Effects of Perineal Warm Compresses during the Second Stage of Labor on Reducing Perineal Trauma and Relieving Postpartum Perineal Pain in Primiparous Women: A Systematic Review and Meta-Analyses

Non-pharmaceutical midwifery techniques, including perineal warm compresses, to improve maternal outcomes remain controversial. The aims of this study are to assess the effects of perineal warm compresses on reducing perineal trauma and postpartum perineal pain relief. This systematic review included randomized controlled trials (RCTs). We searched seven bibliographic databases, three RCT register websites, and two dissertation databases for publications from inception to 15 March 2023. Chinese and English publications were included. Two independent reviewers conducted the risk of bias assessment, data extraction, and the evaluation of the certainty of the evidence utilizing the Cochrane risk of bias 2.0 assessment criteria, the Review Manager 5.4, and the online GRADEpro tool, respectively. Seven RCTs involving 1362 primiparous women were included. The combined results demonstrated a statistically significant reduction in the second-, third- and/or fourth- degree perineal lacerations, the incidence of episiotomy, and the relief of the short-term perineal pain postpartum (within two days). There was a potential favorable effect on improving the integrity of the perineum. However, the results did not show a statistically significant supportive effect on reducing first-degree perineal lacerations and the rate of perineal lacerations requiring sutures. In summary, perineal warm compresses effectively reduced the second-, third-/or fourth-degree perineal trauma and decreased the short-term perineal pain after birth.

The prevention of perineal trauma during vaginal birth

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.

Factors associated with perineal pain on the first postnatal day after vaginal delivery: a cross-sectional study of primiparous women

Many women report postpartum perineal pain due to perineal trauma after vaginal delivery. Perineal pain after giving birth declines over time; however, perineal trauma and pain negatively impact on the women's quality of life and their ability to care for their children. The degree of perineal trauma and instrument delivery with episiotomy are associated with perineal pain. Nevertheless, no studies have examined factors related to postpartum perineal pain, including weight changes during pregnancy as well as the course of delivery so far. We aimed to elucidate obstetric factors associated with perineal pain after vaginal delivery on the first postnatal day in Japanese primiparous women. A cross-sectional study conducted in five maternity hospitals in Japan included 142 primiparous women who vaginally delivered full-term and singleton infants. Perineal pain on the first postnatal day was evaluated using a visual analog scale. The final analysis included 92 participants with a mean age of 30.3 ± 4.6 years. The median visual analog scale score was 54.0 mm. Multiple linear regression analysis demonstrated that gestational weight gain above the recommended Japanese range was positively and significantly associated with perineal pain on the first postnatal day, independent of maternal age, episiotomy, painkiller use, and neonatal birth weight. This finding may provide additional evidence regarding gestational weight gain within the recommended range based on the pre-pregnancy body mass index to reduce perineal pain on the first postnatal day.

Effects of flexible sacrum position at birth on maternal and neonatal outcomes: A retrospective cohort study

OBJECTIVE

To examine the differences in both maternal and neonatal outcomes between flexible and non-flexible sacrum positions at birth.

METHODS

A descriptive, cross-sectional, retrospective study was carried out on a sample of low-risk pregnant women. Univariate and multivariate logistic regressions and multivariate linear regressions were conducted to estimate the association between our discrete or continuous variables of interest. Maternal outcomes were perineal tear, maternal blood loss, second stage length; neonatal outcomes were Apgar scores and neonatal asphyxia. Results were adjusted for maternal age, neonatal birth weight, and epidural analgesia.

RESULTS

We considered for final analysis 2198 women. In primiparous women, women giving birth in the all-fours position were significantly more likely to have an intact perineum (P = 0.011) and a shorter length of the second stage of labor (P = 0.022). Maternal age (P = 0.005) and neonatal weight (P = 0.013) significantly increased perineal tearing; maternal age (P = 0.004) and neonatal birth weight (P < 0.001) were significantly associated with a higher amount of blood loss. Maternal age (P = 0.002) and neonatal weight (P < 0.001) significantly increased the length of the second stage of labor. For multiparous women, the side-lying position was significantly correlated with an intact perineum (P = 0.031); maternal age and intact perineum were statistically inversely associated. Epidural analgesia significantly increased the length of the second stage of labor in both nulliparous (P < 0.001) and pluriparous women (P < 0.001). No significant differences were found in neonatal outcomes.

CONCLUSION

Women with a low-risk labor should be free to choose their birth position as flexible sacrum positions are shown to increase maternal well-being and do not affect neonatal health.

Implementation of Episcissors-60 for Prevention of Obstetric Anal Sphincter Injuries (OASIS) in a Centre with Low Episiotomy Rates

OBJECTIVE

The purpose of this study was to determine whether introduction of Episcissors-60 into a labour and birth unit would decrease the incidence of Obstetric Anal Sphincter Injuries (OASIS).

METHODS

A before-and-after quality improvement study was conducted between April 1, 2020 and March 31, 2021. All patients who had a vaginal delivery were included in this study. All healthcare providers who perform vaginal deliveries were offered an educational session. Episcissors-60 were then introduced into a labour and birth unit. The primary outcome measure was the change in incidence of OASIS before and after introduction of Episcissors-60. Secondary outcome measures were episiotomy rates before and after introduction of Episcissors-60, device-related adverse events, and provider satisfaction and feedback. Data was analyzed using chi-square tests, independent t-tests, and Mann-Whitney tests.

RESULTS

A total of 1383 vaginal deliveries occurred prior and 1254 vaginal deliveries after introduction of Episcissors-60. There was a decrease in the total OASIS rate from 7.37% of all vaginal deliveries prior to 5.37% after introduction of Episcissors-60 (P = .037). The episiotomy rate was 11.42% prior to and 9.97% after introduction of Episcissors-60 (P = .228). OASIS rate in women who had an episiotomy was 12.02% before and 13.60% after introduction of Episcissors-60 (P = .421).

CONCLUSION

Although introduction of Episcissors-60 was associated with a statistically significant decrease in total OASIS rate, there was no difference in OASIS rates within the subgroup that received an episiotomy. Therefore, reduction in the total OASIS rate in this study cannot be attributed to the use of Episcissors-60.

Trends in instrument preference for operative vaginal delivery in a tertiary referral center: 2008-2021

OBJECTIVE

To examine temporal trends in operative vaginal deliveries as well as the ratio between vacuum and forceps deliveries over 15 years in a large tertiary hospital.

METHODS

This retrospective study assessed prospectively collected data from 2008 to 2021. Women with greater than 37 weeks of gestation who underwent an operative vaginal delivery were included. The rate and ratio of instrumental deliveries and perineal trauma were recorded.

RESULTS

From 2008 to 2021 there was a total of 109 230 term deliveries, of which 20 151 were an operative vaginal delivery. The rate of operative vaginal delivery as a proportion of all term deliveries decreased from 21.9% (1547 of 7069) in 2008 to 17.1% in 2021 (1428 of 8338, P < 0.001). The ratio between vacuum and forceps-assisted deliveries decreased significantly over the study period, from 7.06 in 2008 to 2.39 in 2021 (P < 0.001). Perineal trauma remained unchanged during the study period.

CONCLUSION

Operative vaginal delivery rates declined over the 15-year study period. While vacuum-assisted vaginal deliveries remain the favored instrument, forceps-assisted deliveries are becoming more prevalent. The cause for this change in practice is unclear but is likely multifactorial.

Underdiagnosis of internal anal sphincter trauma following vaginal delivery

OBJECTIVE

Damage to the anal sphincter during childbirth remains the leading cause of fecal incontinence in women. Defects in the internal (IAS) or external anal sphincter, alongside symptoms and sphincter tone, will generally dictate the suggested mode of delivery in any successive pregnancy. This study aimed to examine using endoanal ultrasonography the prevalence of IAS damage in women referred with Grade-3a or -3b obstetric anal sphincter injury (OASI) in a tertiary-referral perineal clinic.

METHODS

This was a retrospective observational study of all women referred to a tertiary-referral perineal clinic after primary repair of OASI (Grade 3a-c, 4) diagnosed for the first time following vaginal delivery between January 2016 and December 2019, inclusive. Women were assessed using the Wexner bowel continence questionnaire, digital examination of sphincter tone and endoanal ultrasound. Injuries in each sphincter were classified as a scar (≤ 30°) or defect (> 30-90° or > 90°) on endoanal imaging in the axial plane.

RESULTS

In total, 615 women were referred following primary repair of OASI. Sonographic evidence of damage to the IAS was seen in 9.1% (46/506) of women diagnosed with a Grade-3a/3b injury. In women referred with a Grade-3a/3b tear, symptom scores were statistically higher (P = 0.025) in those with an IAS defect > 30° compared to those with an intact or scarred IAS, although the median score was zero in both groups. The proportion of women in each group with severe symptoms (score > 9) was similar (2.6% vs 6.5%; P = 0.148). Among women referred with a Grade-3a/3b tear, sphincter tone was reduced more frequently in those with a defect of the IAS than in those with an intact or scarred IAS (52.2% vs 11.7%; odds ratio, 8.14 (95% CI, 4.26-15.67); P < 0.001). Regardless of the reason for referral, women with reduced sphincter tone on rectal examination were four times as likely to have had an IAS defect > 30° than were those with normal resting tone (risk ratio, 4.58 (95% CI, 3.25-6.45); P < 0.001).

CONCLUSIONS

One in 11 women diagnosed with a Grade-3a or -3b tear have evidence of damage to their IAS on endoanal ultrasound. Damage to this muscle is linked to fecal incontinence in women and can have a significant impact on the planning of any future deliveries. This study highlights the importance of established perineal clinics with access to ultrasound. Nonetheless, if reduced sphincter tone is felt on rectal examination, a clinician should have a high index of suspicion for an occult IAS injury. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Migrating foreign body into the urinary bladder of children postperineal trauma

Foreign body (FB) in the urinary bladder (UB) is uncommon and rarely reported in pediatric patients. FB migration into the UB is an extremely rare and unpredictable condition that needs a high index of suspicion with meticulous history taking and clinical reasoning, so diagnosis may be challenging. In this study, we report two cases of male pediatric patients from Sudan with FB in the UB, with a history of penetrating perineal trauma, both were presented with irritative lower urinary tract symptoms, history of penetrating perineal trauma, and unremarkable clinical examination. Both were diagnosed by abdominal Ultrasound study (USS) and confirmed by cystoscopy. One child was treated by endoscopic extraction, while the other was treated by open surgical extraction. The outcome of treatment of both the cases was satisfactory.

Immersion in water during the second stage of labor: a randomized controlled trial

BACKGROUND

Current obstetrical guidelines in the United States caution firmly against birth in water, but patients remain interested in this intervention. Limited data are available to evaluate the safety and efficacy of water immersion in the second stage of labor for patients and neonates.

OBJECTIVE

This study aimed to ascertain the effects of water use during the second stage of labor on maternal outcomes. Second, it aimed to propose guidelines for midwives conducting the second stage of labor in water.

STUDY DESIGN

A randomized, prospective design was used to evaluate the primary outcomes of maternal experience in labor and trauma to the birth canal and several secondary neonatal and maternal outcomes when participants delivered in water vs in a conventional setting. Participants were recruited at 2 academic state hospitals serving the same low- to middle-income group urban population in the midwestern suburbs of Johannesburg, South Africa over a period of 2 years. Individuals in active labor without exclusion criteria were asked to participate in the study. A total of 120 participants were enrolled, with 60 randomized to water birth and 60 to conventional birth. Outcomes were compared using the chi-square and Fisher exact tests.

RESULTS

The use of water during birth significantly reduced the participants' perception of experienced pain than what they expected it to be (P=.006) and enhanced their satisfaction with their ability to cope with labor (P=.010). No differences were noted in trauma to the birth canal. No adverse maternal effects were noted. One early neonatal death occurred in the water group. The most likely cause of death was preexisting intrauterine fetal infection.

CONCLUSION

Participants who delivered in water were significantly more satisfied with their birthing experience. The possible harmful effect of inhalation of fresh water by a baby is not resolved, and a large randomized controlled trial is recommended. It is recommended that immersion in water during the second stage of labor should only be offered by competent birth attendants who follow specific guidelines until clear evidence is available on the possible beneficial or harmful effects. Pending further evidence, we recommend adding salt to the bath to produce a physiological saline solution to reduce theoretical risks associated with fresh water inhalation by the neonate.

Imaging Characteristics of Episiotomy Scars on Translabial Ultrasound: An Observational Study

INTRODUCTION

Episiotomy has been purported to protect the anal sphincter from injury; efficacy is, however, disputed. Correct execution of episiotomy may have substantial implications. We aimed to describe the characteristics of episiotomy scars on translabial ultrasound (TLUS).

METHODS

In this retrospective observational study involving women after repair of obstetric anal sphincter injuries, 76 women with a history of episiotomy were analyzed. Episiotomy scars were assessed on tomographic ultrasound in the transverse plane using volumes acquired on pelvic floor muscle contraction. We measured scar length, depth, and angle relative to a vertical reference line. Episiotomy scars were described as 1) ipsilateral if they started on the same side as the direction of the episiotomy, 2) contralateral if on the opposite side, and 3) mediolateral if the scar began in the midline.

RESULTS

The mean scar angle was 50.5° (SD 14°; range 14.4°-79.3°) while mean scar length was 14.2 mm (SD 4.5; range 5.7-27.5 mm) and depth was 8.4 mm (SD 2.8, range 3.1-18.2 mm). Sixteen (21%) scars were located mediolateral while 32 (42%) were ipsilateral. In 28 (37%) women, the starting point of the episiotomy was located contralateral to the direction of the episiotomy.

CONCLUSION

In this pilot series, the mean angle of episiotomy scars was within the safe zone of 40° to 60°, however, in one-third of cases the cut may have been initially directed toward the sphincter, not away from it. This observation suggests that not all episiotomies are performed optimally.

Risk factors for obstetric anal sphincter injury recurrence: A systematic review and meta-analysis

BACKGROUND

Women with previous obstetric anal sphincter injuries (OASIs) are at a higher risk of recurrence in the subsequent pregnancy, which may lead to the development or worsening of anal incontinence. Due to a lack of evidence, few recommendations can be made about the factors that may affect the risk of OASI recurrence.

OBJECTIVE

We sought to conduct a systematic review and meta-analysis to investigate potential risk factors for recurrent OASIs.

SEARCH STRATEGY

Studies up to May 2019 were identified from PubMed, Scopus, Cochrane Library, and ISI Web of Science.

SELECTION CRITERIA

Studies assessing the impact of risk factors on OASI recurrence in subsequent pregnancies were included. Reviews, letters to the editor, conference abstracts, book chapters, guidelines, Cochrane reviews, and expert opinions were excluded.

DATA COLLECTION AND ANALYSIS

Data were extracted by two independent reviewers. Odds ratio and standardized mean difference were chosen as effect measures. Pooled estimates were calculated using the random-effects model.

MAIN RESULTS

The meta-analysis showed that maternal age, gestational age, occiput posterior presentation, oxytocin augmentation, operative delivery, and shoulder dystocia were associated with the risk of recurrent OASIs in the subsequent delivery.

CONCLUSION

Prenatal and intrapartum risk factors are associated with recurrence of OASI. PROSPERO registration no. CRD42020178125.

The effects of perineal trauma on immediate self-reported birth experience in first-time mothers

INTRODUCTION

Childbirth can sometimes be stressful or traumatic, and previous research has considered how birth complications and interventions may contribute to a negative birth experience. One of the most frequent complications during birth is trauma to the perineum. The aim of this study was to investigate whether different levels of perineal trauma were associated with differences in women's evaluation of their birth experience.

MATERIALS AND METHODS

As part of a longitudinal cohort study, the self-reported birth experiences of 202 primiparous women were compared based on the degree of perineal trauma they had experienced. Women who had given birth for the first time, vaginally and within the last 48 h in a large tertiary maternity unit in England were invited to take part. Data were collected from their hospital records with their consent and using the Childbirth Experience Questionnaire (CEQ), Experience of Birth Scale (EBS) and a perineal pain Visual Analogue Scale (VAS).

RESULTS

Women with an obstetric anal sphincter injury (OASI) or episiotomy reported a more negative overall birth experience and perceived themselves as having less ability to give birth compared to those with a 1st/2nd degree sutured tear. Those with an episiotomy also reported feeling less involved in decision making processes during their birth. Significant differences remained between the OASI and 1st/2nd degree tear groups when controlling for factors known to affect birth experience, highlighting severe perineal trauma as a potential contributor to more negative birth experience.

CONCLUSIONS

Perineal trauma may affect a woman's birth experience. Experiencing an episiotomy should not be overlooked as a potential contributor, especially during instrumental birth and in the absence of involved decision making. Further research is needed to disentangle the effects of episiotomy on birth experience, to explore the care needs of women with different degrees of perineal trauma and to explore how a negative birth experience may contribute to poor psychological health in the longer term.

A Case of Rectovesical Fistula Following Blunt Trauma in a Child

Rectovesical fistulae (RVF) are uncommon entities and usually occur after surgery for prostate, radiation, and sometimes due to penetrating trauma. However, RVF occurrence after blunt trauma to the abdomen or perineum is very rare. The management of RVF is challenging, and treatment options should be considered according to the individual. Here we present a case of a 10-year-old boy who presented with fecaluria, pneumaturia, the passage of urine per rectum, and burning micturition for four days after incurring a blunt injury to the perineum. Cystography revealed leakage of contrast material into the rectum and an MRI of the pelvis was done for confirmation, which revealed a 1.3 cm thick fistulous tract of 2.7 cm length with openings at the posterior bladder wall and anterior rectal wall. After conservative management for 14 days failed to show any improvement, primary repair of the fistulous tract along with fecal diversion and urinary diversion were done. The suprapubic catheter was removed after four weeks, and at the two-month follow-up, colostomy closure was done. No recurrence was found in the six-month follow-up period. In cases of small traumatic RVF where conservative management fails, fecal and urinary diversion can be considered, as it is associated with successful outcomes and less recurrence.

Influence of a Virtual Exercise Program throughout Pregnancy during the COVID-19 Pandemic on Perineal Tears and Episiotomy Rates: A Randomized Clinical Trial

The complications associated with COVID-19 confinement (impossibility of grouping, reduced mobility, distance between people, etc.) influence the lifestyle of pregnant women with important associated complications regarding pregnancy outcomes. Therefore, perineal traumas are the most common obstetric complications during childbirth. The aim of the present study was to examine the influence of a supervised virtual exercise program throughout pregnancy on perineal injury and episiotomy rates during childbirth. A randomized clinical trial design (NCT04563065) was used. Data were collected from 98 pregnant women without obstetric contraindications who attended their prenatal medical consultations. Women were randomly assigned to the intervention (IG, N = 48) or the control group (CG, N = 50). A virtual and supervised exercise program was conducted from 8-10 to 38-39 weeks of pregnancy. Significant differences were found between the study groups in the percentage of episiotomies, showing a lower episiotomy rate in the IG (N = 9/12%) compared to the CG (N = 18/38%) (χ² (3) = 4.665; p = 0.031) and tears (IG, N = 25/52% vs. CG, N = 36/73%) (χ² (3) = 4.559; p = 0.033). A virtual program of supervised exercise throughout pregnancy during the current COVID-19 pandemic may help reduce rates of episiotomy and perineal tears during delivery in healthy pregnant women.

Obstetrical Soft Tissue Trauma during Spontaneous Vaginal Birth in the Romanian Adolescent Population-Multicentric Comparative Study with Adult Population

Romania is a country with high rates of adolescent births, associating scarce comprehensive obstetrical management with this specific population. This research aims to assess soft tissue trauma after vaginal birth in teenage mothers compared to their adult counterparts. A retrospective case-control study was conducted for one year in two hospitals. All vaginal deliveries were considered; the age cut-off value was considered at 20 years old for case and control groups. Lacerations were divided into three subgroups, considering the involved anatomical region; group I: labial and periurethral lacerations, group II: vaginal and perineal lacerations, and group III: cervical lacerations. There were 1498 women included in the study: 298 young mothers and 1200 adults. Teenagers were more likely to have an episiotomy during vaginal delivery compared to adult women: 56% versus 26.7% (p = 0.00, Pearson Chi-square) and a 1.89 times increased risk for developing additional group II lacerations: p = 0.01, Pearson Chi-square test with Bonferroni correction: OR = 1.89, 95% CI: 1.18–3.02. Group II lacerations were the most frequent type of birth trauma in both study groups. Fetal weight ≥4000 g was associated with a two times higher risk for vaginal and perineal lacerations when age criterion was not considered (OR = 1.98, 95% CI: 1.13–3.47, p = 0.01). The incidence of group I and II lacerations increased with age: from 0% and 9.1% between 10 and 14 years old to 6% and 26.2% between 18 and 19 years old. All groups of lacerations were more often identified in the case group, compared to the adult group. Fetal macrosomia and spontaneously ruptured membranes at admission could not be documented as risk factors for obstetrical injury in young mothers. Episiotomy performed in teenagers was not a protective procedure for group II lacerations.

Effectiveness of structured education and training in perineal wound assessment and repair for midwives and midwifery students: A review of the literature

INTRODUCTION

Perineal trauma is a commonly observed complication of childbirth, affecting more than 75% of women who have a vaginal birth. Perineal trauma is associated with significant short- and long-term comorbidities that negatively impact women's quality of life. Severe perineal trauma (SPT) rates in Australia have almost doubled in the last decade. Reasons for increased rates are not completely understood; some researchers suggest improvements in diagnosis and reporting, while others have a view that it may be due to a lack of structured and standardized education in perineal wound assessment and repair for clinicians.

METHODS

The Joanna Briggs Institute (JBI) scoping review methodology was adopted as a systemic process to identify studies that have investigated the effectiveness of perineal wound assessment and repair education and training for midwives and midwifery students.

RESULTS

Five studies met the inclusion criteria for this review, to have evaluated a type of education or training, on childbirth-related perineal wound assessment and repair that included midwives and midwifery students. A total of 1279 midwives and midwifery students volunteered to participate in all five studies. The length of the education or training implemented varied between each study from a 1-day workshop to 100 hours of education. All five studies measured the effectiveness of each program through changes in participants' confidence, knowledge and skills in perineal assessment and repair before and after an intervention using various self-assessment questionnaires.

CONCLUSIONS

The implementation of a structured educational workshop on perineal wound assessment and repair improves the confidence, skills and knowledge of midwives and students.

Efficacy of re-do urethroplasty for post-traumatic urethral stricture: An analysis of the anatomical and functional outcomes

OBJECTIVES

To investigate the efficacy of re-do urethroplasty for post-traumatic urethral stricture in terms of anatomical and functional outcomes.

METHODS

A total of 48 patients who underwent re-do urethroplasty for post-traumatic urethral stricture due to perineal trauma (n = 21) and pelvic fracture urethral injury (n = 27) between October 2010 and March 2020 were retrospectively reviewed. Patients were followed by uroflowmetry, post-void residual volume assessment and 17-Fr flexible cystoscopy after re-do urethroplasty. Successful urethroplasty was defined as having a urethral caliber adequate for the passage of a cystoscope and requiring no additional treatments. Patients completed a validated patient-reported outcome measure for urethral stricture surgery, including overall satisfaction, and the sexual health inventory for men.

RESULTS

The type of re-do urethroplasty was anastomotic urethroplasty in 45 (94%) patients and buccal mucosa urethroplasty in three (6%) patients. Urethroplasty was successful in 47 (98%) patients (median follow up 35 months, interquartile range 21-75). The patient-reported outcome measure for urethral stricture surgery and Sexual Health Inventory for Men were assessed in 36 (75%) patients, and the mean lower urinary tract symptom-specific quality of life, EuroQol-5D and EuroQol-visual analog scale scores improved from 2.86, 0.63 and 54.17 preoperatively to 0.78 (P < 0.001), 0.86 (P < 0.001) and 76.94 (P < 0.001) postoperatively, respectively. The pre- and postoperative mean Sexual Health Inventory for Men scores (5.92 and 4.94, respectively) did not significantly differ (P = 0.318). All 36 patients were satisfied with their urethroplasty outcomes, with 20 (56%) very satisfied patients.

CONCLUSIONS

Re-do urethroplasty for post-traumatic urethral stricture shows a high success rate and beneficial effects on both anatomical and functional outcomes.

Childbirth Related Labial Trauma Management in the UK: A Brief Report

Trauma to the labia occurs in up to 49% of vaginal births¹. Trauma to the perineal body resulting from childbirth is well defined using widely used categories, and recommended management of perineal body trauma is based on high level evidence. Currently no similar evidence exists to inform the classification or management of labial trauma. This is reflected in variation in clinical practice with some practitioners favouring suturing of labial trauma, whilst others favour healing by secondary intention. A survey of practice was undertaken in three NHS organisations, over a five-week period in 2019 with data collected on 332 vaginal births. Overall, 47.3% (n=157) of women sustained labial trauma, of whom 29.3% (n=46) sustained trauma described as involving skin and underlying tissues. Of the labial trauma which involved skin and underlying tissues 76.0% (n=35) was sutured and the remainder unsutured. The survey confirmed a lack of consistency in practice and the need for further research to inform care for women.

Practices of midwives working in delivery rooms for protection of perineum during intrapartum period and their feedback on these applications

INTRODUCTION AND HYPOTHESIS

Perineal traumas occurring during labor are undesirable for both the midwives and the woman. Midwives and obstetricians could use different techniques to protect the perineum.

PURPOSE

The aim of this study was to determine the practices of midwives working in the delivery room to protect the perineum during the second stage of labor.

METHODS

This is a prospective observational study regarding practices of midwifes for protection of perineum during intrapartum period. The study was conducted with a total of 20 midwives in a maternity unit of an training and research hospital. The data were collected through the forms prepared by the researchers.

FINDINGS

The average age of the midwives was 34 ± 8.77. The majority of midwives (n: 17, 85%) believed that the need for practices to protect the perineum during labor; 40% of them used perineal protection (hands on) technique to protect perineum and they preferred to perform routine episiotomy in all primiparas.

RESULTS AND CONCLUSIONS

As a result of the study, it was observed that evidence-based practices was not applied sufficiently enough by the midwives although they were knowledgeable and believed that they are beneficial. Studies are needed for the obstacles to these practices to be identified and removed.

Women's experience of episiotomy: a qualitative study from China

OBJECTIVE

To describe women's experience of episiotomy in urban China.

DESIGN

This is a semistructured, indepth interview with women after episiotomy. We analysed transcriptions using thematic analysis in Chinese. Emerging themes were debated in English to finalise interpretation.

SETTING

Two community health centres and four hospitals in Shanghai, China.

PARTICIPANTS

Purposive sampling of 30 postpartum women who had experienced episiotomy; 25 were primiparous and 4 had deliveries by forceps. We interviewed health providers to complement the data.

RESULTS

We identified four main themes: (1) women's views of the procedure vary considerably; (2) pain interferes with daily life for weeks; (3) long-term anxiety is a consequence for some, described as a 'psychological shadow'; and (4) societal norms assume women will not complain.

CONCLUSION

Women receive little information in advance about episiotomy, yet the procedure has a wide range of physical and psychological consequences. This includes long-term anxiety about the damage done to them as women.

A Surgical Technique to Repair Perineal Body Disruption Secondary to Sexual Assault

Perineal trauma is uncommon in the pediatric population and it is estimated that 5 to 21% is secondary to sexual abuse. We aim to present a proposed surgical technique to repair perineal injuries secondary to sexual assault in female children. The technique is based on the posterior sagittal anorectoplasty (PSARP) for repairing anorectal malformations and, between 2017 and 2019, it was used to treat three girls (2 months, 2 years, and 8 years of age) with fourth-degree perineal injuries secondary to sexual assault. One of them underwent laparotomy and Hartmann's colostomy for an acute abdomen. Two underwent wound debridement and suturing and only had a stoma fashioned at 5 days and 6 weeks posttrauma, respectively. The perineal repair was performed 2, 6, and 7 weeks postinjury and done as follows: with the child prone in jack-knife position, stay-sutures are placed on the common wall between the rectum and the vagina. Using a needle tip diathermy, a transverse incision is performed below the sutures lifting the anterior rectal wall up. Stay sutures are then positioned on the posterior wall of the vaginal mucosa. The incision between the walls is deepened until the rectum and the vagina are completely separated. The deep and superficial perineal body is then reconstructed using absorbable sutures and an anterior anoplasty and an introitoplasty are performed. The stoma in each was closed 6 weeks postreconstruction. At follow-up, now 1 year or more postrepair, all patients have an excellent cosmetic outcome and are fully continent for stools.

Mediolateral Episiotomy: Technique, Practice, and Training

Episiotomy is one of the most common obstetric procedures. However, restrictive use of episiotomy has led to a decrease in its use in the United States. Historically, mediolateral episiotomy has been performed less often than median episiotomy in the United States, but both have purported advantages and disadvantages. Emerging research on episiotomy and obstetric anal sphincter injuries has led to an examination of the effects of mediolateral episiotomy. This article describes performance of a mediolateral episiotomy in a situation of fetal bradycardia. Technical aspects of the incision and repair are described, and outcome data and knowledge gaps are summarized. Implications for practice, clinical competency, and education are reviewed.

Are women attending a midwifery-led birthing center at increased risk of anal sphincter injury?

INTRODUCTION AND HYPOTHESIS

In recent years there has been renewed interest in midwifery-led care for women, with studies reporting similar neonatal outcomes despite lower rates of intervention in midwifery-led birthing centers. Research into obstetric anal sphincter injuries (OASI) in these birthing centers is scarce. The objective of this study was to compare the rate of OASI after spontaneous vaginal delivery in nulliparous women in consultant or midwifery-led units over a ten-year period.

METHODS

All spontaneous vaginal deliveries in nulliparous women from 2008 to 2017 were analyzed in a single-center retrospective study. Women who had neuraxial analgesia were excluded. The primary endpoint was OASI. Labor characteristics in both groups were compared, and a multiple regression model was created.

RESULTS

During the study period, there were 3260 spontaneous vaginal deliveries in nulliparous women; 75.7% (2467/3260) delivered in the consultant-led unit and 24.3% (793/3260) in the midwifery-led unit (MLU). Women delivering in the MLU had a greater risk of anal sphincter injury than those delivering in the CLU (4.9% [39/793] vs 2.5% [62/2467], OR 2.01, 95% CI 1.32 - 3.01). Significant risk factors that increased the risk of OASI on regression analysis were birthweight and delivery in the midwifery-led unit.

CONCLUSIONS

Women delivering in the midwifery-led unit appear to be at double the risk of OASI when compared to those delivering in the consultant-led unit. These results are in contrast to previous studies in midwifery-led centers. This difference may be site-specific and further research is required before these results form part of patient counseling.

Randomized, Double-Blind, Placebo-Controlled Trial on the Efficacy of Hyaluronidase in Preventing Perineal Trauma in Nulliparous Women

PURPOSE

Hyaluronidase (HAase) has many uses in medicine, and reports suggest that it affects perineal tissue during fetal passage through the vaginal canal. However, its potential use for preventing perineal trauma has yet to be determined. This study sought to evaluate the efficacy and safety of perineal HAase injections in reducing perineal trauma during vaginal delivery.

MATERIALS AND METHODS

A multi-center, double-blind, placebo-controlled, randomized study was conducted from January 2016 to March 2017. Nulliparous women who planned to undergo vaginal delivery were recruited, and the enrolled women were randomly assigned to the HAase injection group (HAase injection, 5000 IU, n=75) or the control group (normal saline injection, n=73). The degree of perineal laceration, rate of episiotomy, and grade of perineal edema at 1 hour and 24 hours after spontaneous vaginal delivery were compared between the two groups.

RESULTS

A total of 148 women who underwent vaginal delivery were recruited. No significant differences were observed between the HAase injection and control groups in the rates of perineal laceration (p=0.422). Perineal edema significantly decreased 24 hours after delivery in the women treated with perineal HAase injections, compared to women in the control group (p=0.008). The overall incidences of adverse events, such as redness of the injection site, infection, and wound dehiscence, were similar between the two groups.

CONCLUSION

HAase injections in nulliparous women afforded no reductions in the rates of perineal lacerations and episiotomy. However, the use of perineal HAase injections did reduce perineal edema without severe adverse events.

Evaluation of the ease of use and acceptability of an innovative device - the 'Episiometer', in ensuring an accurate mediolateral episiotomy: a pilot study

The present study was undertaken at the Port Moresby General Hospital, Papua New Guinea, to evaluate the ease of use and acceptability of a perineal measuring device (Episiometer) for giving a correct length and angle of a mediolateral episiotomy. An Episiometer was placed on the perineum to guide the angle and length immediately before giving an episiotomy. A feedback survey was collected and the angle and length of the episiotomy were measured at the time of delivery and at 6 weeks postpartum. The length and angle of episiotomy were found to be accurate in 86% of the cases. Forty-two of the fifty (86%) clinicians felt that the Episiometer was easy or very easy to use. They also found this device to be beneficial (92%). The Episiometer seems to be an easy-to-use and feasible device that is well accepted by clinicians and patients and may aid in standardising the length and angle of an episiotomy. Impact statement What is already known on this subject? Episiotomy is the commonest obstetric procedure performed worldwide. However, the angle and length of an episiotomy vary greatly amongst operators. It is also recognised that birth trauma and an inaccurate episiotomy result in debilitating anal sphincter injury. Therefore, a pilot study was conducted to evaluate the ease of use and acceptability of a new, inexpensive, low- tech device "Episiometer" to guide clinicians and midwives to perform an appropriate episiotomy. What do the results of this study add? This pilot study to evaluate the usability of the new innovation amongst clinician and patients revealed high acceptance of the device amongst clinicians and positive attitude of the patients towards the device. The clinicians also felt the device to be an effective teaching tool. Usage if the device results in a more accurate length and angle of an episiotomy. What are the implications of these findings for clinical practice and/or further research? Further research and multicentre randomised control trials are needed to establish the effectiveness of the device in reducing the complications of episiotomy and risk of OASIS. The present study has shown the Episiometer as an acceptable and easy to use device amongst clinicians and can benefit the young clinicians as a teaching tool in directing a correct angle and length of episiotomy.

The Colostomy of Duret for the High Risk Patient

Background: Heitzer and Duret described the surgical creation of colostomy in the 1700s, more than a century before the introduction of anesthesia. With the ever increasing degree of frailty in patients of advanced age who require surgical intervention, a simplified methodology for the creation of a colostomy based on their original reports is described and the advantages for use in high risk patients and the critical care setting is discussed. Methods: Eleven patients underwent simplified colostomy under local anesthesia, without complication. Results: All colostomies functioned normally within hours. There were no bleeding or infectious complications, nor peri-operative adverse events. Conclusions: Colostomy formation can be safely performed under local anesthesia when the patient is considered too high risk to undergo general anesthesia.

Traumatic perineal injury in a 13-year-old female: Case report and review of the literature

Traumatic perineal injury in children is a rather underestimated condition, in terms of occurrence. The rapid stretching of the soft perineal environment, combined with the surrounding osseous tissue of the pelvis, can cause severe injuries. The key to successful management of these injuries includes timely resuscitation, thorough physical examination and quick and safe repair of damages.

Resumption of sex after a second birth: An Australian prospective cohort

BACKGROUND

Few longitudinal studies have examined women's experiences of sex after childbirth. Much of the advice given to couples about what to expect in relation to sex after childbirth is based on cross-sectional studies.

OBJECTIVE

To investigate timing of resumption of sex after a second birth and assess associations with obstetric factors (method of birth and perineal trauma) and time interval between first and second births.

METHOD

Prospective cohort of 1507 nulliparous women recruited before 25 weeks' gestation in Melbourne, Australia followed up at 3, 6, 9, and 12 months after first births, and 6 and 12 months after second births. Measures include: obstetric factors and resumption of vaginal sex after first and second births.

RESULTS

By 8 weeks after their second birth, 56% of women had resumed vaginal sex, compared with 65% after their first birth. Women were more likely to resume sex later than 8 weeks postpartum if they had a spontaneous vaginal birth with episiotomy or sutured perineal tear (aOR: 2.21, 95% CI: 1.5-3.2), operative vaginal birth (aOR: 2.60, 95% CI: 1.3-5.3) or cesarean delivery (aOR: 2.15, 95% CI: 1.4-3.3) compared with a vaginal birth with minimal or no perineal trauma. There was no association between timing of resumption of sex and the time interval between births.

CONCLUSION

For almost half of the cohort, sex was not resumed until at least 8 weeks after the second birth. Timing of resumption of sex was influenced by obstetric factors, but not the time interval between births.

Selective arterial embolization for a high-flow priapism following perineal trauma in a young gymnast

INTRODUCTION

High-flow priapism is a rare condition in children, usually due to a perineal trauma.

MATERIALS AND METHODS

We present a case of traumatic highflow priapism investigated by Doppler ultrasound and managed by angiography and selective embolization of a branch of the internal pudendal artery.

RESULTS

A 13-year-old gymnast underwent perineal trauma during training and developed a high-flow priapism. The first ultrasound (immediately after the trauma) showed the presence of an inhomogeneous area of 3 x 2 cm associated with an anechoic vascularized area (pseudoaneurysm) in the right corpus cavernosum. On the left side there was a similar finding, but of smaller size. After 3 weeks the pseudoaneurysm on the left was completely obliterated while the right one was still present. Angiography and superselective catheterization of a branch of the left pudendal artery and its embolization with microspheres and with metal microcoils were performed. After the procedure, ultrasound showed that the right pseudoaneurysm was completely obliterated and there were no more branches reaching it. The cavernous arteries were both pervious.

CONCLUSIONS

Selective arterial embolization is a safe treatment that can also be used in pediatric patients.

Do we need a core outcome set for childbirth perineal trauma research? A systematic review of outcome reporting in randomised trials evaluating the management of childbirth trauma

BACKGROUND

Selecting appropriate outcomes to reflect both beneficial and harmful effects is a critical step in designing childbirth trauma trials.

OBJECTIVE

To evaluate the outcomes and outcome measures reported in randomised controlled trials evaluating interventions for childbirth trauma.

SEARCH STRATEGY

Randomised trials were identified by searching bibliographical databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE.

SELECTION CRITERIA

Randomised trials evaluating the efficacy and safety of different techniques in the management of perineal lacerations.

DATA COLLECTION AND ANALYSIS

Two researchers independently assessed studies for inclusion, evaluated methodological quality, and extracted the relevant data. Spearman's ρ correlation and multivariate linear regression analysis using the backward stepwise model were used for analysis.

MAIN RESULTS

Forty-eight randomised trials, reporting data from 20 308 women, were included. Seventeen different interventions were evaluated. Included trials reported 77 different outcomes and 50 different outcome measures. Commonly reported outcomes included pain (34 trials; 70%), wound healing (20 trials; 42%), and anorectal dysfunction (16 trials, 33%). In the multivariate analysis, no relationship was demonstrated between the quality of outcome reporting and year of publication (P = 0.31), journal impact factor (P = 0.49), and methodological quality (P = 0.13).

CONCLUSION

Outcome reporting in childbirth trauma research is heterogeneous. Developing, disseminating, and implementing a core outcome set in future childbirth trauma research could help address these issues.

TWEETABLE ABSTRACT

Developing @coreoutcomes for childbirth trauma research could help to reduce #research waste.

Effect of female genital cutting performed by health care professionals on labor complications in Egyptian women: a prospective cohort study

AIM

To examine the effect of the degree of female genital cutting (FGC) performed by health-care professionals on perineal scarring; delivery mode; duration of second stage of labor; incidence of perineal tears and episiotomy in a cohort of uncircumcised versus circumcised (types I and II) women.

METHODS

A prospective cohort study included 450 primigravida women in active labor attending the Faculty of Medicine Cairo University Hospital between January 2013 and August 2014. Women were divided into three groups based on medical examination upon admission. Group I (Control) included 150 uncut women, Group II included 150 women with type I FGC and Group III included 150 women with type II FGC. A structured questionnaire elicited the information on women's socio-demographic characteristics including age, residence, occupation, educational level, age of marriage and FGC circumstances. Association between FGC and labor complications was examined.

MAIN OUTCOMES

risk of perineal scarring; delivery mode; duration of second stage of labor; incidence of perineal tears and episiotomy.

RESULTS

Family history of genitally cut mother/sister was the most significant socio-demographic factor associated with FGC. FGC especially type II was associated with significantly higher incidence of vulvar scar (P<0.0002), perineal tears (P<0.0001) and increased likelihood of additional vaginal and perineal trauma [odds ratio (OR): 1.85, 95% CI: 0.60-5.65. P≤0.001]. There was insignificant difference in risks of cesarean section (CS), instrumental delivery, episiotomy and short-term neonatal outcomes.

CONCLUSION

The study strengthens the evidence that FGC increases the risk of tears in spite of medicalization of the practice.

A systematic mixed studies review of women's experiences of perineal trauma sustained during childbirth

AIM

To explore the quantitative/qualitative literature on women's experiences of perineal trauma sustained during childbirth and the impact it may have on psychological/emotional wellbeing BACKGROUND: Obstetric complications during childbirth can be a risk factor for postpartum psychological distress. Perineal trauma is one of the most frequent obstetric complications and it is important to understand any impact on psychological/emotional wellbeing.

DESIGN

A convergent qualitative design using a hybrid deductive-inductive thematic synthesis approach to data transformation was used.

DATA SOURCES

Web of knowledge, CINAHL, MEDLINE, AMED, PsyArticles, PsycInfo until May 2017.

REVIEW METHODS

Stage 1: transforming findings from the qualitative, quantitative and mixed methods studies into themes using thematic synthesis. Stage 2: integrating themes from the quantitative studies into those derived from the qualitative studies RESULTS: Records (N=2152) found of which 11 qualitative 22 quantitative and 1 mixed methods were included in this review. Five themes were derived from thematic synthesis of qualitative studies 'The mystery of perineal trauma', 'The misery of perineal suturing', 'The postnatal perineum', 'Normalisation and feeling dismissed' and 'Adjusting to a new normal - Coping and compromise' and five themes identified from the quantitative studies, experience of birth (N=4), Sexual functioning (N=12), Social functioning (N=2), Psychological health (N=8) and Quality of Life (N=5).

CONCLUSION

Perineal trauma can have a negative impact on psychological/emotional wellbeing, however the literature is conflicted and in need of clarification. Future research should clearly describe the perineal status of the women in the sample, use validated measures and consider the timing of such measures. This article is protected by copyright. All rights reserved.

An Audit of Perineal Trauma and Vertical Transmisson Of HIV

Restrictive episiotomy is recommended for the prevention of vertical transmission of HIV. The study compared the frequency of episiotomy use and the occurrence of perineal tears; and related factors in HIV positive and HIV negative women and to assess their effect on Mother-to-child transmission (MTCT) of HIV. A total of 110 HIV positive and 134 HIV negative parturients were enrolled in the study. The incidence of episiotomy was more in the HIV negative group (p=0.0000) while that of perineal tear was not affected by HIV status (p=0.17). The rate of episiotomy was significantly affected by primigravidity in HIV negative subjects (OR= 0.032, 95% CI 0.0072-0.13). The rate of perineal tear was significantly affected by primigravidity in HIV positive subjects (OR=8.55, 95% CI 1.91-38.7) and multigravidity in HIV negative subjects (OR= 0.030, 95% CI 0.133-0.71). Gestational age and mean birth weight had no effect on the rate of episiotomy (p value =0.57 and 0.30) and perineal tear (p value= 0.79 and 0.061). There was no mother-to-child HIV transmission. Episiotomies should be given when needed irrespective of HIV status because of the risk of consequent perineal tear and with HAART the risk of MTCT from perineal trauma is minimal.

Demographic characteristics and pregnancy outcomes in adolescents - Experience from an Australian perinatal centre

BACKGROUND

Adolescent pregnancy is defined as pregnancy in girls aged 10-19 years and can be associated with increased risks.

AIM

To investigate obstetric and perinatal outcomes in a cohort of adolescent girls from a major Australian tertiary centre.

MATERIALS AND METHODS

This was a nine-year retrospective cohort study of women who birthed at the Mater Mother's Hospital (MMH) in Brisbane, Australia between 1 January 2007 and 31 December 2015. The adolescent cohort was aged <19 years and the control group was aged 20-24 years.

RESULTS

Over the study period the total study cohort comprised 8904 women. Of these, the adolescent cohort consisted of 1625 girls (18.2%) and the control group consisted of 7279 women (81.8%). Adolescents were more likely to be nulliparous, single, of Indigenous ethnicity or to have refugee status. They had higher rates of smoking, asthma, diabetes mellitus and thyroid disease. They were more likely to have an uncomplicated spontaneous vaginal delivery but were less likely to have an intact perineum and had higher rates of pre-term delivery and low birth weight babies. There were no differences in rates of postpartum haemorrhage.

CONCLUSIONS

Teenage pregnancy results in poorer obstetric and perinatal outcomes. A focus on optimising maternal health care and providing culturally appropriate antenatal and intrapartum care is imperative to improving outcomes.

The effect of maneuvers for shoulder delivery on perineal trauma: a randomized controlled trial

INTRODUCTION

Approximately 85% of vaginal deliveries are accompanied by perineal trauma. The objective of this trial was to compare the incidence of perineal trauma after primary delivery of either the anterior or posterior shoulder during vaginal delivery.

MATERIAL AND METHODS

This was a randomized single-blinded trial comparing primary delivery of either the anterior or posterior shoulder in women having their first vaginal delivery. Primary outcome was any perineal trauma. Results were analyzed according to the intention-to-treat principle and supplemented with a per-protocol and as-treated analysis.

RESULTS

Between June 2013 and March 2015, 650 women were randomized, and 543 (posterior, n = 281; anterior, n = 262) were included in the final intention-to-treat analysis. Most group characteristics were similar. The frequency of any perineal trauma did not differ between the two groups (posterior: 91.5%, anterior: 90.5%; odds ratio 1.130, 95% confidence interval 0.628-2.032, p = 0.684). The results did not change after adjustment for basic characteristics with significant group differences (a1 odds ratio 1.174, 95% confidence interval 0.632-2.179, p = 0.612) or predefined risk factors (a2 odds ratio 1.139, 95% confidence interval 0.599-2.166, p = 0.691). The rate of perineal trauma also did not differ between the groups in a "per-protocol" and "as-treated" analysis.

CONCLUSIONS

There was no difference in the degree of perineal trauma after primary delivery of either the anterior or posterior shoulder. Consequently both maneuvers for shoulder delivery can be used at vaginal delivery, but further trials are warranted before certain methods can be recommended.

How to repair an episiotomy

Rationale and key points Skilful repair of an episiotomy is an important aspect of maternal health care. It is essential that midwives and doctors have the knowledge and skills to undertake this procedure in a safe and effective manner. ▶ An episiotomy should be repaired promptly to reduce blood loss and prevent infection. ▶ Repair of an episiotomy is undertaken in three stages: repair of the vaginal mucosa, repair of the muscle layer and repair of the skin layer. ▶ Adequate pain relief should be provided before suturing. Reflective activity Clinical skills articles can help update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: 1. Why a rectal examination is recommended before and following repair of an episiotomy. 2. What you would do to improve your suturing skills. 3. The factors that may prevent or delay an episiotomy from healing. Subscribers can upload their reflective accounts at rcni.com/portfolio .

Maternal and Newborn Outcomes Following Waterbirth: The Midwives Alliance of North America Statistics Project, 2004 to 2009 Cohort

INTRODUCTION

Data on the safety of waterbirth in the United States are lacking.

METHODS

We used data from the Midwives Alliance of North America Statistics Project, birth years 2004 to 2009. We compared outcomes of neonates born underwater waterbirth (n = 6534), neonates not born underwater nonwaterbirth (n = 10,290), and neonates whose mothers intended a waterbirth but did not have one intended waterbirth (n = 1573). Neonatal outcomes included a 5-minute Apgar score of less than 7, neonatal hospital transfer, and hospitalization or neonatal intensive care unit (NICU) admission in the first 6 weeks. Maternal outcomes included genital tract trauma, postpartum hospital transfer, and hospitalization or infection (uterine, endometrial, perineal) in the first 6 weeks. We used logistic regression for all analyses, controlling for primiparity.

RESULTS

Waterbirth neonates experienced fewer negative outcomes than nonwaterbirth neonates: the adjusted odds ratio (aOR) for hospital transfer was 0.46 (95% confidence interval [CI], 0.32-0.68; P < .001); the aOR for infant hospitalization in the first 6 weeks was 0.75 (95% CI, 0.63-0.88; P < .001); and the aOR for NICU admission was 0.59 (95% CI, 0.46-0.76; P < .001). By comparison, neonates in the intended waterbirth group experienced more negative outcomes than the nonwaterbirth group, although only 5-minute Apgar score was significant (aOR, 2.02; 95% CI, 1.40-2.93; P < 0001). For women, waterbirth (compared to nonwaterbirth) was associated with fewer postpartum transfers (aOR, 0.65; 95% CI, 0.50-0.84; P = .001) and hospitalizations in the first 6 weeks (aOR, 0.72; 95% CI, 0.59-0.87; P < 0.001) but with an increased odds of genital tract trauma (aOR, 1.11; 95% CI, 1.04-1.18; P = .002). Waterbirth was not associated with maternal infection. Women in the intended waterbirth group had increased odds for all maternal outcomes compared to women in the nonwaterbirth group, although only genital tract trauma was significant (aOR, 1.67; 95% CI, 1.49-1.87; P < .001).

DISCUSSION

Waterbirth confers no additional risk to neonates; however, waterbirth may be associated with increased risk of genital tract trauma for women.

A retrospective study on perineal lacerations in vaginal delivery and the individual performance of experienced mifwives

BACKGROUND

Medical staff's influence on patient outcomes has become a subject of interest. We evaluated experienced midwives and compared their performance concerning perineal lacerations (PL).

METHODS

In a retrospective cohort study, 1937 women with singleton pregnancies who had delivered spontaneously with a cephalic presentation by experienced midwives in the Medical University of Vienna from January 2009 to April 2014 were included. As predictive parameters, we included basic patient-, pregnancy- and delivery-related characteristics including the individual midwife who delivered the child. The incidence of PL was the main outcome measure.

RESULTS

Overall PL and severe PL were found in 508/1937 (26.2%) and 19/1937 women (1.0%), respectively. In a multivariate analysis for PL of any degree, maternal age (ß = 0.170 ± 0.080), gestational age at delivery (ß = 0.190 ± 0.320), and birth weight (ß = 0.002 ± 0.000) significantly increased the risk, whereas multiparity (ß = -0.379 ± 0.141) and mediolateral episiotomy (ß = -1.514 ± 0.284) decreased it (p < 0.05). In addition, the individual midwife who delivered the child was a significant influencing factor, with ß-values ranging from -0.028 to 0.899 compared to the reference midwife. For severe PL, the midwife was not of significant influence.

CONCLUSIONS

The individual midwife is an independent factor that influences the risk for overall PL, not for severe PL. Other risk factors include maternal age, gestational age at delivery, birth weight, parity and episiotomy.

Cross-sectional study comparing public and private hospitals in Catalonia: is the practice of routine episiotomy changing?

BACKGROUND

In Spain, the Strategy for Assistance in Normal Childbirth (SANC) promoted a model of care, which respects the physiological birth process and discards unnecessary routine interventions, such as episiotomies. We evaluated the rate of episiotomy use and perineal trauma as indicators of how selective introduction of the SANC initiative has impacted childbirth outcomes in hospitals of Catalonia.

METHODS

Cross-sectional study of all singleton vaginal term deliveries without instrument registered in the Minimum Basic Data Set (MBDS) of Catalonia in 2007, 2010 and 2012. Hospitals were divided into types according to funding (public or private), and four strata were differentiated according to volume of births attended. Episiotomies and perineal injury were considered dependent variables. The relationship between qualitative variables was analysed using the chi-squared test, and Student's t-test was used for quantitative variables. Comparison of proportions was performed on the two hospital groups between 2007 and 2012 using a Z-test. Logistic regression models were used to analyse the relationship between episiotomy or severe perineal damage and maternal age, volume of births and hospital type, obtaining odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

The majority of normal singleton term deliveries were attended in public hospitals, where maternal age was lower than for women attended in private hospitals. Analysis revealed a statistically significant (P < 0.001) decreasing trend in episiotomy use in Catalonia for both hospital types. Private hospitals appeared to be associated with increased episiotomy rate in 2007 (OR = 1.099, CI: 1,057-1,142), 2010 (OR = 1.528, CI: 1,472-1,587) and 2012 (OR = 1.459, CI: 1,383-1,540), and a lower rate of severe perineal trauma in 2007 (OR = 0.164, CI: 0.095-0.283), 2010 (OR = 0.16, CI: 0.110-0.232) and 2012 (OR = 0.19, CI: 0.107-0.336). Regarding severe perineal injury, when independent variables were adjusted, maternal age ceased to have a significant correlation in 2012 (OR = 0.994, CI: 0.970-1.018).

CONCLUSIONS

Episiotomy procedures during normal singleton vaginal term deliveries in Catalonia has decreased steadily since 2007. Study results show a stable incidence trend below 1% for severe perineal trauma over the study period.

The effects of mode delivery on postpartum sexual function: a prospective study

OBJECTIVE

To determine the effect of mode of delivery and perineal injury on sexual function at 6 and 12 months postpartum.

DESIGN

Prospective cohort study.

SETTING

Tertiary women's hospital in Melbourne, Australia.

POPULATION

A cohort of 440 primigravid women.

METHODS

The Female Sexual Function Index (FSFI) was completed at first visit (7-19 weeks of gestation), and at 6 and 12 months postpartum.

MAIN OUTCOME MEASURES

A statistically significant difference in total FSFI or domain scores over time according to mode of delivery or perineal injury.

RESULTS

In this cohort 54% of women had a normal vaginal delivery, 21% had an instrumental delivery, and 25% gave birth by caesarean section. No difference was found in total FSFI or domain scores according to mode of delivery over time between antenatal assessment and 12 months postpartum. Pain was decreased in the caesarean group only at 6 months postpartum. All groups showed pain scores at 12 months that were comparable with antenatal levels. For those who gave birth vaginally, 27% had an intact perineum, 50% had an episiotomy, and 6%, 14%, and 3% had first, second, and third-degree tears, respectively. The only differences between groups were found over time according to perineal injury at 6 months in the arousal domain. At 12 months, total FSFI and domain scores were no different to initial scores.

CONCLUSIONS

At 12 months postpartum sexual function has returned to early pregnancy levels, irrespective of mode of delivery or perineal injury.

Does a large infant head or a short perineal body increase the risk of obstetrical perineal trauma?

BACKGROUND

Perineal trauma after vaginal delivery can have significant long-term consequences. It is unknown if a larger infant head circumference or smaller maternal perineal anatomy are risk factors for perineal trauma after vaginal delivery.

METHODS

We conducted a prospective cohort study of low-risk nulliparous women. Data collected included maternal characteristics, antepartum Pelvic Organ Prolapse Quantification measurements of the perineal body and genital hiatus, labor characteristics, perineal trauma, and infant head circumference. Perineal trauma was defined as trauma that extended into the muscles of the perineum (second-degree or deeper). Univariate and multivariate logistic models were created to calculate odds ratios (OR) and 95 percent confidence intervals (CI).

RESULTS

We observed 448 vaginal births. Multivariate analysis demonstrated a significant association between infant head circumference at birth and perineal trauma: OR 1.22 for each increase of 1 cm in head circumference (95% CI 1.05-1.43). There was no association between perineal body or genital hiatus length and perineal trauma.

CONCLUSIONS

In nulliparous low-risk women a larger infant head circumference at birth increases the likelihood of perineal trauma, although the effect is modest. Antenatal perineal body and genital hiatus measurements do not predict perineal trauma. These results do not support alteration in mode of delivery or other obstetric practices.

Incidence of and risk factors for perineal trauma: a prospective observational study

BACKGROUND

Our aim was to describe the range of perineal trauma in women with a singleton vaginal birth and estimate the effect of maternal and obstetric characteristics on the incidence of perineal tears.

METHODS

We conducted a prospective observational study on all women with a planned singleton vaginal delivery between May and September 2006 in one obstetric unit, three freestanding midwifery-led units and home settings in South East England. Data on maternal and obstetric characteristics were collected prospectively and analysed using univariable and multivariable logistic regression. The outcome measures were incidence of perineal trauma, type of perineal trauma and whether it was sutured or not.

RESULTS

The proportion of women with an intact perineum at delivery was 9.6% (125/1,302) in nulliparae, and 31.2% (453/1,452) in multiparae, with a higher incidence in the community (freestanding midwifery-led units and home settings). Multivariable analysis showed multiparity (OR 0.52; 95% CI: 0.30-0.90) was associated with reduced odds of obstetric anal sphincter injuries (OASIS), whilst forceps (OR 4.43; 95% CI: 2.02-9.71), longer duration of second stage of labour (OR 1.49; 95% CI: 1.13-1.98), and heavier birthweight (OR 1.001; 95% CI: 1.001-1.001), were associated with increased odds. Adjusted ORs for spontaneous perineal truama were: multiparity (OR 0.42; 95% CI: 0.32-0.56); hospital delivery (OR 1.48; 95% CI: 1.01-2.17); forceps delivery (OR 2.61; 95% CI: 1.22-5.56); longer duration of second stage labour (OR 1.45; 95% CI: 1.28-1.63); and heavier birthweight (OR 1.001; 95% CI: 1.000-1.001).

CONCLUSIONS

This large prospective study found no evidence for an association between many factors related to midwifery practice such as use of a birthing pool, digital perineal stretching in the second stage, hands off delivery technique, or maternal birth position with incidence of OASIS or spontaneous perineal trauma. We also found a low overall incidence of OASIS, and fewer second degree tears were sutured in the community than in the hospital settings. This study confirms previous findings of overall high incidence of perineal trauma following vaginal delivery, and a strong association between forceps delivery and perineal trauma.

How good are we at implementing evidence to support the management of birth related perineal trauma? A UK wide survey of midwifery practice

BACKGROUND

The accurate assessment and appropriate repair of birth related perineal trauma require high levels of skill and competency, with evidence based guideline recommendations available to inform UK midwifery practice. Implementation of guideline recommendations could reduce maternal morbidity associated with perineal trauma, which is commonly reported and persistent, with potential to deter women from a future vaginal birth. Despite evidence, limited attention is paid to this important aspect of midwifery practice. We wished to identify how midwives in the UK assessed and repaired perineal trauma and the extent to which practice reflected evidence based guidance. Findings would be used to inform the content of a large intervention study.

METHODS

A descriptive cross sectional study was completed. One thousand randomly selected midwives were accessed via the Royal College of Midwives (RCM) and sent a questionnaire. Study inclusion criteria included that the midwives were in clinical practice and undertook perineal assessment and management within their current role. Quantitative and qualitative data were collated. Associations between midwife characteristics and implementation of evidence based recommendations for perineal assessment and management were examined using chi-square tests of association.

RESULTS

405 midwives (40.5%) returned a questionnaire, 338 (83.5%) of whom met inclusion criteria. The majority worked in a consultant led unit (235, 69.5%) and over a third had been qualified for 20 years or longer (129, 38.2%). Compliance with evidence was poor. Few (6%) midwives used evidence based suturing methods to repair all layers of perineal trauma and only 58 (17.3%) performed rectal examination as part of routine perineal trauma assessment. Over half (192, 58.0%) did not suture all second degree tears. Feeling confident to assess perineal trauma all of the time was only reported by 116 (34.3%) midwives, with even fewer (73, 21.6%) feeling confident to perform perineal repair all of the time. Two thirds of midwives (63.5%) felt confident to perform an episiotomy. Midwives qualified for 20 years or longer and those on more senior clinical grades were most likely to implement evidence based recommendations and feel confident about perineal management.

CONCLUSIONS

There are considerable gaps with implementation of evidence to support management of perineal trauma.

Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: a randomized trial

Genital tract trauma after spontaneous vaginal childbirth is common, and evidence-based prevention measures have not been identified beyond minimizing the use of episiotomy. This study randomized 1211 healthy women in midwifery care at the University of New Mexico teaching hospital to 1 of 3 care measures late in the second stage of labor: 1) warm compresses to the perineal area, 2) massage with lubricant, or 3) no touching of the perineum until crowning of the infant's head. The purpose was to assess whether any of these measures was associated with lower levels of obstetric trauma. After each birth, the clinical midwife recorded demographic, clinical care, and outcome data, including the location and extent of any genital tract trauma. The frequency distribution of genital tract trauma was equal in all three groups. Individual women and their clinicians should decide whether to use these techniques on the basis of maternal comfort and other considerations.