A prospective observational case series study.

SETTING

International centers.

POPULATION

Eighteen consecutive women at term during vaginal delivery.

METHODS

V-shape excision made on the hymeneal membrane, hymeneal ring, and hymeneal plate without extending an incision to the posterior perineal structures. Outlectorrhaphy (repairing the vaginal outlet to repair the surgical defect. Excisional specimens are subjected to histological examinations.

MAIN OUTCOME MEASURES

The primary maternal outcome measures were postpartum posterior perineum pain associated with vaginal outlectomy. The secondary outcomes measured a) complication of vaginal outlectomy; b) occurrence of dyspareunia after vaginal outlectomy; c) applicability of vaginal outlectomy; d) neonatal outcome measured by an APGAR score to show how the neonate tolerated the vaginal delivery process with vaginal outlectomy implementation.

RESULTS

The V-shape excision widened the vaginal outlet sufficiently for a vaginal delivery without a perineal incision. Outlectorrhaphy requires two or three simple interrupted sutures to close surgical defects and eliminate the vaginal gapping appearance. Eleven out of eighteen women were primigravida (61.1 %), and four multiparas (38.9 %) delivered a live newborn vaginally with a newly developed vaginal outlectomy. A median newborn's weight was 350 g ± 250 g, and APGAR scores at 5 min were median of 9 ± 1. One out of eighteen patients experienced extension of the skin, perineal fascia, and bulbospongiosus muscle. Bleeding from the extension tearing of vaginal outlectomy was heavier than from uncomplicated vaginal outlectomy but negligible. Immediately postpartum, patients reported no moderate or severe perineal pain. At a 3-month postpartum, none of the subjects reported superficial or deep dyspareunia. Histology from the vaginal outlectomy specimens described the direct connection of the longitudinal vaginal smooth muscles to the hymeneal plate and compact connective tissues (like cartilage) of the hymeneal ring. Additionally, the histological examination showed the absence of the perineal skeletal muscle within the vaginal outlectomy specimens.

CONCLUSIONS

The vaginal outlet is responsible for the most vital resistance force on a fetal head during delivery. Vaginal outlectomy widens the vaginal outlet sufficiently for a fetal vaginal birth with minimal bleeding and is easy to repair. No moderate-severe perineal pain or dyspareunia occurred in this study group.

TWEETABLE ABSTRACT

Vaginal outlectomy eliminates postpartum moderate-to-severe perineal pain and superficial dyspareunia. The posterior perineum creates no resistance force on the fetal head during vaginal delivery to warrant incision.

Obstetric anal sphincter injury events prior and after Episcissors-60 implementation: A systematic review and meta-analysis

OBJECTIVE

To assess the effect of Episcissors-60 upon obstetric anal sphincter injuries (OASIS) reduction in nulliparous women.

STUDY DESIGN

Independent literature search for relevant studies was performed up to 30th May 2021 on five databases: Embase (OVID), MEDLINE (R) (OVID), CAB Abstracts (OVID), ClinicalTrials.gov, and Google Scholar. The primary outcome was to assess OASIS events prior and after Epi-60 implementation in clinical practice in natural births (NB), whilst secondary outcomes included overall operative vaginal delivery (OVD) %/spontaneous vaginal deliveries (SVD) % deliveries, episiotomy rates and operator satisfaction. All included studies (retrospective, prospective and time-series) examined the effect of Episcissors-60 implementation upon observed OASIS %.

RESULTS

A total of 14,027 nulliparous females were included in the meta-analysis. Overall, study heterogeneity was high at I²: 79% with collectively fair quality of studies, as assessed by the Newcastle-Ottawa scale. Overall, this analysis highlights significant differences of OASIS events that might suggest their implementation as standard practice [RD -0.02, 95% CI -0.03 to 0.00; P = 0.03].

CONCLUSION

The present analysis highlights significant differences of OASIS events pre- and post- Epi-60, that may suggest Episcissors-60 implementation as standard practice. Nonetheless, to ensure data integrity, well reported observational studies and robust randomized controlled trials (RCTs) are required prior to introduction of Epi-60 as standard episiotomy technique in clinical practice.

The prediction of morbidity related to vaginal delivery in nulliparous women - A secondary analysis from the genesis multicenter trial

OBJECTIVE

In the prospective multicenter Genesis study, we developed a prediction model for Cesarean delivery (CD) in term nulliparous women. The objective of this secondary analysis was to determine whether the Genesis model has the potential to predict maternal and neonatal morbidity associated with vaginal delivery.

STUDY DESIGN

The national prospective Genesis trial recruited 2,336 nulliparous women with a vertex presentation between 39 + 0- and 40 + 6-weeks' gestation from seven tertiary centers. The prediction model used five parameters to assess the risk of CD: maternal age, maternal height, body mass index, fetal head circumference and fetal abdominal circumference. Simple and multiple logistic regression analyses were used to develop the Genesis model. The risk score calculated using this model were correlated with maternal and neonatal morbidity in women who delivered vaginally: postpartum hemorrhage (PPH), obstetric anal sphincter injury (OASI), shoulder dystocia, one- and five-minute Apgar score ≤ 7, neonatal intensive care (NICU) admission, cephalohematoma, fetal laceration, nerve palsy and fractures. The morbidities associated with spontaneous vaginal delivery were compared with those associated with operative vaginal delivery (OVD). The likelihood ratios for composite morbidity and the morbidity associated with OVD based on the Genesis risk scores were also calculated.

RESULTS

A total of 1,845 (79%) nulliparous women had a vaginal delivery. A trend of increasing intervention and morbidity was observed with increasing Genesis risk score, including OVD (p < 0.001), PPH (p < 0.008), NICU admission (p < 0.001), low Apgar score at one-minute (p < 0.001) and OASI (p = 0.009). The morbidity associated with OVD was significantly higher compared to spontaneous vaginal delivery, including NICU admission (p < 0.001), PPH (p = 0.022), birth injury (p < 0.001), shoulder dystocia (p = 0.002) and Apgar score of<7 at one-minute (p < 0.001). The positive likelihood ratios for composite outcomes (where the OVD was excluded) increases with increasing risk score from 1.005 at risk score of 5% to 2.507 for risk score of>50%.

CONCLUSION

In women who ultimately achieved a vaginal birth, we have shown more maternal and neonatal morbidity in the setting of a Genesis nomogram-determined high-risk score for intrapartum CD. Therefore, the Genesis prediction tool also has the potential to predict a more morbid vaginal delivery.

Surface electromyography of the pelvic floor at 6-8 weeks following delivery: a comparison of different modes of delivery

INTRODUCTION AND HYPOTHESIS

The objective of this study was to compare the impact of different modes of delivery, especially forceps delivery (FD), on pelvic floor muscles (PFMs) through vaginal surface electromyography (sEMG) in primiparous women at early (6-8 weeks) postpartum.

METHODS

A total of 1259 primiparous women with full-term singleton births were included in this cross-sectional study. Of these, 98 were delivered by forceps, 865 underwent spontaneous vaginal delivery (SD) and 296 underwent elective cesarean delivery (CD). Clinical demographic characteristics and vaginal sEMG variables of parturients 6-8 weeks after birth were collected and analyzed using SPSS software. One-way ANOVA with Bonferroni correction, Chi-square test or Student's t-test was used according to the variable type. Spearman correlation and binary logistic regression analyses were also used. P/α ≤ 0.05 was considered statistically significant.

RESULTS

Amplitude of fast and sustained contractions on sEMG in the FD group was significantly lower compared with the CD and SD groups. The sEMG amplitude of all contractions was significantly higher in the CD group compared with the FD and SD groups (P < 0.01). According to binary logistic regression analysis, mode of delivery was a major influencing factor in sEMG.

CONCLUSIONS

An early postpartum sEMG test appears to be helpful for the assessment of PFM activity. Mode of delivery was a major influencing factor on sEMG. Forceps delivery significantly inversely influenced PFM activity.

Large retroperitoneal hematoma following vaginal delivery: a case report

Background

Retroperitoneal hematoma after vaginal delivery is rare but can lead to maternal morbidity and mortality. Diagnosis of this condition is challenging due to its complexity and its nonspecific signs and symptoms. To date, studies and case reports regarding retroperitoneal hematoma are few, particularly in low-income countries where risk factors for this condition may be more prevalent and the prognosis poorer.

Case presentation

We report the case of a 37-year-old multiparous african (Congolese) woman who presented to the emergency department of a large referral hospital in Bukavu, Democratic Republic of the Congo (DRC), 2 weeks after a spontaneous nontraumatic vaginal delivery. She had abdominal pain that began immediately after delivery and progressed throughout the postpartum period. The patient had anemia, hypotension, tachycardia, and a left costo-lumbar arch distorting the body shape on a soft and depressed abdomen. She had visited a private clinic on days 3 and 7 postpartum; however, signs and symptoms of retroperitoneal hematoma went unrecognized. Using abdominal ultrasound, we diagnosed an extensive hematoma in the retroperitoneal space from the left iliac fossa to the left flank. Laparotomy was performed to evacuate the hematoma, and the patient recovered.

Conclusion

Retroperitoneal hematoma following a nontraumatic vaginal delivery is an unusual situation in general obstetrical practice. The knowledge of this potentially life-threatening condition in resource-limited settings enables effective diagnosis and management by ultrasound and laparotomy.

Evaluation of a policy of restrictive episiotomy on the incidence of perineal tears among women with spontaneous vaginal delivery: A ten-year retrospective study

INTRODUCTION

Routine episiotomy is no longer recommended to limit obstetrical anal sphincter injuries (OASIs). We aimed to evaluate the effect of a restrictive policy of episiotomy on the risk of OASIs during spontaneous vaginal deliveries.

MATERIAL AND METHODS

We performed a retrospective single-center observational study among women with a term singleton cephalic fetus, with spontaneous vaginal delivery. The occurrence of episiotomy, intact perineum, first, second, third or fourth-degree (OASIs) perineal tears were compared before (period A, from 01/01/2006 to 12/31/2008) and after (period B, from 01/01/2012 to 12/31/2016) implementation of the restrictive policy. Odds of perineal tear were estimated using multivariable logistic regression models, stratified by parity.

RESULTS

From 2006-2016, the rate of episiotomy decreased, from 14.9 % (n/N=200/1141) to 4.7 % (94/1912). In period B (N=8984) vs A (N=8984), the rates of episiotomy were, 12.9 vs 26.6 % for nulliparas (p<0.01) and 2.3 vs 6.8 % for multiparas (p<0.01). Odds of OASIs were not different in period B vs A, both for nulliparas (0.9 vs 0.8 %, AOR=0.88(0.38-2.05)) and multiparas (0.4 vs 0.2 %, AOR=2.28(0.63-8.29). Odds of second-degree tear were higher in period B vs A, both for nulliparas (39.8 vs 17.4 %, AOR=2.55(2.11-3.08) and multiparas (26.2 vs 12.8 %, AOR=2.26(1.95-2.66)); and odds of intact perineum were lower (for nulliparas, 15.8 vs 24.9 %, AOR=0.61(0.42-0.90) and for multiparas, 47.1 vs 56.0 %, AOR=0.61(0.49-0.76)). No difference was observed for first-degree tears.

CONCLUSION

The progressive implementation of a restrictive policy of episiotomy during spontaneous vaginal delivery was not associated with an increased risk of OASIs over a ten-year period.

Cesarean Section and Maternal-fetal Mortality Rates in Nigeria: An Ecological Lens into the Last Decade

BACKGROUND OR OBJECTIVES

Despite the global decline in maternal mortality within the last decade, women continue to die excessively from pregnancy-related complicationsin developing countries. We assessed the trends in maternal mortality, fetal mortality and cesarean section (C-Section) rates within 25 selected Nigerian hospitals over the last decade.

METHODS

Basic obstetric data on all deliveries were routinely collected by midwives using the maternity record book developed for the project in all the participating hospitals. Trends of C-Section Rates (CSR), Maternal Mortality Rates (MMR), Fetal Mortality Rates (FMR) and Spontaneous Vaginal Delivery rates (SVD) were calculated using joinpoint regression models.

RESULTS

The annual average percent change in CSR was 12.2%, which was statistically significant, indicating a rise in CSR over the decade of the study. There was a noticeable fall in MMR from a zenith of about 1,868 per 100,000 at baseline down to 1,315/100,000 by the end of the study period, representing a relative drop in MMR of about 30%. An average annual drop of 3.8% in FMR and 1.5% drop in SVD over time were noted over the course of the study period.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

We observed an overall CSR of 10.4% and a significant rise in CSR over the 9-year period (2008-2016) of about 108% across hospital facilities in Nigeria. Despite the decrease in MMR, it was still high compared to the global average of 546 maternal deaths per 100 000 livebirths. The FMR was also high compared with the global average. The MMR found in this study clearly indicates that Nigeria is far behind in making progress toward achieving the Sustainable Development Goal 3 (SGD 3) which aims to reduce the global MMR to less than 70 per 100 000 live births by 2030.

Does music during labor affect mode of delivery in first labor after epidural anesthesia? A prospective study

KEY MESSAGE

Listening to music during labor increases the likelihood that primiparas will have a spontaneous vaginal delivery.

PURPOSE

To examine the effects of exposure to music during labor on the mode of delivery and parturients' stress levels.

METHODS

This prospective, interventional study included 124 low-risk women who were recruited during latent phase of their first labor after epidural anesthesia. Patients were grouped according to their preference to receive music intervention or not. The music intervention included two subgroups: soft classical music and rhythmic music. We evaluated cortisol levels in saliva as a surrogate for stress level and State-Trait Personality Inventory at enrollment and 1-3 h later in all women who were still in labor. Delivery and perinatal outcomes were collected from electronic medical records. Correlations between the music intervention and maternal and perinatal outcomes were evaluated.

RESULTS

Spontaneous vaginal delivery was significantly more frequent among women listening to music compared to the non-music group (P = 0.035). A trend towards lower rates of cesarean delivery was noted in the music group (P = 0.08), with no difference in instrumental vaginal delivery rates. Stress levels, as measured by questionnaires and by cortisol levels, blood pressure and pulse rate, remained similar throughout the study. No differences were noted between the different genres of music when examining obstetric and perinatal outcomes and stress levels.

CONCLUSION

Listening to music during labor, improves the likelihood of primiparas to have a vaginal delivery regardless of stress level. As this treatment is simple, easy, and harmless to administer, we suggest it may be offered to all patients during labor.

Simulation of a Spontaneous Vaginal Delivery and Neonatal Resuscitation in a Biocontainment Unit

This article describes a large-scale scenario designed to test the capabilities of a US biocontainment unit to manage a pregnant woman infected with a high-consequence pathogen, and to care for a newborn following labor and spontaneous vaginal delivery. We created and executed a multidisciplinary functional exercise with simulation to test the ability of the Johns Hopkins Hospital biocontainment unit (BCU) to manage a pregnant patient in labor with an unknown respiratory illness and to deliver and stabilize her neonate. The BCU Exercise and Drill Committee established drill objectives and executed the exercise in partnership with the Johns Hopkins Simulation Center in accordance with Homeland Security and Exercise Program guidelines. Exercise objectives were assessed by after-action reporting and objective measurements to detect contamination, using a fluorescent marker to simulate biohazardous fluids that would be encountered in a typical labor scenario. The immediate objectives of the drill were accomplished, with stabilization of the mother and successful delivery and resuscitation of her newborn. There was no evidence of contamination when drill participants were inspected under ultraviolet light at the end of the exercise. Simulation optimizes teamwork, communication, and safety, which are integral to the multidisciplinary care of the maternal-fetal unit infected, or at risk of infection, with a high-consequence pathogen. Lessons learned from this drill regarding patient transportation, safety, and obstetric and neonatal considerations will inform future exercises and protocols and will assist other centers in preparing to care for pregnant patients under containment conditions.

Membrane sweeping added to formal induction method to increase the spontaneous vaginal delivery: a meta-analysis

BACKGROUND

Membrane sweeping (MS) could increase the likelihood of spontaneous labor within 48 h. However, the rationale for performing routinely an intervention with the potential to induce labor in women with an uneventful pregnancy at 38 weeks of gestation is, at least, questionable. We conducted a meta-analysis of randomized controlled trial (RCT) studies to assess evaluated the effect of MS added to formal induction method on the spontaneous vaginal delivery, compared with formal induction alone.

METHODS

PubMed, Embase, Cochrane Library databases, Web of Science, and Clinical Trials were searched from their inception to March 8, 2017. We estimate summarized relative risk (RR) and 95% confidence intervals (CIs) for dichotomous outcomes. The primary outcome was vaginal delivery, and second outcomes (side effects of MS) included meconium-stained liquor, admission to the neonatal unit, instrumental delivery.

RESULTS

Four RCTs with a total of 1377 participants were identified. The summary RR in the overall group was 1.12 (95% CI 1.05-1.18), with moderate heterogeneity (P = 0.22, I² = 33%). The summary RR in the nulliparas' subgroup was 1.32 (95% CI 1.18-1.48), with no heterogeneity (P = 0.79, I² = 0%). MS did not increase the risk of side effects.

CONCLUSIONS

MS added to formal induction significantly increased vaginal delivery rates, especially in nulliparas compared with formal induction alone. Notably, there are no obvious side effects of MS. Meanwhile, more RCTs studies are needed to investigate the side effects of MS on instrumental delivery, postpartum hemorrhage, and cervical laceration.

Obstetric anal sphincter injuries after episiotomy: systematic review and meta-analysis

Introduction

There is conflicting evidence on whether mediolateral episiotomy (MLE) reduces the risk of obstetric anal sphincter injuries (OASI) in spontaneous vaginal deliveries (SVD).

Objectives

A systematic review was undertaken to compare rates of OASI amongst women who had undergone mediolateral episiotomy versus those who did not.

Methods

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Search strategy

Electronic searches were performed in literature databases: CINAHL, Cochrane, EMBASE, Medline and MIDIRS from database inception to July 2015. Studies were eligible if MLE was compared to spontaneous tears and if OASI was the outcome of interest.

Two reviewers independently selected and extracted data on study characteristics, quality and results. We computed events of OASI in those who did and did not have an episiotomy from individual studies and pooled these results in a meta-analysis where possible.

Main results

Of the 2090 citations, 16 were included in the review. All were non-randomised, population based or retrospective cohort studies. There was great variation in quality amongst these studies. Data from 7 studies was used for meta-analysis. On collating data from these studies where the majority of women (636755/651114) were nulliparous, MLE reduced the risk of OASI (RR 0.67 95 % CI 0.49-0.92) in vaginal delivery.

Conclusion

The pooled analysis of a large number of women undergoing vaginal birth, most of who were nulliparous, indicates that MLE has a beneficial effect in prevention of OASI. An accurately given MLE might have a role in reducing OASI and should not be withheld, especially in nulliparous women. Caution is advised as the data is from non-randomised studies.