West Berkshire perineal management trial

Vaginal childbirth and pelvic floor disorders

Childbirth is an important event in a woman's life. Vaginal childbirth is the most common mode of delivery and it has been associated with increased incidence of pelvic floor disorders later in life. In this article, the authors review and summarize current literature associating pelvic floor disorders with vaginal childbirth. Stress urinary incontinence and pelvic organ prolapse are strongly associated with vaginal childbirth and parity. The exact mechanism of injury associating vaginal delivery with pelvic floor disorders is not known, but is likely multifactorial, potentially including mechanical and neurovascular injury to the pelvic floor. Observational studies have identified certain obstetrical exposures as risk factors for pelvic floor disorders. These factors often coexist in clusters; hence, the isolated effect of these variables on the pelvic floor is difficult to study.

The current state of midwifery and development of midwifery research in four European countries

OBJECTIVE

to describe the current state of midwifery and explore the development of midwifery research during the last two decades in four non-English speaking European countries in order to understand what factors influenced the course of establishing research as a professional activity.

DESIGN

qualitative collective case study.

SETTING

Germany, Austria, Switzerland and the Netherlands.

FINDINGS

with the ICM Workshop in Germany in 1989 as a central starting point for midwifery research in all four countries, different courses, in timing as well as content, characterised its development in the individual countries. Major factors contributing to this development during the last decades involved the history and character of midwifery, initiatives of individual midwifery researchers, alliances with other professions and the transition of midwifery programmes into higher education. Whereas midwifery research is currently established as a professional role in all countries, future challenges involve the creation of its own profile and identity, while building up its own academic workforce and strengthening the role of midwifery in multidisciplinary alliances.

KEY CONCLUSIONS AND IMPLICATIONS

although a common vision was shared between the four countries in 1989, midwifery research developed as a context-specific phenomenon related to the character of midwifery and education in each country. These factors have to be taken into account in the further development of midwifery as an academic discipline at a national as well as at an international level.

Continuous and interrupted suturing techniques for repair of episiotomy or second-degree tears

BACKGROUND

Millions of women worldwide undergo perineal suturing after childbirth and the type of repair may have an impact on pain and healing. For more than 70 years, researchers have been suggesting that continuous non-locking suture techniques for repair of the vagina, perineal muscles and skin are associated with less perineal pain than traditional interrupted methods.

OBJECTIVES

To assess the effects of continuous versus interrupted absorbable sutures for repair of episiotomy and second-degree perineal tears following childbirth.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 January 2012).

SELECTION CRITERIA

Randomised trials examining continuous and interrupted suturing techniques for repair of episiotomy and second-degree tears after vaginal delivery.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial quality. Two of the three authors independently extracted data and a third review author checked them. We contacted study authors for additional information.

MAIN RESULTS

Sixteen studies, involving 8184 women at point of entry, from eight countries, were included. The trials were heterogeneous in respect of operator skill and training. Meta-analysis showed that continuous suture techniques compared with interrupted sutures for perineal closure (all layers or perineal skin only) are associated with less pain for up to 10 days' postpartum (risk ratio (RR) 0.76; 95% confidence interval (CI) 0.66 to 0.88, nine trials). There was an overall reduction in analgesia use associated with the continuous subcutaneous technique versus interrupted stitches for repair of perineal skin (RR 0.70; 95% CI 0.59 to 0.84). There was also a reduction in suture removal in the continuous suturing groups versus interrupted (RR 0.56; 95% CI 0.32 to 0.98), but no significant differences were seen in the need for re-suturing of wounds or long-term pain.

AUTHORS' CONCLUSIONS

The continuous suturing techniques for perineal closure, compared with interrupted methods, are associated with less short-term pain, need for analgesia and suture removal. Furthermore, there is also some evidence that the continuous techniques used less suture material as compared with the interrupted methods (one packet compared to two or three packets, respectively).

[A policy of selective episiotomy in a ward: an example of medical professional assessment]

OBJECTIVES

To reduce the episiotomy rates, according to the Clinical Practice Guidelines, of 2005, from the French College of Obstetricians and Gynaecologists.

PATIENTS AND METHODS

A cross sectional study was conducted, in the university hospital maternities (Maternity 1 and 2) with a retrospective record from medical files. Patients who had delivered in those maternities, by vaginal route, after 22 weeks amenorrhea were eligible. The global rate of episiotomy was analysed from 2006 to 2008. A descriptive clinical study was performed with a retrospective analysis (from July to December 2005 on 100 medical files and from July to December 2007 on 85 files). Besides, a study of episiotomy rate was conducted from 2006 to 2008. Improvement actions were developed between the two phases of assessment of the audit: sharing and comparing the results to standardized episiotomy rates, and elaborating an informatized regional perinatality file with episiotomy related items and national recommendations.

RESULTS

Episiotomy rate decreased during the study, from 22.35% in 2005 to 19.34% in 2008, in the Ward 1 (p<0.0001) and from 33.62% in 2005 to 17.93% en 2008 (p<0.0001) in the Ward 2. An improvement was observed between the two periods of audits, for each item of the chart but without statistical signification.

DISCUSSION AND CONCLUSION

Theses procedures have led to a positive impact on practices thanks to the work group and because of the politics of the perinatal network in favour of an episiotomy reduction. We hope these results could be improved in the future.

Local cooling for relieving pain from perineal trauma sustained during childbirth

BACKGROUND

Perineal trauma is common during childbirth and may be painful. Contemporary maternity practice includes offering women numerous forms of pain relief, including the local application of cooling treatments.

OBJECTIVES

To evaluate the effectiveness and side effects of localised cooling treatments compared with no treatment, other forms of cooling treatments and non-cooling treatments.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (10 January 2012), CINAHL (1982 to 10 January 2012), the Australian New Zealand Clinical Trials Register (10 January 2012) and contacted experts in the field.

SELECTION CRITERIA

Published and unpublished randomised and quasi-randomised trials (RCTs) that compared localised cooling treatment applied to the perineum with no treatment or other treatments applied to relieve pain related to perineal trauma sustained during childbirth.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trials for inclusion, assessed trial quality and extracted data. A sub-set of data were double checked for accuracy. Analyses were performed on an intention-to-treat basis where data allowed. We sought additional information from the authors of three trials.

MAIN RESULTS

Ten published RCTs were included (involving 1825 women). Comparisons were local cooling treatments (ice packs, cold gel pads (with or without compression) or cold/iced baths) with no treatment, gel pads with compression, hamamelis water (witch hazel), pulsed electromagnetic energy (PET), hydrocortisone/pramoxine foam (Epifoam), oral paracetamol or warm baths. Ice packs provided improved pain relief 24 to 72 hours after birth compared with no treatment (risk ratio (RR) 0.61; 95% confidence interval (CI) 0.41 to 0.91; one study, n = 208). Women preferred the utility of the gel pads compared with ice packs or no treatment (RR 0.82; 95% CI 0.73, 0.92). Differences detected in a composite of perineal oedema and bruising and overall wound healing were noted in one small study, favouring cold gel pads (n = 37) over ice (n = 35, mean difference (MD) 0.63 on a scale of 0 to 15; 95% CI 0.20 to 1.06) or no treatment (n = 39, MD -2.10; 95% CI -3.80 to -0.40) three to 14 days after giving birth. Women reported more pain (RR 5.60; 95% CI 2.35 to 13.33; one study, 100 women) and used more additional analgesia (RR 4.00; 95% CI 1.44 to 11.13; one study, 100 women) following the application of ice packs compared with PET.

AUTHORS' CONCLUSIONS

There is only limited evidence to support the effectiveness of local cooling treatments (ice packs, cold gel pads, cold/iced baths) applied to the perineum following childbirth to relieve pain.

A qualitative study exploring women's personal experiences of their perineum after childbirth: expectations, reality and returning to normality

OBJECTIVE

to explore the feelings, perceptions and experiences of women in relation to their perineum following childbirth in the early postnatal period.

DESIGN

a qualitative study using grounded theory. Data were collected using diaries and interviews and analysed using constant comparative method.

SETTING

hospital and community setting in the South of England.

PARTICIPANTS

women (n=11) aged 20-42 years who had a vaginal birth.

FINDINGS

one core category, 'Striving for normality' and five major categories emerged: (1) 'preparing for the unknown', (2) 'experiencing the unexpected', (3) 'adjusting to reality', (4) 'getting back to normal' and (5) 'recovery of self'. 'Striving for normality' was where women wanted to be able to do normal things and feel like their normal selves soon after the birth of their baby. Much of what the women described doing during the early postnatal period was related to achieving this goal.

KEY CONCLUSIONS

the initial impact of childbirth on the perineum and surrounding area meant that in the first few postnatal days women largely concentrated on managing the effects of this. The impact however, went beyond the immediacy of coping with bodily functions extending into other daily activities in terms of managing and completing them. Examples of daily living activities in this context include bathing, eating, walking as well as completing household chores. Returning to normal following childbirth is significant for women and successfully achieving daily living activities is part of this process. However, women in this study seemed unprepared for the reality of this experience.

IMPLICATIONS FOR PRACTICE

women may be poorly prepared for the impact that perineal pain and discomfort can have on their lives especially related to successfully completing daily living activities in the early postnatal period. Consideration should be given to finding different ways of communicating the impact to women such as in the early postnatal period, rather than during pregnancy. The underpinning philosophy of care for the postnatal period should encapsulate a holistic approach, where physical symptoms of perineal pain and discomfort experienced by women are not tackled in isolation from any psychosocial impact this may also have.

Surgical repair of spontaneous perineal tears that occur during childbirth versus no intervention

BACKGROUND

Perineal tears commonly occur during childbirth. They are sutured most of the time. Surgical repair can be associated with adverse outcomes, such as pain, discomfort and interference with normal activities during puerperium and possibly breastfeeding. Surgical repair also has an impact on clinical workload and human and financial resources.

OBJECTIVES

To assess the evidence for surgical versus non-surgical management of first- and second-degree perineal tears sustained during childbirth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 May 2011), CENTRAL (The Cochrane Library 2011, Issue 2 of 4) and MEDLINE (Jan 1966 to 2 May 2011). We also searched the reference lists of reviews, guidelines and other publications and contacted authors of identified eligible trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) investigating the effect on clinical outcomes of suturing versus non-suturing techniques to repair first- and second-degree perineal tears sustained during childbirth.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed trial quality. Three review authors independently extracted data.

MAIN RESULTS

We included two RCTs (involving 154 women) with a low risk of bias. It was not possible to pool the available studies. The two studies do not consistently report outcomes defined in the review. However, no significant differences were observed between the two groups (surgical versus non-surgical repair) in incidence of pain and wound complications, self-evaluated measures of pain at hospital discharge and postpartum and re-initiation of sexual activity. Differences in the use of analgesia varied between the studies, being high in the sutured group in one study. The other trial showed differences in wound closure and poor wound approximation in the non-suturing group, but noted incidentally also that more women were breastfeeding in this group.

AUTHORS' CONCLUSIONS

There is limited evidence available from RCTs to guide the choice between surgical or non-surgical repair of first- or second-degree perineal tears sustained during childbirth. Two studies find no difference between the two types of management with regard to clinical outcomes up to eight weeks postpartum. Therefore, at present there is insufficient evidence to suggest that one method is superior to the other with regard to healing and recovery in the early or late postnatal periods. Until further evidence becomes available, clinicians' decisions whether to suture or not can be based on their clinical judgement and the women's preference after informing them about the lack of long-term outcomes and the possible chance of a slower wound healing process, but possible better overall feeling of well being if left un-sutured.

Perineal care

INTRODUCTION

Over 85% of women having a vaginal birth suffer some perineal trauma. Spontaneous tears requiring suturing are estimated to occur in at least a third of women in the UK and US, with anal sphincter tears in 0.5% to 7% of women. Perineal trauma can lead to long-term physical and psychological problems.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of intrapartum surgical and non-surgical interventions on rates of perineal trauma? What are the effects of different methods and materials for primary repair of first- and second-degree tears and episiotomies? What are the effects of different methods and materials for primary repair of obstetric anal sphincter injuries (third- and fourth-degree tears)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to March 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 38 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: active pushing, spontaneous pushing, and sustained breath-holding (Valsalva) method of pushing; continuous support during labour; conventional suturing; different methods and materials for primary repair of obstetric anal sphincter injuries; episiotomies (midline and mediolateral incisions); epidural analgesia; forceps; methods of delivery ("hands-on" method, "hands poised"); water births; non-suturing of muscle and skin (or perineal skin alone); passive descent in the second stage of labour; positions (supine or lithotomy positions, upright position during delivery); restrictive or routine use of episiotomy; sutures (absorbable synthetic sutures, catgut sutures, continuous sutures, interrupted sutures); and vacuum extraction.

Absorbable suture materials for primary repair of episiotomy and second degree tears

BACKGROUND

Approximately 70% of women will experience perineal trauma following vaginal delivery and will require stitches. This may result in pain, suture removal and superficial dyspareunia.

OBJECTIVES

To assess the effects of different suture materials on short- and long-term morbidity following perineal repair.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2010).

SELECTION CRITERIA

Randomised trials comparing different suture materials for perineal repair after vaginal delivery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

We included 18 trials with 10,171 women; comparisons included: catgut with standard synthetic (nine trials), rapidly absorbing synthetic (two trials), and glycerol impregnated catgut sutures (two trials); and standard synthetic sutures with rapidly absorbing synthetic (five trials) and monofilament sutures (one trial).Compared with catgut, standard synthetic sutures were associated with less pain up to three days after delivery (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.76 to 0.90); and less analgesia up to ten days postpartum (RR 0.71, 95% CI 0.59 to 0.87). More women with catgut sutures required resuturing (15/1201) compared with synthetic sutures (3/1201) (RR 0.25, 95% CI 0.08 to 0.74); while more women with standard synthetic sutures required the removal of unabsorbed suture material (RR 1.81, 95% CI 1.46 to 2.24). Comparing standard synthetic with rapidly absorbing sutures, short- and long-term pain were similar; in one trial fewer women with rapidly absorbing sutures reported using analgesics at 10 days (RR 0.57, 95% CI 0.43 to 0.77). More women in the standard synthetic suture group required suture removal compared with those in the rapidly absorbed group (RR 0.24, 95% CI 0.15 to 0.36). There was no evidence of significant differences between groups for long-term pain (three months after delivery) or for dyspareunia at three, or at six to 12 months. When catgut and glycerol impregnated catgut were compared, results were similar for most outcomes, although the latter was associated with more short-term pain. One trial examining monofilament versus standard polyglycolic sutures found no differences for most outcomes.

AUTHORS' CONCLUSIONS

Catgut may increase short-term pain compared with synthetic sutures. There were few differences between standard and rapidly absorbing synthetic sutures but more women needed standard sutures removing. For other materials, there was insufficient evidence to draw conclusions. Findings should be interpreted in the context of the related Cochrane review on suturing techniques.

Impact of a structured, hands-on, surgical skills training program for midwives performing perineal repair

OBJECTIVE

To evaluate the effect of structured hands-on training for midwives performing perineal repair.

METHODS

The training was performed using models and ox tongues. A total of 719 midwives completed an anonymous questionnaire prior to and immediately after training. Out of 300 participants, 151 completed a follow-up questionnaire 4 months later. Participants rated their knowledge and skills in the domains of instrument handling, knot tying, and subcuticular perineal repair.

RESULTS

Compared with the situation before receiving the training, there was a significant increase in the use of the recommended evidence-based technique for perineal repair 4 months after training (28% vs 100%; P<0.001), and in the mean scores for knowledge and skills in all the domains (P<0.001). Participants believed that their patients were happier with the new technique.

CONCLUSIONS

Structured hands-on training is an effective way of improving the skills of midwives performing perineal repair and leads to modification of clinical practice.

Episiotomy for vaginal birth

BACKGROUND

Episiotomy is done to prevent severe perineal tears, but its routine use has been questioned. The relative effects of midline compared with midlateral episiotomy are unclear.

OBJECTIVES

The objective of this review was to assess the effects of restrictive use of episiotomy compared with routine episiotomy during vaginal birth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2008).

SELECTION CRITERIA

Randomized trials comparing restrictive use of episiotomy with routine use of episiotomy; restrictive use of mediolateral episiotomy versus routine mediolateral episiotomy; restrictive use of midline episiotomy versus routine midline episiotomy; and use of midline episiotomy versus mediolateral episiotomy.

DATA COLLECTION AND ANALYSIS

The two review authors independently assessed trial quality and extracted the data.

MAIN RESULTS

We included eight studies (5541 women). In the routine episiotomy group, 75.15% (2035/2708) of women had episiotomies, while the rate in the restrictive episiotomy group was 28.40% (776/2733). Compared with routine use, restrictive episiotomy resulted in less severe perineal trauma (relative risk (RR) 0.67, 95% confidence interval (CI) 0.49 to 0.91), less suturing (RR 0.71, 95% CI 0.61 to 0.81) and fewer healing complications (RR 0.69, 95% CI 0.56 to 0.85). Restrictive episiotomy was associated with more anterior perineal trauma (RR 1.84, 95% CI 1.61 to 2.10). There was no difference in severe vaginal/perineal trauma (RR 0.92, 95% CI 0.72 to 1.18); dyspareunia (RR 1.02, 95% CI 0.90 to 1.16); urinary incontinence (RR 0.98, 95% CI 0.79 to 1.20) or several pain measures. Results for restrictive versus routine mediolateral versus midline episiotomy were similar to the overall comparison.

AUTHORS' CONCLUSIONS

Restrictive episiotomy policies appear to have a number of benefits compared to policies based on routine episiotomy. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy.

Perineal care

INTRODUCTION

Over 85% of women having a vaginal birth suffer some perineal trauma. Spontaneous tears requiring suturing are estimated to occur in at least a third of women in the UK and USA, with anal sphincter tears in 0.5% to 7% of women. Perineal trauma can lead to long-term physical and psychological problems.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of intrapartum surgical and non-surgical interventions on rates of perineal trauma? What are the effects of different methods and materials for primary repair of first- and second-degree tears and episiotomies? What are the effects of different methods and materials for primary repair of obstetric anal sphincter injuries (third- and fourth-degree tears)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2007 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 38 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: active pushing, spontaneous pushing, and sustained breath-holding (Valsalva) method of pushing; continuous support during labour; conventional suturing; different methods and materials for primary repair of obstetric anal sphincter injuries; episiotomies (midline and mediolateral incisions); epidural analgesia; forceps; methods of delivery ("hands-on" method, "hands poised"); water births; non-suturing of muscle and skin (or perineal skin alone); passive descent in the second stage of labour; positions (supine or lithotomy positions, upright position during delivery); restrictive or routine use of episiotomy; sutures (absorbable synthetic sutures, catgut sutures, continuous sutures, interrupted sutures); and vacuum extraction.

Sexual function 6 months after first delivery

OBJECTIVE

To explore the association of anal sphincter laceration and sexual function 6 months postpartum in the Childbirth and Pelvic Symptoms (CAPS) cohort.

METHODS

The primary CAPS study, a prospective cohort study, was designed to estimate the postpartum prevalence and incidence of urinary and fecal incontinence. Three cohorts of new mothers (vaginal delivery with a third- or fourth-degree anal sphincter tear, vaginal delivery without a third- or fourth-degree anal sphincter tear, and cesarean delivery without labor) were compared at 6 months postpartum. Sexual function was assessed with the Pelvic Organ Prolapse/Urinary Incontinence/Sexual Function Short Form Questionnaire (PISQ-12). Urinary and fecal incontinence were assessed using the Medical Epidemiological and Social Aspects of Aging questionnaire and the Fecal Incontinence Severity Index, which is embedded within the Modified Manchester Health Questionnaire.

RESULTS

Most women (459 [90%]) of those with partners reported sexual activity at the 6-month visit. Fewer women whose delivery was complicated by anal sphincter laceration reported sexual activity when compared with those who delivered vaginally without sphincter laceration (88 compared with 94%, P=.028). The mean PISQ-12 score (39+/-4) did not differ between delivery groups (P=.92). Pain (responses of "sometimes," "usually," or "always") during sex affected one of three sexually active women (164 [36%]).

CONCLUSION

At 6 months postpartum, primiparous women who delivered with anal sphincter laceration are less likely to report sexual activity.

LEVEL OF EVIDENCE

II.

Evaluation of postpartum perineal pain and dyspareunia—A prospective study

OBJECTIVE

Postpartum perineal pain and dyspareunia have been reported to affect 42% of women within the first 2 weeks after their first vaginal delivery. We aimed to determine the prevalence of dyspareunia and perineal pain using validated pain scores following accurate classification of perineal trauma according to the guidelines of the Royal College of Obstetricians and Gynaecologists.

STUDY DESIGN

Prospective study of women having their first vaginal delivery. All women had a perineal and rectal examination. Pain was assessed with a 4-point Verbal Rating Score and an 11-point visual analogue scale on day 1, day 5 and 2 months after delivery.

RESULTS

Two hundred and fifty-four women were invited and 95% participated. Ninety-two percent experienced perineal pain on day one, resolving in 88% (p<0.001) at 2 months. Compared to an intact perineum or first degree tear significantly more women experienced perineal pain after a second, third or fourth degree tear. Forty percent resumed coitus within 2 months regardless of whether perineal trauma occurred or not. Five days after delivery, uncomplicated episiotomies resulted in more perineal pain than second degree tears.

CONCLUSIONS

Although perineal pain affected 92% of mothers, it resolved in the majority within 2 months of delivery. Obstetric anal sphincter injury is associated with more perineal pain than other perineal trauma. Spontaneous second degree tears cause less perineal pain than episiotomies. The 11-point visual analogue scale may be more sensitive than the 4-point Verbal Rating Score.

Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labor: a randomized controlled trial

BACKGROUND

Perineal warm packs are widely used during childbirth in the belief that they reduce perineal trauma and increase comfort during late second stage of labor. The aim of this study was to determine the effects of applying warm packs to the perineum on perineal trauma and maternal comfort during the late second stage of labor.

METHODS

A randomized controlled trial was undertaken. In the late second stage of labor, nulliparous women (n = 717) giving birth were randomly allocated to have warm packs (n = 360) applied to their perineum or to receive standard care (n = 357). Standard care was defined as any second-stage practice carried out by midwives that did not include the application of warm packs to the perineum. Analysis was on an intention-to-treat basis, and the primary outcome measures were requirement for perineal suturing and maternal comfort.

RESULTS

The difference in the number of women who required suturing after birth was not significant. Women in the warm pack group had significantly fewer third- and fourth-degree tears and they had significantly lower perineal pain scores when giving birth and on "day 1" and "day 2" after the birth compared with the standard care group. At 3 months, they were significantly less likely to have urinary incontinence compared with women in the standard care group.

CONCLUSIONS

The application of perineal warm packs in late second stage does not reduce the likelihood of nulliparous women requiring perineal suturing but significantly reduces third- and fourth-degree lacerations, pain during the birth and on days 1 and 2, and urinary incontinence. This simple, inexpensive practice should be incorporated into second stage labor care.

Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery

OBJECTIVE

To determine the risk factors for anal sphincter injuries during operative vaginal delivery.

SETTING AND DESIGN

A population-based observational study.

POPULATION

All 21 254 women delivered with vacuum extraction and 7478 women delivered with forceps, derived from the previously validated Dutch National Obstetric Database from the years 1994 to 1995.

METHODS

Anal sphincter injury was defined as any injury, partial or complete, of the anal sphincters. Risk factors were determined with multivariate logistic regression analysis.

MAIN OUTCOME MEASURES

Individual obstetric factors, e.g. fetal birthweights, duration of second stage, etc.

RESULTS

Anal sphincter injury occurred in 3.0% of vacuum extractions and in 4.7% of forceps deliveries. Primiparity, occipitoposterior position and fetal birthweight were associated with an increased risk for anal sphincter injury in both types of operative vaginal delivery, whereas duration of second stage was associated with an increased risk only in vacuum extractions. Mediolateral episiotomy protected significantly for anal sphincter damage in both vacuum extraction (OR 0.11, 95% CI 0.09-0.13) and forceps delivery (OR 0.08, 95% CI 0.07-0.11). The number of mediolateral episiotomies needed to prevent one sphincter injury in vacuum extractions was 12, whereas 5 mediolateral episiotomies could prevent one sphincter injury in forceps deliveries.

CONCLUSIONS

Primiparity and occipitoposterior presentation are strong risk factors for the occurrence of anal sphincter injury during operative vaginal delivery. The highly significant protective effect of mediolateral episiotomies in both types of operative vaginal delivery warrants the conclusions that this type of episiotomy should be used routinely during these interventions to protect the anal sphincters.

Local cooling for relieving pain from perineal trauma sustained during childbirth

BACKGROUND

Perineal trauma is common during childbirth and may be painful. Contemporary maternity practice includes offering women numerous forms of pain relief, including the local application of cooling treatments.

OBJECTIVES

To evaluate the effectiveness and side effects of localised cooling treatments compared with no treatment, other forms of cooling treatments and non-cooling treatments.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2007), CINAHL (1982 to January 2007) and contacted experts in the field.

SELECTION CRITERIA

Published and unpublished randomised and quasi-randomised trials (RCTs) that compared localised cooling treatment applied to the perineum with no treatment or other treatments applied to relieve pain related to perineal trauma sustained during childbirth.

DATA COLLECTION AND ANALYSIS

At least two independent authors performed data extraction for each study. Analyses were performed on an intention-to-treat basis where data allowed. We sought additional information from the authors of three trials.

MAIN RESULTS

Seven published RCTs were included, comparing local cooling treatments (ice packs, cold gel pads or cold/iced baths) with no treatment, hamamelis water (witch hazel), pulsed electromagnetic energy (PET), hydrocortisone/pramoxine foam [Epifoam] or warm baths. The RCTs reported on a total of 859 women. Ice packs provided improved pain relief 24 to 72 hours after birth compared with no treatment (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.41 to 0.91). Women preferred the utility of the gel pads compared with ice packs or no treatment, although no differences in pain relief were detected between the treatments. None of our comparisons of treatments resulted in differences detected in perineal oedema or bruising. Women reported more pain (RR 5.60, 95% CI 2.35 to 13.33) and used more additional analgesia (RR 4.00, 95% CI 1.44 to 11.13) following the application of ice packs compared with PET.

AUTHORS' CONCLUSIONS

There is only limited evidence to support the effectiveness of local cooling treatments (ice packs, cold gel pads, cold/iced baths) applied to the perineum following childbirth to relieve pain.

Continuous versus interrupted sutures for repair of episiotomy or second degree tears

BACKGROUND

Millions of women worldwide undergo perineal suturing after childbirth and the type of repair may have an impact on pain and healing. For more than 70 years, researchers have been suggesting that continuous non-locking suture techniques for repair of the vagina, perineal muscles and skin are associated with less perineal pain than traditional interrupted methods.

OBJECTIVES

To assess the effects of continuous versus interrupted absorbable sutures for repair of episiotomy and second degree perineal tears following childbirth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (June 2007).

SELECTION CRITERIA

Randomised trials comparing continuous versus interrupted sutures for repair of episiotomy and second-degree tears after vaginal delivery.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial quality. Two of the three authors independently extracted data and a third author checked them. We contacted study authors for additional information.

MAIN RESULTS

Seven studies, involving 3822 women at point of entry, from four countries, have been included. The trials were heterogeneous in respect of operator skill and training. Meta-analysis showed that continuous suture techniques compared with interrupted sutures for perineal closure (all layers or perineal skin only) are associated with less pain for up to 10 days postpartum (relative risk (RR) 0.70, 95% confidence interval 0.64 to 0.76). Subgroup analysis showed that there is a greater reduction in pain when continuous suturing techniques are used for all layers (RR 0.65, 95% CI 0.60 to 0.71). There was an overall reduction in analgesia use associated with the continuous subcutaneous technique versus interrupted stitches for repair of perineal skin (RR 0.70, 95% CI 0.58 to 0.84). Subgroup analysis showed some evidence of reduction in dyspareunia experienced by participants in the groups that had continuous suturing for all layers (RR 0.83, 95% CI 0.70 to 0.98). There was also a reduction in suture removal in the continuous suturing groups versus interrupted (RR 0.54, 95% CI 0.45 to 0.65), but no significant differences were seen in the need for re-suturing of wounds or long-term pain.

AUTHORS' CONCLUSIONS

The continuous suturing techniques for perineal closure, compared to interrupted methods, are associated with less short-term pain. Moreover, if the continuous technique is used for all layers (vagina, perineal muscles and skin) compared to perineal skin only, the reduction in pain is even greater.

An Australian prospective cohort study of risk factors for severe perineal trauma during childbirth

OBJECTIVE

to determine risk factors for the occurrence of severe perineal trauma (third and fourth degree tears) during childbirth.

DESIGN

a prospective cohort study was conducted using the hospital's computerised obstetric information system. Additional data were gathered on women who sustained severe perineal trauma. Descriptive statistics and logistic regression were used to assess risk factors for severe perineal trauma. Midwives were asked to comment on possible reasons for severe perineal trauma. Written responses made by midwives were analysed using content analysis. Discussion groups with midwives were held to further explore their experiences.

SETTING

Royal Prince Alfred Hospital, Sydney, Australia.

PARTICIPANTS

all women having vaginal births (n=6595) in a 2-year period between 1 April 1998 and 31 March 2000, in both the birth centre and the labour ward.

MEASUREMENTS AND FINDINGS

2% of women (n=134) experienced severe perineal trauma. One hundred and twenty-two women had third-degree tears and 12 had fourth-degree tears. Primiparity, instrumental delivery, Asian ethnicity and heavier babies were associated with an elevated risk of severe perineal trauma. Midwives identified several factors they believed contributed to severe perineal trauma. These were lack of effective communication with the woman during the birth, different birth positions, delivery technique, ethnicity and obstetric influences.

KEY CONCLUSIONS

findings support current knowledge that primiparity, instrumental birth, heavier babies and being of Asian ethnicity are associated with increased rates of severe trauma. Specific attention needs to be paid to the strong association found between being of Asian ethnicity and experiencing severe perineal trauma.

IMPLICATIONS FOR PRACTICE

further identification and validation of the concerns expressed by midwives to reduce severe perineal trauma is warranted so that preventative strategies can be used and researched.

Research and theory for Nursing and Midwifery: Rethinking the Nature of Evidence

BACKGROUND AND RATIONALE

The rise in the principles of evidence-based medicine in the 1990s heralded a re-emerging orthodoxy in research methodologies. The view of the randomised controlled trial (RCT) as a "gold standard" for evaluation of medical interventions has extended recently to evaluation of organisational forms and reforms and of change in complex systems-within health care and in other human services. Relatively little attention has been given to the epistemological assumptions underlying such a hierarchy of research evidence.

AIMS AND METHODS

Case studies from research in maternity care are used in this article to describe problems and limitations encountered in using RCTs to evaluate some recent policy-driven and consumer-oriented developments. These are discussed in relation to theory of knowledge and the epistemological assumptions, or paradigms, underpinning health services research. The aim in this discussion is not to advocate, or to reject, particular approaches to research but to advocate a more open and critical engagement with questions about the nature of evidence.

FINDINGS AND DISCUSSION

Experimental approaches are of considerable value in investigating deterministic and probabilistic cause and effect relationships, and in testing often well-established but unevaluated technologies. However, little attention has been paid to contextual and cultural factors in the effects of interventions, in the culturally constructed nature of research questions themselves, or of the data on which much research is based. More complex, and less linear, approaches to methodology are needed to address these issues. A simple hierarchical approach does not represent the complexity of evidence well and should move toward a more cyclical view of knowledge development.

Sequence variant in the laminin gamma1 (LAMC1) gene associated with familial pelvic organ prolapse

Pelvic organ prolapse is a common condition, affecting up to a third of women throughout their lifetime. Genetic factors are believed to account for about 30% of the incidence, and are the least understood component of the disorder. Familial cases, particularly those in which prolapse manifests in young women, are especially valuable in the effort to find the genes involved. We recently reported autosomal dominant transmission as the most likely mode of inheritance, based on a collection of families with high incidence of prolapse. Of greatest interest was a family in which three generations of female relatives suffered from prolapse at a very young age. A genome-wide linkage scan performed using the Affymetrix GeneChip Human mapping 10K array identified ten regions with a LOD score of 1.5, the maximum possible for this family. Candidate genes within those regions were analyzed for expression in vaginal tissue by RT-PCR. Of the genes confirmed to be expressed, LAMC1 was further evaluated by sequencing and select single nucleotide polymorphism (SNP) genotyping for causative sequence variants in affected family members. We identified one such SNP, rs10911193. The rare T variant segregating with the condition is present at a frequency of 4.9% in the general population and 22% among probands from our cohort of families. It affects the binding site for NFIL3, a transcription factor that we verified to be co-expressed in vaginal tissue. Altogether these data suggest that a polymorphism in the promoter of LAMC1 may increase the susceptibility to early-onset pelvic organ prolapse.

Impact of chromic catgut versus polyglactin 910 versus fast-absorbing polyglactin 910 sutures for perineal repair: a randomized, controlled trial

OBJECTIVE

The goal of our study was to compare the impact of 3 suture materials on perineal pain and on resumption of sexual intercourse.

STUDY DESIGN

This randomized, controlled trial compared 3 types of suture materials (chromic catgut, polyglactin 910, fast-absorbing polyglactin 910) for second-degree perineal laceration or uncomplicated episiotomy. Patients were enrolled in early labor and assigned randomly to 1 of the 3 suture materials. Pain was evaluated at 48 hours, 6 weeks, and 3 months. The study subjects were questioned about residual perineal pain, resumption of sexual activity, and pain-free sexual intercourse. Logistic regression analyses were undertaken.

RESULTS

Of the 192 patients who were assigned randomly to groups, 66 patients had their perineal laceration repaired with chromic catgut; 60 patients had repair with polyglactin 910, and 66 patients had repair with fast-absorbing polyglactin 910. At 48 hours, there was no significant difference according to the pain measurement scores, but the median consumption of analgesics was significantly lower with fast-absorbing polyglactin 910 than with standard polyglactin 910. There was no difference in the resumption of sexual intercourse at 6 weeks after the delivery between chromic catgut (42%) compared with standard polyglactin 910 group (56%; P = .23). However, it was more frequent for women in the fast-absorbing polyglactin 910 group (66%; P = .02). After adjustment for confounding variables, perineal repair with fast-absorbing polyglactin 910 was associated with a higher rate of sexual intercourse (odds ratio, 2.55; 95% CI, 1.07-6.10) and a higher rate of pain-free sexual intercourse (odds ratio, 2.51; 95% CI, 1.03-6.10) at 6 weeks after delivery.

CONCLUSION

Fast-absorbing polyglactin 910 for perineal repair is associated with earlier resumption of sexual intercourse when compared with chromic catgut.