Episiotomy for vaginal birth

The Risk Factors of Postpartum Urinary Retention for Women by Vaginal Birth: A Systematic Review and Meta-Analysis

INTRODUCTION AND HYPOTHESIS

Postpartum urinary retention is one of the most common complications in women during the immediate postpartum period. The objective was to systematically assess risk factors for postpartum urinary retention after vaginal delivery.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we retrieved relevant studies from PubMed, Embase, Cochrane Library, Web of Science Core Collection, China National Knowledge Internet, Wangfang Database, and Chinese Biomedical Database for observational studies investigating the risk factors for postpartum urinary retention from inception to 11 November 2022. The Newcastle-Ottawa Scale and Joanna Briggs Institute's tool were used to assess the risk of bias. We conducted a meta-analysis using RevMan 5.3.

RESULTS

In total, 3,074 articles were screened and data from 27 studies were used in the meta-analysis. Sixteen risk factors were identified, namely, labor augmentation (OR = 1.72, 95% CI = 1.17-2.51), primiparity (OR = 2.36, 95% CI = 1.64-3.38), manual fundal pressure (OR = 2.84, 95% CI = 1.00-8.11), perineal hematoma (OR = 7.28, 95% CI = 1.62-32.72), vulvar edema (OR = 7.99, 95% CI = 5.50-11.63), the total duration of labor (MD = 90.10, 95% CI = 49.11-131.08), the duration of the first stage of labor (MD = 33.97, 95% CI = 10.28-57.65), the duration of the second stage of labor (MD = 14.92, 95% CI = 11.79-18.05), the duration of the second stage of labor > 60 min (OR = 3.18, 95% CI = 1.32-7.67), mediolateral episiotomy (OR = 3.65, 95% CI = 1.70-7.83), severe perineal tear (OR = 3.21, 95% CI = 1.84-5.61), epidural analgesia (OR = 3.23, 95% CI = 1.50-6.96), forceps delivery (OR = 4.95, 95% CI = 2.88-8.51), vacuum delivery (OR = 2.44, 95% CI = 1.30-4.58), neonatal birth weight > 4,000 g (OR = 3.61, 95% CI = 1.96-6.65), and neonatal birth weight > 3,500 g (OR = 1.89, 95% CI = 1.12-3.19).

CONCLUSIONS

Our results demonstrated that labor augmentation, primiparity, manual fundal pressure, perineal hematoma, vulvar edema, the total duration of labor, the duration of the first stage of labor, the duration of the second stage of labor, the duration of the second stage of labor > 60 min, mediolateral episiotomy, severe perineal tear, epidural analgesia, forceps delivery, vacuum delivery, and neonatal birth weight > 4,000 g and > 3,500 g were risk factors for postpartum urinary retention in women with vaginal delivery. The specific ranges of the first and the second stages of labor causing postpartum urinary retention need to be clarified.

Emerging trends in research on perineal trauma management: A bibliometric analysis of articles published since 1985

BACKGROUND

The purpose of this bibliometric analysis is to explore global trends in scientific research involving spontaneous perineal tears sustained during childbirth. This research is critical as a significant number of women have vaginal lacerations after birth resulting in complications such as pain and pelvic floor dysfunction.

METHODS

The articles used in this bibliometric analysis were collected from PubMed, Web of Science, Cochrane library and Scopus. Analysis was carried out in Python and R programming languages with some visualizations created using VOS software. Apart from traditional methods, this analysis also involved time series forecasting and assessment of rolling correlations.

RESULTS

Results indicate authors and institutions from the United Kingdom as the most productive in the research on this subject research. National level analyses for six countries showed that productivity was positively correlated with GDP/capita, average health expenditure and negatively associated with proportion of C-sections. Recent and emerging themes include those involving pharmacological interventions for pain management.

CONCLUSION

There is a growing global interest in the research on postnatal perineal trauma with authors from the UK playing a leading role so far. Countries with high vaginal birth rates, need to promote research in this field to minimise trauma-associated comorbidities.

Women's Perceptions and Knowledge Toward Episiotomy in Qassim Region, Saudi Arabia

INTRODUCTION

Episiotomy, despite being one of the most common interventions during childbirth, carries significant risks and uncertain benefits. Previous global studies highlight varying awareness levels and practices, with decreasing episiotomy rates attributed to increased knowledge. This study aims to assess women's knowledge to enhance intrapartum decision-making and communication between patients and obstetricians, ultimately improving maternal outcomes in the region.

METHODOLOGY

 The study was a cross-section design. It was conducted through an online survey that was distributed by different social media platforms (Twitter, WhatsApp, and Telegram) from February 2023 to January 2024. It included women living in the Qassim region, Saudi Arabia, who were 15 years old or older. Data was analyzed using the SPSS program (IBM, Chicago, Illinois, USA).

RESULTS

Among the 402 participants, 62.7% demonstrated awareness of episiotomy, with 94.0% accurately identifying it as a surgical cutting with scissors. About 82.5% acknowledged that not all women require episiotomies, while 48.8% recognized the necessity of anesthesia before the procedure. Understanding the indications for episiotomy varied, with facilitating and accelerating childbirth (64.3%) and dealing with a large baby (62.3%) being the most recognized reasons. Impressively, 90.5% believed that there are methods to avoid perineal cutting, with knowing the correct mechanism for pushing during childbirth (69.4%) and exercise (54.4%) being the most acknowledged preventive measures. Regarding post-cutting care, antibiotics (61.5%) were identified as essential, followed by analgesia (52.8%) and laxatives (48.8%).

CONCLUSION

The study reveals a notable awareness among participants, with a majority demonstrating a solid understanding of the procedure, its indications, and post-procedure care. It identified specific knowledge gaps, such as the need for anesthesia awareness and divergent beliefs about post-episiotomy care practices.

Is water delivery a good idea to prevent obstetric anal sphincter injuries in low risk primiparae? An exploratory study in a Swiss public teaching hospital

OBJECTIVE

Obstetric anal sphincter injuries are feared perineal injuries that are associated with increased pelvic floor disorders. The knowledge of influencing factors as the mode of delivery is therefore important. The aim of this study is to compare the rate of obstetric anal sphincter injuries in primiparae after water and bed deliveries.

STUDY DESIGN

In this retrospective cohort study 3907 primiparae gave birth in water or on a bed in a Swiss teaching hospital. The diagnosis of obstetric anal sphincter injuries was confirmed by a consultant of obstetrics and gynecology and treated by them. The rates of these injuries after water and bed births were compared. Subgroup analysis was performed to detect possible associative factors, such as birth weight, episiotomy, use of oxytocin in first and second stage of labor.

RESULTS

1844 (47.2 %) of the primiparae had a water delivery and 2063 (52.8 %) a bed delivery. 193 (4.94 %) were diagnosed with obstetric anal sphincter injuries, of which 68 (3.7 %) had a water delivery and 125 (6.1 %) a bed delivery, p < 0.001. Subgroup analysis revealed that, in the first and second stage of labor, the rate of obstetric anal sphincter injuries with oxytocin was significantly lower in water than in bed deliveries; p = 0.025, p < 0.017, respectively. The rate of obstetric anal sphincter injuries in the birth weight or episiotomy subgroups did not reach significance.

CONCLUSIONS

In a teaching hospital setting with standardized labor management, primiparae with a water delivery have the lowest risk for obstetric anal sphincter injuries.

The association of maternal obesity and obstetric anal sphincter injuries at time of vaginal delivery

BACKGROUND

The risk of third- and fourth-degree perineal laceration after vaginal delivery in patients with obesity is relatively understudied and has mixed findings in existing literature.

OBJECTIVE

This study aimed to examine the association of maternal obesity and obstetric anal sphincter injuries at vaginal delivery.

STUDY DESIGN

The Healthcare Cost and Utilization Project's National Inpatient Sample was retrospectively queried to examine 7,385,341 vaginal deliveries from January 2017 to December 2019. The exposure assignment was obesity status. The main outcomes were third- and fourth-degree perineal lacerations after vaginal delivery. Statistical analysis examining the exposure-outcome association included (1) inverse probability of treatment weighting with log-Poisson regression generalized linear model to account for prepregnant and pregnant confounders for the exposure and (2) multinomial regression model to account for delivery factors in the inverse probability of treatment weighting cohort. The secondary outcomes included (1) the temporal trends of fourth-degree laceration and its associated factors at cohort level and (2) risk factor patterns for fourth-degree laceration by constructing a classification tree model.

RESULTS

In the inverse probability of treatment weighting cohort, patients with obesity were less likely to have fourth-degree lacerations and third-degree lacerations than patients without obesity (fourth-degree laceration: 2.3 vs 3.9 per 1000 vaginal deliveries, respectively; adjusted odds ratio, 0.62; 95% confidence interval, 0.56-0.69; third-degree laceration: 15.6 vs 20.1 per 1000 vaginal deliveries, respectively; adjusted odds ratio, 0.79; 95% confidence interval, 0.76-0.82). In contrast, in patients with obesity vs those without obesity, forceps delivery (54.7 vs 3.3 per 1000 vaginal deliveries, respectively; adjusted odds ratio, 17.73; 95% confidence interval, 16.17-19.44), vacuum-assisted delivery (19.8 vs 2.9 per 1000 vaginal deliveries, respectively; adjusted odds ratio, 5.18; 95% confidence interval, 4.85-5.53), episiotomy (19.2 vs 2.8 per 1000 vaginal deliveries, respectively; adjusted odds ratio, 3.95; 95% confidence interval, 3.71-4.20), and shoulder dystocia (17.8 vs 3.4 per 1000 vaginal deliveries, respectively; adjusted odds ratio, 2.60; 95% confidence interval, 2.29-2.94) were associated with more than a 2-fold increased risk of fourth-degree perineal laceration. Among the group with obesity, patients who had forceps delivery and shoulder dystocia had the highest incidence of fourth-degree laceration (105.3 per 1000 vaginal deliveries). Among the group without obesity, patients who had forceps delivery, shoulder dystocia, and macrosomia had the highest incidence of fourth-degree laceration (294.1 per 1000 vaginal deliveries). The incidence of fourth-degree perineal laceration decreased by 11.9% over time (P trend=.004); moreover, forceps delivery, vacuum-assisted delivery, and episiotomy decreased by 3.8%, 7.6%, and 29.5%, respectively (all, P trend<.05).

CONCLUSION

This national-level analysis suggests that patients with obesity are less likely to have obstetric anal sphincter injuries at the time of vaginal delivery. Furthermore, this analysis confirms other known risk factors for fourth-degree laceration, such as forceps delivery, vacuum-assisted delivery, episiotomy, and shoulder dystocia. However, we noted a decreasing trend in fourth-degree lacerations, which may be due to evolving obstetrical practices.

[Birth in the Midwife-Led Delivery Room of a Perinatal Center - Learning Curve, Outcomes and Benchmark]

INTRODUCTION

Most births in Germany take place in a clinical setting. Midwife-led units have been offered in Germany since 2003 as an addition to the primarily physician-led obstetric care. The purpose of this study was to analyze differences regarding medical parameters between a midwife-led and a primarily physician-led unit in a level 1 perinatal center.

MATERIAL AND METHODS

Between 12/2020 and 12/2021, all births begun in the midwife-led unit were retrospectively analyzed and compared to a physician-led control cohort. Outcome measures were defined as obstetric interventions, delivery mode and duration, delivery position, and maternal and neonatal outcome.

RESULTS

The percentage of deliveries started in the midwife-led unit out of the total birth rate was 4.8% (n=132). Most transfers were made for more effective analgesia (52.6%). Among medically indicated transfers (n=30, 39.5%), transfers due to CTG abnormalities and failure to progress in labor after rupture of membranes predominated. 43.9% (n=58) of patients gave birth successfully in the midwife-led unit. The rate of episiotomy was significantly higher in the primarily physician-led unit compared to the successful midwife-led unit (p=0.019).

CONCLUSION

Birth in a midwife-led unit within a perinatal center can be considered an equivalent alternative to primarily physician-led birth for low-risk pregnant women.

Is there still an indication for episiotomy? Results from a French national database analysis

OBJECTIVE

To assess the link between mediolateral episiotomy and the occurrence of obstetrical anal sphincter injury (OASIS).

METHODS

Data were collected from the national database (PMSI; Programme de Médicalisation des Systèmes d'Information). Women between 18 and 50 years old, undergoing a vaginal delivery in France in 2018 were included. The main outcome was factors associated with a higher adjusted OASIS rate after a vaginal delivery.

RESULTS

Of 623 003 women with a vaginal delivery, 239 949 were primiparous (38.5%), 62 310 experienced mediolateral episiotomy (10.0%) and 7077 had a third- or fourth-degree perineal tear (1.14%). Risk factors for OASIS were primiparity (adjusted odds ratio [OR] 2.97), shoulder dystocia (aOR 2.57), instrumental delivery (aOR 2.81), gestational diabetes (aOR 1.20), and post-term delivery (aOR 1.53). Mediolateral episiotomy increased the occurrence of OASIS for women without an instrumental delivery, either for parous (OR 1.32, 95% confidence interval [CI] 1.07-1.62) or primiparous (OR 1.26, 95% CI 1.13-1.39) women. In contrast, episiotomy among primiparous women with episiotomy and a vacuum or forceps delivery significantly decreased the risk for OASIS (OR 0.62, 95% CI 0.56-0.67).

CONCLUSIONS

The practice of routine episiotomy should be discouraged. Selective mediolateral episiotomy should be considered with extreme caution and mainly for primiparous women during instrumental vaginal delivery. Further randomized trial may confirm such results.

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

OBJECTIVES

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

DESIGN

A prospective observational case series study.

SETTING

International centers.

POPULATION

Eighteen consecutive women at term during vaginal delivery.

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

TWEETABLE ABSTRACT

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

Effect of Dry Heat Application on Perineal Pain and Episiotomy Wound Healing among Primipara Women

Background

Women who undergo perineal episiotomy can be affected by several complications such as bleeding, infection, perineal pain, dyspareunia, reduction of sexual desire, as well as urinary and anal incontinence. Perineal pain related to episiotomy has been reported to interfere with women's daily activities postpartum and can prevent proper breastfeeding, proper rooming-in, and maternal-infant bonding. The purpose of this study was to determine the effect of dry heat application on perineal pain and episiotomy wound Healing among primipara women.

Method

A quasi-experimental, two-group, pre-post-test research study was conducted at the postnatal inpatient ward and the outpatient clinic of the El-Shatby Maternity University Hospital in Alexandria. A sample of 100 parturient women was divided into the following two groups at random: dry heat and moist (control) heat. Women in the moist heat group were advised to sit in a basin (tub) of warm water for 10 minutes, while those in the dry heat group were instructed to set an infrared light (230 volts) at a distance of 45 cm from the perineum after 12 hours post episiotomy. Both interventions were applied twice a day for ten consecutive days. They evaluated the severity of their perineal pain at baseline and repeated it on the 5^th and 10^th days after obtaining the interventions while the episiotomy wound healing was assessed on the 5^th and 10^th days.

Results

It was discovered that the dry heat group had a significantly improved episiotomy wound healing as regards perineal redness, edema of the perineal area, ecchymosis, wound discharge, and approximation of wound edges on the 5th (P < 0.001, P < 0.001, P < 0.007, P < 0.003, and P < 0.001, respectively) and 10th day after intervention (P < 0.001, P < 0.001, P < 0.001, P < 0.005, and P < 0.001, respectively) than the moist heat group. The primipara women had significantly lower perineal pain intensity in the dry heat group on the 5th and 10th days after intervention than in the moist heat group (^MH P < 0.001 for the dry heat group and ^MH P = 0.004 for the moist heat group).

Conclusion

The application of dry heat promoted episiotomy wound healing among primipara women and reduced their perineal pain during early postpartum days than moist heat.

Magnitude of episiotomy practice and associated factors among women who gave birth at Hiwot Fana Specialized University Hospital, Eastern Ethiopia

BACKGROUND

Episiotomy is an intentional surgical incision made on the perineum with the aim of enlarging the introits during the second stage of labor or just before delivery of the baby. It sometimes also interferes with the mother's comfort during the postpartum period and has associated complications especially when it is done without indication. However, there is limited information regarding episiotomy practice in the study area.

OBJECTIVE

This study aimed to determine the magnitude of episiotomy practice and associated factors among women who gave birth at the Hiwot Fana Specialized University Hospital, Eastern Ethiopia, 2021.

METHODS

A facility-based cross-sectional study was conducted among 408 systematically selected mothers who gave birth at the Hiwot Fana Specialized University Hospital, from 1 January to 30 December 2021. Datas were collected from delivery medical records using a pretested checklist. The extracted data were checked, coded, and entered into the Epi-data version 3.1 and exported to the STATA version 16 software for analysis. Binary logistic regression was fitted to identify factors associated with episiotomy practice. P-values < 0.05 were considered to declare the presence of statistical significance.

RESULTS

The overall prevalence of episiotomy practice was found to be 43.4 % (95% CI: 38.7, 48.9), and mediolateral was the most commonly practiced episiotomy type (41.4%). Parity [AOR: 6.2; 95% CI (3.8-17.6)], 1st min Apgar score [AOR: 1.6; 95% CI (1.04-2.67)], presence of maternal medical disease [AOR: 3.3; 95% CI (1.09-6.9)], and induced labor [AOR: 1.6; 95%CI (1.12, 4.13)] were significantly associated with the episiotomy practice.

CONCLUSION

The prevalence of episiotomy practice in the study area was high. Parity, presence of maternal medical disease, induction of labor, and 1st min APGAR score were significant factors associated with episiotomy practice. Considering the presence of appropriate indications or preventing unjustifiable indications, can help to reduce the current high practice rates.

Postpartum Dyspareunia Following Continuous Versus Interrupted Perineal Repair: A Systematic Review and Meta-Analysis

Research evaluating optimal repair techniques for the reduction of postpartum dyspareunia following obstetric laceration is severely limited. Prevailing guidelines from the American College of Obstetricians and Gynecologists (ACOG) are reliant on data from just nine clinical trials conducted from 1980 to 2012. While the literature on this topic is still limited today, this review aims to synthesize data from past and present studies to ensure that standing clinical recommendations are supported by current literature. A review was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane Library, and Google Scholar were searched. Included articles (1) compared continuous with interrupted repair techniques for subjects with episiotomies and/or second-degree tears, (2) were available in full length, and (3) reported dyspareunia as an outcome variable. Excluded articles were those (1) inclusive of first-, third-, or fourth-degree tears; (2) comparing suture material rather than technique; and (3) not available in English. A meta-analysis was conducted for both acute dyspareunia (<3 months) and chronic dyspareunia (>3 months) utilizing Meta-Essentials Microsoft Excel (Microsoft Corp., Redmond, WA) workbook. Bias was evaluated via Egger regression and Begg and Mazumdar rank correlation tests. Twelve articles met inclusion and exclusion guidelines, seven for acute dyspareunia and eight for chronic dyspareunia. All publications were randomized controlled trials and were inclusive of a total of 4,081 patients. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using a random effect model. Analysis revealed no statistically significant difference between continuous and interrupted suture groups for acute dyspareunia (RR: 0.98; 95% CI: 0.89-1.08) or chronic dyspareunia (RR: 0.96; 95% CI: 0.83-1.12). Egger regression test (p-value=0.534) and Begg and Mazumdar rank correlation test (p-value=0.570) indicated minimal publication bias. Compiled data does not indicate a preferential suture technique for the reduction of postpartum dyspareunia. These findings are congruent with the ACOG guidelines; therefore, there is no supporting evidence for ACOG's recommendation of continuous suturing to be overturned.

Selective versus routine use of episiotomy for vaginal births in Shanghai hospitals, China: a comparison of policies

Background

To assess the effects of policy of selective versus routine episiotomy on mother and baby for women delivering vaginally in Shanghai and whether the hospital type has any effect on the outcomes.

Method

This was a multi-center retrospective cohort study in Shanghai between March 2015 and May 2017. The study population were vaginal births with selective or routine episiotomy (n = 5478) in 20 secondary or tertiary hospitals. Main Outcome Measure was the incidence of severe perineal lacerations. The adjusted odds ratios (aOR) and 95% confidence intervals (CI) were estimated by logistic regression and presented as the effect sizes. All models were stratified by the utilization of level (secondary and tertiary) and type (general and Obstetric) of hospital.

Results

The primary outcome was not significantly different between vaginal births with routine and selective episiotomy. Patients with selective episiotomy had a lower risk of postpartum hemorrhage, and newborns in the selective episiotomy group had a lower risk of shoulder dystocia and Neonatal Ward compared to those with routine episiotomy. Newborns in selective episiotomy group had a lower risk of birth injury in tertiary hospital. However, newborns in selective episiotomy group had a higher risk of birth injury in general hospitals.

Conclusion

Selective episiotomy is safe and can be recommended over routine episiotomy in obstetric and tertiary hospital settings in China.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04790-0.

Aspects of Pelvic Floor Protection in Spontaneous Delivery - a Review

The necessity of increasingly addressing aspects of pelvic floor protection, i.e., prevention of the most frequent female pelvic floor disorders, such as urinary incontinence, faecal incontinence and pelvic organ prolapse, is the result of the steadily improving understanding of the association of pregnancy and delivery with the prevalence of these disorders. About a quarter of all women experience one or more such symptoms during their life. Apart from age and weight, pregnancies and births play an important part. While initial discussion of pelvic floor protection often focused very rapidly on the mode of delivery and elective caesarean section as a possible protective intervention, it has become apparent in the last few decades how varied and wide-ranging the options are that can be used to protect against pelvic floor disorders. The mode of delivery as such is "only" one element among numerous other considerations and has diminished markedly in importance. Interprofessionality and interdisciplinarity undoubtedly represent an important development as resulting recommendations must always be incorporated in an overall context that considers mother and child at the same time. Considering the pelvic floor only certainly does not make sense. This review article will analyze in greater detail important pre-, intra- and postpartum aspects that in their entirety can provide insight into the various aspects of pelvic floor protection. The authors regard the following article as an additional basis for discussion on achieving a sustained reduction in the incidence and prevalence of female pelvic floor disorders.

A nationwide cross-sectional survey of episiotomy practice in China

Background

A restrictive use of episiotomy was recommended by the obstetric society in China, but limited information on the epidemiology and the effects of restrictive use of episiotomy on maternal and fetal outcomes have been published.

Methods

The China Labor and Delivery Survey is a cross-sectional investigation with a cluster random sampling scheme in 2015-2016 with the aim to describe detailed epidemiology of labor and delivery in China. We calculated the episiotomy rate by parity using the survey data. Associated factors of episiotomy were selected using mixed models with a random effect for the hospital-level clustering. Logistic regression models were fitted to examine the effects of mediolateral episiotomy on maternal and neonatal outcomes among the propensity score-matched women.

Findings

The episiotomy rate among vaginal births was 41·7% [95% confidence interval (CI): 40·1% - 43·2%] in nulliparae and 21·5% (95% CI: 19·4% - 23·5%) in multiparae in China. Associated factors of episiotomy included prepregnancy BMI, maternal diseases, and obstetric factors. More than half of episiotomies in nulliparae and one-fourth in multiparae had no indications. Mediolateral episiotomy without indicators increased the risk of 3^rd or 4^th degree perineal laceration [odds ratio (OR) =2·64, 95% CI: 1·08-6·48)] in nulliparae without neonatal benefits.

Interpretation

Episiotomy was performed more than medically necessary in China. Mediolateral episiotomy without indications more than doubled the risk of 3^rd and 4^th degree perineal laceration in nulliparae without neonatal benefits.

Funding

National Natural Science Foundation of China and Shanghai Health Commission Programme.

Effects of lateral episiotomy on the emergence of urinary incontinence during the first postpartum year in primiparas: prospective cohort study

AIM OF THE STUDY

Lateral episiotomy is a widely used procedure, although it is rarely mentioned in the literature and its effects on the pelvic floor are largely unexplored. The purpose of this study is to evaluate the impact of lateral episiotomy on the incidence of urinary incontinence (UI) after vaginal delivery in primiparas.

MATERIAL AND METHODS

The study design is a prospective cohort study. The primiparas were divided into two groups. The first group consisted of women who gave birth with lateral episiotomy, while the second group included women who gave birth with an intact perineum or with perineal tears of first and second degree. Assessments of UI were performed at 5 and 8 months after childbirth using the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) questionnaire followed by the stress test.

RESULTS

The results revealed no significant differences (p > 0.05) in emergence of stress urinary incontinence (SUI) between the groups at the two time points. There were no statistically significant differences in overall rate of UI, urge urinary incontinence (UUI), or mixed urinary incontinence according to the ICIQ-SF questionnaire. The overall incontinence rate on the first examination was 24% in the episiotomy group and 36% in the perineal laceration group, although the difference was not statistically significant (p = 0.064). On the second examination, rates were similar and without a statistically significant difference.

CONCLUSIONS

Lateral episiotomy has a neutral effect on the onset of UI in primiparous women in the first year after delivery.

Delivery Mode after Ileal Pouch-Anal Anastomosis among Pregnant Women with Ulcerative Colitis

Objectives:

The appropriate and recommended delivery mode after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) has not been sufficiently evaluated. This study was designed to compare the delivery outcomes associated with cesarean section (CS) and vaginal delivery (VD) after IPAA.

Methods:

We conducted a questionnaire-based survey of female patients who underwent IPAA for UC between July 1987 and May 2018. Additionally, we reviewed clinical data and collected information regarding pouch function and postpartum complications.

Results:

In total, 45 patients had 68 deliveries, including 64 CS deliveries and four VDs. Fecal incontinence worsened in seven patients, including six CS patients and one VD patient. The Wexner scores of these patients before and after delivery were 5.4 ± 0.4 and 14.8 ± 1.0, respectively (p = 0.005). Four patients in the CS group and one in the VD group (p = 0.32) had increased stool frequency. Bowel obstructions developed during 11/64 (17.2%) deliveries, and one patient required surgical intervention. One patient with four VDs (three before IPAA and one after IPAA) developed vaginal fistula 5 months after the final VD. Information on episiotomies could not be obtained.

Conclusions:

Pouch function can decline even after CS. Notably, bowel obstruction can develop after CS. However, we cannot recommend a particular delivery method after IPAA. Further analyses to elucidate the relationship between CS and postoperative complications or vaginal fistula and episiotomy in VDs should be conducted.

Health care workers' perceptions of episiotomy in the era of respectful maternity care: a qualitative study of an obstetric training program in Mexico

BACKGROUND

Episiotomy in Mexico is highly prevalent and often routine - performed in up to 95% of births to primiparous women. The WHO suggests that episiotomy be used in selective cases, with an expected prevalence of 15%. Training programs to date have been unsuccessful in changing this practice. This research aims to understand how and why this practice persists despite shifts in knowledge and attitudes facilitated by the implementation of an obstetric training program.

METHODS

This is a descriptive and interpretative qualitative study. We conducted 53 pre and post-intervention (PRONTO© Program) semi-structured interviews with general physician, gynecologists and nurses (N = 32, 56% women). Thematic analysis was carried out using Atlas-ti© software to iteratively organize codes. Through interpretive triangulation, the team found theoretical saturation and explanatory depth on key analytical categories.

RESULTS

Themes fell into five major themes surrounding their perceptions of episiotomy: as a preventive measure, as a procedure that resolves problems in the moment, as a practice that gives the clinician control, as a risky practice, and the role of social norms in practicing it. Results show contradictory discourses among professionals. Despite the growing support for the selective use of episiotomy, it remains positively perceived as an effective prophylaxis for the complications of childbirth while maintaining control in the hands of health care providers.

CONCLUSIONS

Perceptions of episiotomy shed light on how and why routine episiotomy persists, and provides insight into the multi-faceted approaches that will be required to affect this harmful obstetrical practice.

Diagnosis and Treatment of Obstetric Anal Sphincter Injuries: New Evidence and Perspectives

Perineal injury during childbirth is a common event with important morbidity associated in particular with third-and-fourth degree perineal tears (also referred to as obstetric anal sphincter injuries-OASIS). Early diagnosis of these damages is mandatory to define a prompt therapeutic strategy and thus avoid the development of late-onset consequences, such as faecal incontinence. For this purpose, various diagnostic exams can be performed after a thorough clinical examination. The management of OASIS includes several measures and should be individualized according to the timing and features of the clinical presentation.

The perception and knowledge about episiotomy: A cross-sectional survey involving healthcare workers in a low- and middle-income country

BACKGROUND

Episiotomy was introduced into clinical practice without clear evidence of its benefits.The knowledge and understanding of episiotomy guidelines and practice by healthcare workers is substandard in our setting; hence, the injudicious use of this procedure have led to high rates.

AIM

To assess the knowledge, perception and practice of episiotomy by healthcare workers.

SETTING

Research was conducted in a Pietermaritzburg complex, South AfricaMethods: A questionnaire-based survey was conducted amongst healthcare workers regarding episiotomy practice. In addition to providing demographic data, the participants were requested to respond to 35 proposed statements regarding episiotomy practice. Data were analysed using SPSS (Statistical Package for the Social Sciences) software.

RESULTS

One hundred and forty-two midwives and 66 medical practitioners completed the questionnaires. There were variations in responses to several statements on episiotomy practice by medical practitioners and nurses based on their level of experience. This study found that the majority of HCWs did not have access to a protocol or policy on episiotomy practice in their units; furthermore, nor knowledge of the South African guidelines for maternity care on episiotomy practice. Significantly, more medical practitioners felt a need for more in-service training and an increase in the number of episiotomies performed under supervision. The commonly reported reason for performing an episiotomy by both medical practitioners and midwives was to reduce 3rd - 4th degree perineal tears.

CONCLUSION

Healthcare workers in our setting displayed poor knowledge about the practice of episiotomy and were not aware of existing national guidelines on episiotomy practice.

Is mediolateral episiotomy angle associated with postpartum perineal pain in primiparous women?

OBJECTIVE:

Our aim is to elucidate the relationship between mediolateral episiotomy (MLE) angle and postpartum perineal pain.

METHODS:

This study was designed prospectively. Primiparous women with MLE in the postpartum period were included in the study and divided into three groups according to episiotomy angle ranges (Group 1: <40°, Group 2: 40°–60°, and Group 3: >60°). Postpartum perineal pain was quantified with the short-form McGill Pain questionnaire (SF-MPQ) consisting of the following three parts: Sensory-affective-verbal descriptions, visual pain scale (VPS), and present pain intensity scale (PPI). Postpartum perineal pain scores on days 1 and 7 were compared among the angle group.

RESULTS:

Overall, 86 eligible women were enrolled in this study. Seventy-three women (85%) scored the perineal pain between 0 and 3 on the VPS and 13 women (15%) rated the pain from 4 to 6 on the 1^st postpartum day. No significant differences were noted among the three groups regarding the total pain scores on SF-MPQ and on the each part of form at the 1^st postpartum day. At 7 days postpartum, total pain score was found significantly high in Group 1 [Med; IQR (min-max)=0; 4 (0–5)] compared with Group 2 [Med; IQR (min-max)=0; 0(0–5)]. The pain scores obtained from the sensory, affective, VPS, and PPI parts of the questionnaire were [Med; IQR (min-max)=0; 1 (0–2)], [Med; IQR (min-max)=0; 1 (0–1)], [Med; IQR (min-max)=0; 2 (0–2)], and [Med; IQR (min-max)=0; 0.25 (0–1)], respectively, in Group 1. For Group 2, pain scores obtained from the sensory, affective, and PPI were [Med; IQR (min-max)=0; 0(0-1)]; and VPS was [Med; IQR (min-max)=0; 0(0-2)]. No significant differences were observed between Groups 1 and 2 for each part of the questionnaire on day 7. Percentage of need for analgesics on day 7 was found significantly higher in Group 1 (42.9%) than Group 2 (31.2%)

CONCLUSION:

MLE at an angle <40° to the midline is associated with a higher score of perineal pain and an increase need for analgesics during the early postpartum days.

Knowledge, attitude and experience of episiotomy practice among obstetricians and midwives: a cross-sectional study from China

OBJECTIVE

Episiotomy is still performed widely by obstetricians and midwives in some Chinese maternity units, but the reasons are unknown. This study aims to determine the knowledge, attitude and experience towards the practice of episiotomy among obstetricians and midwives in China's public hospitals and consider strategies to reduce its practice.

METHODS

A cross-sectional web survey using a self-administered questionnaire was conducted among obstetricians and midwives in 90 public hospitals in Henan Province, China.

RESULTS

900 (82.21%) participants completed the questionnaire. Average knowledge level (4.15, SD=1.10) on complications and overuse was identified among participants. Episiotomy was performed more frequently in secondary hospitals than in tertiary hospitals (p<0.05). Senior clinicians were more likely to perform episiotomy than younger ones (p<0.05). Almost half of the clinicians (42.11%) considered the current rate of episiotomy (45%) to be right or too low. The most common reason for performing episiotomy identified by obstetricians (83.94%) and midwives (79.69%) was to reduce third-degree or fourth-degree perineal laceration. Both obstetricians (80.29%) and midwives (82.57%) agreed that the most significant obstacle to reducing the rate of episiotomy was lack of training on reducing perineal tears.

CONCLUSION

In sum, episiotomy was driven by previous training, practitioners' experience and local norms rather than the latest medical evidence. Clinicians in secondary hospitals and senior clinicians are key training targets. It is urgent to improve current clinical policies and surgical procedure guidelines for obstetricians and midwives regarding episiotomy.

Language barrier as a risk factor for obstetric anal sphincter injury - A case-control study

INTRODUCTION

The incidence of grade 3-4 perineal tears, also known as obstetric anal sphincter injury (OASI), is reported to be between 0.5 and 2.5%. Beyond the medico-economic burden, the consequences of OASI on a woman's emotional, psychological, sexual, and physical wellbeing are considerable. Among the various risk factors of OASI, few data are available about the impact of a language barrier on its incidence.

MATERIAL AND METHODS

We conducted a case-control study to evaluate the effect of language barriers on the risk of OASI comparing 171 women with OASI and 163 matched controls. The matched criteria included ethnicity, age, previous vaginal delivery, delivery mode, prophylactic episiotomy and birthweight. Patients' characteristics were compared and crude ORs and 95% CIs estimated using unadjusted logistic models. Multivariate analysis was performed with recognized potential confounders.

RESULTS

All of the cases had grade 3 tears. Language barrier was a determinant factor of OASI with an OR of 3.32 [1.36-8.90], p = 0.01. Other risk factors were occipito-posterior delivery, African origin and prolonged labor duration (OR 6.33, 95% CI: 2.04-27.78, p = 0.004, OR 1.85, 95% CI: 1.08-3.19, p = 0.03 and OR 1.03, 95% CI: 1.01-1.05, p = 0.004, respectively).

CONCLUSION

Our data suggest that language barrier is an independent risk factor of OASI. Physicians and midwives should attempt to identify patients with a language barrier during prenatal visits. Education about simple terms used during delivery could decrease the incidence of this complication.

The Most Comfortable Posture at First Postnatal Day in Women With Episiotomy for Breastfeeding and Routine Activities

Background: Episiotomy is a common procedure in vaginal deliveries. It was thought that episiotomy reduces the risk of severe perineal injuries, but now in various studies it has been observed that it is associated with increased perineal pain, sexual problems, and incontinence in the postpartum period.

Purpose: This study was carried out to assess pain score on first postnatal day in women with episiotomy during breastfeeding and daily activities.

Method: The consecutive patients who underwent normal vaginal delivery with episiotomy from November 1, 2020 to December 1, 2020 in the Department of Obstetrics and Gynecology at Safdarjung Hospital were evaluated. The patients with vulval edema; vulval hematoma; instrumental delivery; and cervical, vaginal, and perineal tear were excluded from the study. The episiotomy pain during routine activities and breastfeeding was assessed at first postnatal day by Visual Analogue Scale (VAS) pain score. The analysis of variance (ANOVA) was used to compare the VAS score in different positions for breastfeeding and routine activities. The most comfortable posture was with lowest VAS pain score.

Results and conclusion: Overall 73 patients were enrolled in the study, mean age was 23.48 ± 2.49 years, 47/73 (64.38%) were primigravida, and mean birth weight of neonate was 2.79 ± 0.43 kg. The mean VAS pain score during breastfeeding in crossed-leg position was 74.82 ± 28.33, and in left lateral position, the score was 14.51 ± 11.65 (p [U1] = 0.0001). The mean VAS pain score during resting position in sitting with leg down was 56.52 ± 21.23, and in left lateral position, the score was 21.25 ± 13.95 (p= 0.0001). The VAS score was increased as the birth weight (p= 0.302), and the duration of second stage of labor was increased (p = 0.047). The severe pain was in 5/73 patients using Western toilet and in 46/73 Indian toilet (p≤ 0.0001).

Conclusion: The left lateral position for breastfeeding and resting supine are least painful positions. The Western-style toilets are more comfortable than Indian-style toilets.

Dispareunia en mujeres después de parto vaginal. Prevalencia en dos clínicas de Armenia, Colombia, 2012-2017

Se realizó un estudio de corte transversal que tuvo como objetivo determinar la prevalencia de la dispareunia en mujeres con parto vaginal, evaluar posibles factores de riesgo y la asociación con la episiotomía. Ingresaron mujeres atendidas por parto vaginal entre 2012 y 2017 en dos clínicas de alta complejidad en Armenia (Colombia). Se utilizó el cuestionario Índice de Función Sexual Femenina (IFFS-6) para evaluar la función sexual. Los resultados reportan una prevalencia de dispareunia del 59,37%, siendo más prevalente en mujeres sometidas a episiotomía (OR: 68,17; IC95 %: 60,57-79,15). Respecto a la asociación de la episiotomía con la presencia de dispareunia se encontró asociación significativa con la episiotomía medio-lateral (OR: 8,17; IC95%: 2,15-56,32), lesión del esfínter (OR: 7,32; IC95%: 4,86-12,75) y dehiscencia de la sutura (OR: 6,48; IC95%: 4,92-14,28). Se observaron como factores de riesgo: antecedente de endometriosis (OR: 11,6; IC95 %: 9,15-17,52), dolor pélvico crónico (OR: 3,56; IC95%: 2,21–6,32) e ITS (OR: 2,67; IC95%: 1,54–5,14), p=0,003). Se concluye que la prevalencia de dispareunia en mujeres con parto vaginal, atendidas en Armenia, varía en función de la realización de episiotomía, asociándose tanto a las complicaciones de esta como a otros antecedentes.

The beneficial effects of fractional CO2 laser treatment on perineal changes during puerperium and breastfeeding period: a multicentric study

Childbirth is a great change in woman life because of hormonal, physical and psychological alterations that are associated with this process. Dyspareunia and perineal pain are commonly reported symptoms in the postpartum period, mainly due to perineal trauma, lacerations, episiotomy, and forceps or vacuum use at delivery. Among non-pharmacological treatment, a new trend is gaining popularity, which is the energy-based therapy, including fractional micro-ablative CO₂ laser. We conducted a multicentric retrospective study to assess the efficacy and the possible side effects of CO₂ laser treatment on transient vulvovaginal atrophy and perineal postpartum pain related to puerperium and breastfeeding period. All patients were submitted to 3 or 4 sessions of CO₂ laser treatment. As per protocol, an initial, intermediate (after 2 sessions) and final (3 months after the last cycle) evaluation of the symptoms were made, using a VAS (Visual Analogue Scale 0-10). We also compared this group of patients with a control group with no treatment. At the final evaluation, patients showed a significant improvement for dyspareunia (VAS from 7.95 to 3.14, p < 0.0001). A significant improvement was also registered in pain at the vaginal orifice (VAS from 6.94 to 2.05, p = 0.0001), dryness (VAS from 6.6 to 2.9, p = 0.0022), itching (VAS from 4.5 to 1.16, p = 0.0053), heat (VAS from 3 to 0, p = 0.0119) and burning (VAS from 5.5 to 1.6, p = 0.0013) if compared with the control group. Quality of life for the women during the breastfeeding and puerperium is important and training is mandatory to avoid side effects in order to improve the CO₂ laser performance.

Episiotomy practices in France: epidemiology and risk factors in non-operative vaginal deliveries

Episiotomy use has decreased due to the lack of evidence on its protective effects from maternal obstetric anal sphincter injuries. Indications for episiotomy vary considerably and there are a great variety of factors associated with its use. The aim of this article is to describe the episiotomy rate in France between 2013 and 2017 and the factors associated with its use in non-operative vaginal deliveries. In this retrospective population-based cohort study, we included vaginal deliveries performed in French hospitals (N = 584) and for which parity was coded. The variable of interest was the rate of episiotomy, particularly for non-operative vaginal deliveries. Trends in the episiotomy rates were studied using the Cochran-Armitage test. Hierarchical logistic regression was used to identify variables associated with episiotomy according to maternal age and parity. Between 2013 and 2017, French episiotomy rates fell from 21.6 to 14.3% for all vaginal deliveries (p < 0.01), and from 15.5 to 9.3% (p < 0.01) for all non-operative vaginal deliveries. Among non-operative vaginal deliveries, epidural analgesia, non-reassuring fetal heart rate, meconium in the amniotic fluid, shoulder dystocia, and newborn weight (≥ 4,000 g) were risk factors for episiotomy, both for nulliparous and multiparous women. On the contrary, prematurity reduced the risk of its use. For nulliparous women, breech presentation was also a risk factor for episiotomy, and for multiparous women, scarred uterus and multiple pregnancies were risk factors. In France, despite a reduction in episiotomy use over the last few years, the factors associated with episiotomy have not changed and are similar to the literature. This suggests that the decrease in episiotomies in France is an overall tendency which is probably related to improved care strategies that have been relayed by hospital teams and perinatal networks.

Factors Associated with Episiotomy Practices in Bahirdar City, Ethiopia: A Cross-Sectional Study

Background

Episiotomy is the surgical enlargement of the vaginal orifice during the last part of the second stage of labor or childbirth by an incision to the perineum. The World Health Organization advises the use of episiotomy on a restricted and selective basis. Indeed, the rate of episiotomy in developed countries is decreasing, but in developing countries, including Ethiopia, it still remains high. Therefore, this study tried to assess the proportion and factors associated with episiotomy among women who gave birth at Felege Hiwot Referral Hospital, Bahir Dar City, North West Ethiopia, 2017.

Methods

An institution-based cross-sectional study was conducted among 411 mothers from February to April 2017. Data were collected through face-to-face interviews and supported by observation using standard checklist with systematic random sampling technique. Data was entered by Epi Info and analyzed by SPSS version 23. The association between variables was analyzed using bivariable and multivariable logistic regression model. P-value <0.05 at 95% CI was considered to be statistically significant.

Results

The proportion of episiotomy was 41.1% with 95% CI (36.5%, 46.2%). Multivariable logistic regression showed that primiparity (AOR=6.026, 95% CI (3.542,10.253)), prolonged second stage of labor (AOR=4.612, 95% CI (2.247,9.465)), instrument delivery (AOR =3.933, 95% CI (1.526,10.141)), using oxytocin (AOR=2.608, 95% CI (1.431,4.751)), medical resident attendant (AOR =3.225, 95% CI (1.409,7.382)) and birth weight ≥4000 grams (AOR=5.127,95% Cl (1.106,23.772)) were significantly associated with episiotomy practice.

Conclusion

The proportion of episiotomy was high. Parity, using oxytocin, second-stage labor duration, instrument delivery, birth weight, and delivery attendant were statistically significant factors for episiotomy practice. Therefore, as per our findings, we suggest awareness creation, and the setting and use of new national guidelines, the practice of routine episiotomy should be abandoned, and selective and restrictive use of episiotomy is highly advised.

Birthweight and urinary incontinence after childbirth: a systematic review and meta-analysis

Birthweight and urinary incontinence after childbirth: a systematic review and meta-analysis Stian Langeland WESNES, Elin SEIM MD Urinary incontinence (UI) is common after childbirth. Many cohort and cross-sectional studies have reported data on birthweight, but results have not been pooled. It is unclear how birthweight affects UI after childbirth. The objective is to review the effect of birthweight on UI after childbirth through meta-analyses. Searches were performed in Medline, Embase, Svemed+, ClinicalTrials.gov, Cochrane, and Cinahl in August 2016. Additional reference checking was performed. Included articles evaluated birthweight as a possible risk factor for maternal UI. We included articles that were presented in Norwegian, Danish, Swedish, or English. Two independent reviewers extracted the data and analysed it using Review Manager 5.3 software. Available data from included studies on birthweight (≥4000 g and ≥3500 g, respectively) and UI were combined in meta-analyses. PRISMA and MOOSE guidelines were used. Eighteen studies (N = 30 070) reported data on birthweight >4000 g vs <4000 g. Birthweight>4000 g compared to weight <4000 g was associated with a significantly increased OR of any UI (OR 1.49, 95% CI 1.24 - 1.80). Five studies (N = 15 066) reported data on birthweight >3500 g vs <3500 g. Birthweight>3500 g was also associated with a significantly increased OR of UI (OR 1.26, 95% CI 1.15 - 1.37). High birthweight appears to increase OR of UI after childbirth. Preventative strategies should be targeted towards women at particular risk.

Birth tears after spontaneous and vacuum-assisted births with different vacuum cup systems - a retrospective cohort study

Objectives Birth tears are a common complication of vaginal childbirth. We aimed to evaluate the outcomes of birth tears first by comparing the mode of vaginal birth (VB) and then comparing different vacuum cups in instrumental VBs in order to better advise childbearing women and obstetrical professionals. Methods In a retrospective cohort study, we analyzed nulliparous and multiparous women with a singleton pregnancy in vertex presentation at ≥37 + 0 gestational weeks who gave birth vaginally at our tertiary care center between 06/2012 and 12/2016. We compared the distribution of tear types in spontaneous births (SBs) vs. vacuum-assisted VBs. We then compared the tear distribution in the vacuum group when using the Kiwi Omnicup or Bird's anterior metal cup. Outcome parameters were the incidence and distribution of the different tear types dependent on the mode of delivery and type of vacuum cup. Results A total of 4549 SBs and 907 VBs were analyzed. Birth tear distribution differed significantly between the birth modes. In 15.2% of women with an SB an episiotomy was performed vs. 58.5% in women with a VB. Any kind of perineal tear was seen in 45.7% after SB and in 32.7% after VB. High-grade obstetric anal sphincter injuries (OASIS) appeared in 1.1% after SB and in 3.1% after VB. No significant changes in tear distribution were found between the two different VB modes. Conclusions There were more episiotomies, vaginal tears and OASIS after VB than after SB. In contrast, there were more low-grade perineal and labial tears after SB. No significant differences were found between different vacuum cup systems, just a slight trend toward different tear patterns.

The effect of Lavender on pain and healing of episiotomy: A systematic review

INTRODUCTION

Some studies have investigated the effect of Lavender on pain and the healing of wounds. The aim of this systematic review was to investigate the effect of Lavender on pain and wound healing of episiotomy.

METHODS

The Cochrane Library, MEDLINE (PubMed), Scopus, and Web of Science (all databases from inception until February 2020) were searched. Data were extracted from eligible studies by two review authors individually. Our inclusion criteria were full-text interventional studies published in English or any other languages. All data were analyzed using Review Manager 5.3. The protocol of this systematic review was registered in PROSPERO with the reference number CRD42020140623.

RESULTS

Our search found six trials involving 415 participants. The use of Lavender could significantly reduce pain in women with episiotomy (95 % CI: -1.06 - -0.32). The use of Lavender has significantly improved the healing of episiotomy compared to the placebo (95 % CI: -2.13 - -1.34). In all studies, pain and healing of episiotomy were evaluated with Visual Analog Scale (VAS) and Redness, Edema, Ecchymosis, Discharge, Approximation (REEDA) scale respectively.

CONCLUSION

This review showed that the use of Lavender (in any form) in postpartum has a significant effect on pain relief and healing of episiotomy wound. All six studies that were included in this systematic review were from developing countries. A high level of heterogeneity was observed in the effect of Lavender on pain but not the healing of the episiotomy. Therefore, the results should be considered with caution. Using Lavender may be considered for wound healing of episiotomy.

Ropivacaine 75 mg versus placebo in perineal infiltration for analgesic efficacy at mid- and long-term for episiotomy repair in postpartum women - the ROPISIO study: a two-center, randomized, double-blind, placebo-controlled trials

Background

Perineal pain due to episiotomy is commonly reported and can be severe enough to disturb the mother–infant dyad during the postpartum period. Its incidence at day 7 postpartum varies from 63% to 74%. Recent studies have investigated the analgesic efficacy of perineal infiltration of ropivacaine after episiotomy but have only focused on the immediate postpartum period (at 24 and 48 h after birth). Large, adequately powered, multicenter, randomized controlled trials are required to evaluate the impact of ropivacaine infiltration on perineal pain and mid- and long-term quality of life before the widespread use of ropivacaine to prevent perineal pain after episiotomy can be recommended.

Methods/design

The ROPISIO study is a two-center, randomized, double-blind, placebo-controlled trial being conducted in La Roche sur Yon and Nantes, France. It will involve 272 women with vaginal singleton delivery and mediolateral episiotomy at term (≥ 37 weeks). Perineal infiltration (ropivacaine 75 mg or placebo) will be administrated just after vaginal birth and before episiotomy repair. The primary outcome will be the analgesic efficacy at day 7 postpartum (midterm), defined by the Numeric Pain Rating Scale (NPRS) strictly superior to 3/10 on the perineal repair area. Secondary outcomes will be the analgesic efficacy (NPRS) and the impact of pain on daily behavior, on the quality of life (36-item Short Form Health Survey), on the occurrence of symptoms of postpartum depression (Edinburgh Postnatal Depression Scale), and on sexual health (Female Sexual Function Index) at 3 and 6 months (long-term) using validated online questionnaires. This study will have 90% power to show approximately 30% relative risk reduction in the incidence of perineal pain at day 7, from 70.0% to 50.0%.

Discussion

Ropivacaine is a promising candidate drug, inexpensive, and easy to administer, and it would be suitable to include in the routine management of deliveries in labor ward. This study will investigate if perineal ropivacaine infiltration just after birth can reduce mid- and long-term postpartum pain and increase quality of life in women with mediolateral episiotomy.

Trial registration

ClinicalTrials.gov, NCT03084549. Registered on 14 April 2017.

The Effect of Pregnancy in the Hemoglobin Concentration of Pregnant Women: A Longitudinal Study

Background

The objective of this study was to estimate and identify the determinants of hemoglobin concentration before pregnancy, during pregnancy, and after labor and delivery.

Methods

A prospective cohort study design was implemented. Data were collected from May 2015 to September 2018. A simple random sampling technique was used to select the participants. An interview technique was used to collect the data. Blood samples were collected before pregnancy, during each trimester, during labor and delivery, after third stage of labor, and at the 6-week postpartum period. Descriptive statistics were used to describe the profile of study participants. Generalized estimating equations were used to identify the determinants of hemoglobin concentration during each phase of pregnancy.

Results

The mean hemoglobin concentrations of primigravida and multigravida before pregnancy were 12.41 g/dl and 10.78 g/dl, respectively. The hemoglobin concentration decreases with consecutive trimester reaching the lowest level at 42 days after delivery. The hemoglobin concentrations of pregnant women were decreased by hookworm 0.24 g/dl [95% CI:0.18-0.29], multiple pregnancy 0.16 g/dl [95% CI: 0.07-0.24], episiotomy 0.05 g/dl [95% CI: 0.01-0.09], gravidity 0.15 g/dl [95% CI: 0.09-0.21], age 0.03 g/dl [95% CI: 0.03-0.04], and gestational age 0.1 g/dl [95% CI: 0.09-0.11]. The hemoglobin concentration increased by iron supplementation 1.02 g/dl [95% CI: 0.97-1.07] and birth weight 0.14 g/dl [95% CI: 0.02-0.11].

Conclusion

Pregnancy significantly decreases the hemoglobin concentration of pregnant women reaching the lowest point during labor and delivery. Recommendation. Regular anemia screening intervention should be implemented after delivery.

Risk factors associated with severe perineal tears: A five-year study

OBJECTIVE

Our aim was to describe risk factors associated with 34DPT in operative and non-operative vaginal deliveries, over a five-year period.

STUDY DESIGN

This was a retrospective cohort study including 39,227 vaginal deliveries from 2013 to 2017 in a single French University Hospital. Annual characteristics of the analyzed population were recorded. Univariate logistic regression was used to evaluate the association between these characteristics and 34DPT. Multivariate analysis was used to identify combinations of risk factors associated with instrumental delivery.

RESULTS

The rate of perineal tears was constantly rising but rate of 34DPT was stable, ranging between 0.8 and 1.4% over the study period. Cesarean section rate was stable between 18.8% and 19.6%. Rate of diabetes, preeclampsia and obesity (BMI < 40) was increasing and episiotomy rate decreasing (from 19.8% to 11.8%). Operative deliveries rate remained stable between 11 and 12.8%. Multivariate regression showed that gestational age over 39 weeks (aOR 1.18, 95% CI [1.02; 1.35]), birth weight over 3500 g (aOR 1.62, 95% CI [1.05; 2.49]) were associated with 34DPT in patients without operative vaginal deliveries but not episiotomy. Gestational age (aOR 1.71, 95% CI [1.18; 2.47]), episiotomy (aOR 0.55, 95% CI [0.38; 0.79]) and diabetes (aOR 1.73, 95% CI [1.15; 2.61]) were associated with 34DPT among patients with operative vaginal deliveries.

CONCLUSION

In a tertiary medical center model with low cesarean section rate, factors associated with 34DPT were different among patients with or without operative vaginal delivery. The question of the protective effect of mediolateral episiotomy against 34DPT in case of operative delivery deserves further investigations.

Is it time to abandon episiotomy use? A randomized controlled trial (EPITRIAL)

INTRODUCTION AND HYPOTHESIS

The objective of this trial was to evaluate whether avoidance of episiotomy can decrease the risk of advanced perineal tears.

METHODS

In this randomized (1:1) parallel-group superiority trial, primiparous women underwent randomization into "avoidance of episiotomy" (the study group in which episiotomy was allowed only in cases of fetal distress) or "standard care." The primary outcome was the incidence of advanced (3rd- and 4th-degree) perineal tears.

RESULTS

The participants were randomized into "standard care" (n = 337) vs. "no episiotomy" (n = 339) groups, not differing in any demographic or obstetric characteristics. Episiotomy rates were significantly lower in the study group (19.6%) compared with the standard care group (29.8%, p = 0.004). Five (1.5%) advanced tears were diagnosed in the study group vs. ten = 3.0% in the controls, yielding an odds ratio of 0.50 (95% CI 0.17-1.50) in favor of the "no episiotomy" group (p = 0.296). No differences were noted in any secondary outcomes. By per protocol analysis (omitting cases in which episiotomy was performed for indications other than fetal distress in the study group), a trend to decreased risk of advanced tears in the study group was noted (p = 0.0956). By per protocol analyses, no severe tears were noted in the 53 vacuum deliveries in the study group vs. 4/65 (6.2%) tears in the controls (p = 0.126).

CONCLUSIONS

Since decreased use of episiotomy was not associated with higher rates of severe tears or any other adverse outcomes, we believe this procedure can be avoided in spontaneous as well as vacuum-assisted deliveries. Trial registration no. NCT02356237.

Review of Episiotomy and the Effect of its Risk Factors on Postepisiotomy Complications at the University of Port Harcourt Teaching Hospital

Aim

This study aimed to determine the prevalence of episiotomy and postepisiotomy complications and to assess the relationship between the risk factors and postepisiotomy complications in the University of Port Harcourt Teaching Hospital.

Methodology

This was a descriptive longitudinal study, in which 403 consecutive women who had episiotomy in the labor ward were recruited for the study. They were followed up and reviewed at the postnatal clinic on the 1^st and 6^th weeks postdelivery. Data regarding age, marital status, occupation, educational status, address, parity, booking status, postepisiotomy complications, and the associated risk factors were entered adequately into a prestructured pro forma, and statistical analysis was done using statistical software (SPSS for Windows^® version 19.0). t-test was used to explore the association of risk factors to postepisiotomy complications.

Results

The episiotomy rate was 22.1%. The prevalence of postepisiotomy complications was 52.1%. The mean age of the women was 23.8 (standard deviation ± 3.2) years. Seventy-two (34.3%) patients had perineal pain, which lasted for 72 h or more; 61 (29.1%) had difficulty in walking, while 37 (17.6%) had perineal discomfort. Four (1.9%) had wound infection and only one (0.4%) had wound dehiscence. The development of postepisiotomy complications was not statistically significantly associated with risk factors such as gestational age (T = 1.4, P = 0.1), packed cell volume on admission (T = 1.0, P = 0.2), duration of first stage of labor (T = 0.5, P = 0.1), duration of second stage of labor (T = 0.7, P = 0.3), duration of rupture of fetal membranes (T = 0.8, P = 0.4), delivery repair interval (T = 0.6, P = 0.2), estimated blood loss (T = 0.9, P = 0.2), duration of Sitz bath (T = 1.0, P = 0.2), duration of analgesic (T = 1.2, P = 0.1), duration of antibiotics (T = 1.3, P = 0.1), or the operator who performed or repaired the episiotomy (P = 0.2).

Conclusion

The prevalence of episiotomy and postepisiotomy complications in this study was high. Necessary attention should be given to ensure adequate pain relief for all parturients who had episiotomy, and the policy of restrictive use of episiotomy should be fully implemented in the department in line with the best practices and evidence-based recommendations. This will further reduce the incidence of episiotomy rate as well complications that may arise from it and ensure a positive pregnancy experience for pregnant women.

Respectful and evidence-based birth care in Mexico (or lack thereof): An observational study

PROBLEM

In Mexico, women are often disrespected and abused during birth, evidence-based practices are seldom used, while outdated and dangerous procedures linger.

BACKGROUND

Disrespectful and abusive practices in Mexico have been reported but are not necessarily well-documented; none of the reports so far have relied on direct observation of births.

AIM

To describe birth practices and factors associated with respectful and evidence-based care at 15 referral hospitals in Mexico.

METHODS

We observed 401 births from 2010-2016. We analysed woman, provider, and hospital characteristics and their association with the performance of 14 evidence-based and 15 respectful birth practices via descriptive statistics and multiple logistic regression models.

FINDINGS

Only in four births were all the analysed evidence-based and respectful-birth practices performed. Essential interventions like uterine massage was only given to 46.1% of women and the administration of a uterotonic soon after birth only occurred in 58.3% of births. Professionals who were trained in respectful birth care were more likely to address women by their name (Odds Ratio=3.34, p<0.05), allow consumption of liquids during labour (Odds Ratio=31.6, p<0.05), encourage skin-to-skin contact (Odds Ratio=31.82, p<0.05), and examine the placenta after birth (Odds Ratio=16.55, p<0.01); they were less likely to perform episiotomies (Odds Ratio=0.27, p<0.05).

DISCUSSION

This study reveals low rates of evidence-based practices and respectful maternity care but shows training in the topic can have a considerable positive impact. Our results call for further efforts to improve the quality of maternal healthcare, a universal right.

Evidence-based intrapartum practice and its associated factors at a tertiary teaching hospital in the Philippines, a descriptive mixed-methods study

Background

Evidenced-based practice is a key component of quality care. However, studies in the Philippines have identified gaps between evidence and actual maternity practices. This study aims to describe the practice of evidence-based intrapartum care and its associated factors, as well as exploring the perceptions of healthcare providers in a tertiary hospital in the Philippines.

Methods

A mixed-methods study was conducted, which consisted of direct observation of intrapartum practices during the second and third stages, as well as semi-structured interviews and focus group discussions with care providers to determine their perceptions and reasoning behind decisions to perform episiotomy or fundal pressure. Univariate and multivariate logistic regression were used to analyse the relationship between observed practices and maternal, neonatal, and environmental factors. Qualitative data were parsed and categorised to identify themes related to the decision-making process.

Results

A total of 170 deliveries were included. Recommended care, such as prophylactic use of oxytocin and controlled cord traction in the third stage, were applied in almost all the cases. However, harmful practices were also observed, such as intramuscular or intravenous oxytocin use in the second stage (14%) and lack of foetal heart rate monitoring (57%). Of primiparae, 92% received episiotomy and 31% of all deliveries received fundal pressure. Factors associated with the implementation of episiotomy included primipara (adjusted Odds Ratio [aOR] 62.3), duration of the second stage of more than 30 min (aOR 4.6), and assisted vaginal delivery (aOR 15.0). Factors associated with fundal pressure were primipara (aOR 3.0), augmentation with oxytocin (aOR 3.3), and assisted delivery (aOR 4.8). Healthcare providers believe that these practices can prevent laceration. The rate of obstetric anal sphincter injuries (OASIS) was 17%. Associated with OASIS were assisted delivery (aOR 6.0), baby weights of more than 3.5 kg (aOR 7.8), episiotomy (aOR 26.4), and fundal pressure (aOR 6.2).

Conclusions

Our study found that potentially harmful practices are still conducted that contribute to the occurrence of OASIS. The perception of these practices is divergent with current evidence, and empirical knowledge has more influence. To improve practices the scientific evidence and its underlying basis should be understood among providers.

Factors influencing utilisation of ‘free-standing’ and ‘alongside’ midwifery units for low-risk births in England: a mixed-methods study

Background

Midwifery-led units (MUs) are recommended for ‘low-risk’ births by the National Institute for Health and Care Excellence but according to the National Audit Office were not available in one-quarter of trusts in England in 2013 and, when available, were used by only a minority of the low-risk women for whom they should be suitable. This study explores why.

Objectives

To map the provision of MUs in England and explore barriers to and facilitators of their development and use; and to ascertain stakeholder views of interventions to address these barriers and facilitators.

Design

Mixed methods – first, MU access and utilisation across England was mapped; second, local media coverage of the closure of free-standing midwifery units (FMUs) were analysed; third, case studies were undertaken in six sites to explore the barriers and facilitators that have an impact on the development of MUs; and, fourth, by convening a stakeholder workshop, interventions to address the barriers and facilitators were discussed.

Setting

English NHS maternity services.

Participants

All trusts with maternity services.

Interventions

Establishing MUs.

Main outcome measures

Numbers and types of MUs and utilisation of MUs.

Results

Births in MUs across England have nearly tripled since 2011, to 15% of all births. However, this increase has occurred almost exclusively in alongside units, numbers of which have doubled. Births in FMUs have stayed the same and these units are more susceptible to closure. One-quarter of trusts in England have no MUs; in those that do, nearly all MUs are underutilised. The study findings indicate that most trust managers, senior midwifery managers and obstetricians do not regard their MU provision as being as important as their obstetric-led unit provision and therefore it does not get embedded as an equal and parallel component in the trust’s overall maternity package of care. The analysis illuminates how provision and utilisation are influenced by a complex range of factors, including the medicalisation of childbirth, financial constraints and institutional norms protecting the status quo.

Limitations

When undertaking the case studies, we were unable to achieve representativeness across social class in the women’s focus groups and struggled to recruit finance directors for individual interviews. This may affect the transferability of our findings.

Conclusions

Although there has been an increase in the numbers and utilisation of MUs since 2011, significant obstacles remain to MUs reaching their full potential, especially FMUs. This includes the capacity and willingness of providers to address women’s information needs. If these remain unaddressed at commissioner and provider level, childbearing women’s access to MUs will continue to be restricted.

Future work

Work is needed on optimum approaches to improve decision-makers’ understanding and use of clinical and economic evidence in service design. Increasing women’s access to information about MUs requires further studies of professionals’ understanding and communication of evidence. The role of FMUs in the context of rural populations needs further evaluation to take into account user and community impact.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 12. See the NIHR Journals Library website for further project information.

Aspectos epidemiológicos del parto en una población Kaqchikel en Guatemala

Introducción: La atención de recién nacidos en centros de salud del área rural se centra en partos eutócicos sin complicaciones. Al detectar condiciones distócicas son referidas a centros asistenciales de tercer nivel como una emergencia.  Objetivo: El principal objetivo de este estudio es caracterizar epidemiológicamente a pacientes embarazadas para resolución del parto, determinando así cuántas resolvieron el parto vía vaginal, a cuántas se les realizó episiotomía medio lateral derecha y cuántas fueron referidas a un centro asistencial de tercer nivel. Metodología: Estudio descriptivo con una muestra de 786 pacientes en el Centro de Salud Bárbara (CSB) para resolución del trabajo de parto de enero de 2017 a diciembre de 2018. Se excluyó a 71 pacientes por no cumplir con criterios de inclusión. Resultados: De los 715 casos analizados, 36 fueron referidos por indicación de cesárea, a 102 se les realizó episiotomía durante el trabajo de parto y 671 tuvieron un parto eutócico simple. Conclusiones: Las pacientes primigestas tienen más del 50% de probabilidad de necesitar episiotomía que una con más de una gesta. Una paciente primigesta tiene el doble de probabilidad de ser referida por una complicación obstétrica durante el trabajo de parto que una paciente con una o más gestas. El 10% de pacientes con talla ≤ 140 cm, fueron referidas por posibilidad de complicaciones obstétricas durante el trabajo de parto.

Birth-Related Perineal Trauma in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis

Introduction Birth-related perineal trauma (BPT) is a common consequence of vaginal births. When poorly managed, BPT can result in increased morbidity and mortality due to infections, haemorrhage, and incontinence. This review aims to collect data on rates of BPT in low- and middle-income countries (LMICs), through a systematic review and meta-analysis. Methods The following databases were searched: Medline, Embase, Latin American and Caribbean Health Sciences Literature (LILACs), and the World Health Organization (WHO) regional databases, from 2004 to 2016. Cross-sectional data on the proportion of vaginal births that resulted in episiotomy, second degree tears or obstetric anal sphincter injuries (OASI) were extracted from studies carried out in LMICs by two independent reviewers. Estimates were meta-analysed using a random effects model; results were presented by type of BPT, parity, and mode of birth. Results Of the 1182 citations reviewed, 74 studies providing data on 334,054 births in 41 countries were included. Five studies reported outcomes of births in the community. In LMICs, the overall rates of BPT were 46% (95% CI 36–55%), 24% (95% CI 17–32%), and 1.4% (95% CI 1.2–1.7%) for episiotomies, second degree tears, and OASI, respectively. Studies were highly heterogeneous with respect to study design and population. The overall reporting quality was inadequate. Discussion Compared to high-income settings, episiotomy rates are high in LMIC medical facilities. There is an urgent need to improve reporting of BPT in LMICs particularly with regards to births taking in community settings.

Selective use of episiotomy: what is the impact on perineal trauma? Results from a retrospective cohort study

PURPOSE

To evaluate the effects of selective use of episiotomy on perineal trauma.

METHODS

We performed a retrospective cohort study on consecutive vaginal deliveries from January 2010 to December 2016. From January 2010 to December 2011 episiotomy was performed liberally, based only on individual midwife/doctor's decision. Since January 2012, a shared selective use of episiotomy policy has been introduced. To evaluate the range of perineal trauma in spontaneous second-degree perineal tears, a sub-classification of second-degree lacerations has been introduced dividing them into two sub-groups: A (smaller than the average episiotomy) and B (spontaneous vaginal tear larger than the average episiotomy). The primary outcomes were the incidence and type of perineal trauma, with the proportion of type A and type B second-degree spontaneous tears under a policy of selective episiotomy.

RESULTS

Deliveries not exposed to selective use of episiotomy were 1583 (Group 1), those exposed to selective use of episiotomy were 6409 (Group 2). In Group 2 episiotomy rate decreased, and incidence of intact perineum, first- and second-degree lacerations increased. The incidence of third- and fourth-degree lacerations did not change. Spontaneous second-degree lacerations occurred in 19.4% and 36.8% of women in group 1 and 2, respectively. With a selective episiotomy policy, 88.3% of second-degree tears was classified as type A.

CONCLUSIONS

The selective use of episiotomy is clinically feasible and effective. This policy seems to be associated with a lower delivery-related perineal trauma as showed by the sub-classification, that could be a useful tool to monitor obstetric care.

Pelvic Floor and Sexual Dysfunction After Vaginal Birth With Episiotomy in Vietnamese Women

Introduction

Episiotomy has been the most common procedure in obstetrical practice; however, its benefits remain controversial, especially in case of postpartum pelvic floor disorder and sexual dysfunction.

Aim

The aim of this study was to evaluate early complications, pelvic floor, and sexual dysfunction after delivery with episiotomy and their associated factors.

Methods

158 healthy pregnant women at term (38 weeks 0 days to 41 weeks 6 days), aged above 18 years old, who vaginally delivered a singleton baby with cephalic presentation were recruited. The subjects were evaluated through 3 interviews at 1−3 days, 6 weeks, and 3 months after delivery, respectively.

Main Outcome Measure

The evaluations were accomplished primarily by administration of 2 validated questionnaires: the Pelvic Floor Distress Inventory Short-form 20 to evaluate symptoms of pelvic floor dysfunction, and the Female Sexual Function Index to evaluate effects on the women’s sexual life.

Results

Among early complications, pain while sitting (30.4%) was the most prominent trouble, other pelvic disorders, such as urinary incontinence (11.4%), urinary retention (10.8%), or flatus incontinence (8.9%), were also observed in a remarkable number of participants. Average Pelvic Floor Distress Inventory Short-form 20 score was 7.0 ± 10.2 after 3 months. At that time, the prevalence of sexual dysfunction was 40.7%. Trouble occurred commonly in the domains of desire (68.9%) and pain (58.5%). Associated factors of sexual dysfunction were maternal age over 30 years and parity. These factors, in combination with birth weight over 3,500 gram (g), were also associated factors of pelvic floor disorders.

Conclusion

Pelvic pain was the most popular postdelivery complication. Urinary and bowel dysfunction were self-limited complications. Despite being considered a simple technique, episiotomy and its repair must be performed rigorously in order to allow the best recovery of pelvic floor and sexual function.

Huy Quoc NV, Phuc An LS, Phuong LS, et al. Pelvic Floor and Sexual Dysfunction After Vaginal Birth With Episiotomy in Vietnamese Women. Sex Med 2019;7:514–521.

A novel classification for evaluating episiotomy practices: application to the Burgundy perinatal network

Background

Though the rate of episiotomy has decreased in France, the overall episiotomy rate was 20% in the 2016 national perinatal survey. We aimed to develop a classification to facilitate the analysis of episiotomy practices and to evaluate whether episiotomy is associated with a reduction in the rate of obstetric anal sphincter injuries (OASIS) for each subgroup.

Methods

This population-based study included all the deliveries that occurred in the Burgundy Perinatal Network from 2011 to 2016. The main outcome was episiotomy, which was identified thanks to the French Common Classification of Medical Procedures. An ascending hierarchical cluster analysis was performed to build the classification. A clinical audit using the classification was conducted yearly in all obstetric units. The episiotomy rates were described throughout the study period for each subgroup of the classification. The OASIS rates were evaluated by subgroup and the association between mediolateral episiotomy and OASIS was investigated for each subgroup.

Results

Our analyses included 81,290 pregnant women. The classification comprised 7 subgroups: ₍₁₎ nulliparous single cephalic at term, ₍₂₎ nulliparous single cephalic at term with instrumental delivery, ₍₃₎ multiparous single cephalic at term, ₍₄₎ multiparous single cephalic at term with instrumental delivery, ₍₅₎ all preterm deliveries (< 37 weeks gestation), ₍₆₎ all breech deliveries, ₍₇₎ all multiple deliveries.

Episiotomy rates ranged from 6.2% in Group 3 to 40.9% in Group 2. From 2011 to 2016, every group except breech deliveries experienced a significant decrease in episiotomy rates, ranging from − 28.1 to − 61.0%.

The prevalence of OASIS was the highest in Groups 2 (3.0%) and 4 (2.2%). Overall OASIS rates did not significantly differ with episiotomy use (P = 0.25). However, we found that the use of episiotomy was associated with a reduction in OASIS rates in Groups 1 and 2 (odds ratio 0.6 [95% CI 0.4–0.9] and 0.4 [0.3–0.5], respectively). This reduction was only observed in Group 4 with forceps delivery (odds ratio 0.4 [0.1–0.9]).

Conclusion

We developed the first classification for the evaluation of episiotomy practices based on 7 clinically relevant subgroups. This easy-to-use tool can help obstetricians and midwives improve their practices through self-assessment.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2424-2) contains supplementary material, which is available to authorized users.

Intact Perineum: What are the Predictive Factors in Spontaneous Vaginal Birth?

Introduction

Perineal trauma at birth is distressing for women and can cause serious short and long term morbidity.

Aim

Investigate the prevalence and predictive factors of intact perineum after normal vaginal birth among Portuguese women who had spontaneous vaginal births.

Methods

A descriptive, cross-sectional, retrospective study was carried out among pregnant women who had spontaneous vaginal births, between January 1, 2017, and December 31, 2017, in a single birth centre in Portugal. Following ethical approval, the prevalence of intact perineum was calculated and multivariate analysis with logistic regression was carried out, to identify the predictive factors of having an intact perineum after spontaneous vaginal birth.

Results

A total of 1748 pregnant women had spontaneous vaginal births. Four hundred and forty-one women (25.2%) had intact perineum whereas in 1307 (74.8%) of women, the perineum was not intact. First-degree tears occurred in 23.2% (405/1748) of women, second-degree tears occurred in 4% (70/1748) of women while three women (0.2%) experienced a third-degree tear. The rate of episiotomies was 43.8% (766/1748). Episiotomy and first-degree tears occurred in 2.6% (45/1748), episiotomy and second-degree tears occurred in 0.7% (12/1748), while episiotomy and third-degree tears occurred in 0.3% (6/1748) of women. Having a previous caesarean section reduced the odds of intact perineum by 60%, while nulliparity reduced the odds by 70%. For every 250 grams increase in birth weight, the odds of sustaining an intact perineum were decreased by 13%. Alternative birth positions (excluding lithotomy) doubled the odds of maintaining an intact perineum.

Conclusion

The prevalence of intact perineum is 25,2%. Predictive factors for intact perineum include birth weight, parity, previous caesarean section and birthing position. Recognizing these factors could support and facilitate the management of spontaneous vaginal birth to promote an intact perineum. Further research is needed to gain better understanding of this phenomenon.