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Kırıcı P, Kaplan S, Aydin Turk B, Annac E. Histopathological Examination of the Mucosal Effects of Obstetric Gel on Vaginal Wound Healing in an Incision-Inflicted Rat Model. Cureus 2021; 13:e18254. [PMID: 34712531 PMCID: PMC8542395 DOI: 10.7759/cureus.18254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 11/05/2022] Open
Abstract
Background and objective The present study intended to investigate the histopathological efficacy of obstetric gels on the healing of vaginal lacerations in rats. To the best of our knowledge, this is the first such study. Materials and methods Twenty-one female Wistar albino rats were divided into three groups, comprising seven animals per group. The first group (group 1) was the control group, the second (group 2) was the polyvinyl iodine (PI) group, and the third group (group 3) was the obstetric gel (OG) group. In all three groups, a vaginal incision was made with a No. 10 scalpel, and the incision site was sutured with a 3-0 Vicryl suture. In the control group, the incision site was left for routine healing. The incision site was washed with PI in the PI group and with OG in the OG group. After 15 days, vaginal tissues were obtained from all three groups for histopathological examination. In addition, immunohistochemistry staining was performed using caspase 3 and fibrillin 1 antibodies. Results There was no significant difference between the groups in terms of congestion, vascular proliferation, and inflammation stages in the examinations performed on the vaginal wall. However, the amount of collagen and elastic fibers increased during the remodeling and fibrosis phase, and the fibrillin 1 score increased in immunohistochemistry staining (p < 0.001). Conclusion It has been shown in rat vaginal tissue that obstetric gels do not have negative effects on wound healing; however, they contribute to wound healing by positively affecting the fibrosis stage.
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Affiliation(s)
- Pınar Kırıcı
- Obstetrics and Gynaecology, Adiyaman University, Adıyaman, TUR
| | - Selçuk Kaplan
- Obstetrics and Gynaecology, Adiyaman University Faculty of Medicine, Adıyaman, TUR
| | - Bilge Aydin Turk
- Pathology, Adiyaman University Faculty of Medicine, Adıyaman, TUR
| | - Ebru Annac
- Histology and Embryology, Adiyaman University Faculty of Medicine, Adıyaman, TUR
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Is mediolateral episiotomy angle associated with postpartum perineal pain in primiparous women? North Clin Istanb 2021; 8:150-159. [PMID: 33851079 PMCID: PMC8039104 DOI: 10.14744/nci.2020.23911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 08/27/2020] [Indexed: 11/29/2022] Open
Abstract
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 1st 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 1st 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.
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Abalos E, Sguassero Y, Gyte GM. Paracetamol/acetaminophen (single administration) for perineal pain in the early postpartum period. Cochrane Database Syst Rev 2021; 1:CD008407. [PMID: 34559424 PMCID: PMC8094229 DOI: 10.1002/14651858.cd008407.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Perineal pain is a common but poorly studied adverse outcome following childbirth. Pain may result from perineal trauma due to bruising, spontaneous tears, surgical incisions (episiotomies), or in association with operative vaginal births (ventouse or forceps-assisted births). This is an update of a review last published in 2013. OBJECTIVES To determine the efficacy of a single administration of paracetamol (acetaminophen) used in the relief of acute postpartum perineal pain. SEARCH METHODS For this update, we searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (9 December 2019), and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials (RCTs), including cluster-RCTs, comparing paracetamol to placebo. We excluded quasi-RCTs and cross-over trials. Data from abstracts would be included only if authors had confirmed in writing that the data to be included in the review had come from the final analysis and would not change. DATA COLLECTION AND ANALYSIS Two review authors assessed each study for inclusion and extracted data. One review author reviewed the decisions and confirmed calculations for pain relief scores. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS This update identified no new trials so the results remain unchanged. However, by applying the GRADE assessment of the evidence, the interpretation of main results differed from previous version of this review. We identified 10 studies involving 2044 women, but all these studies involved either three or four groups, looking at differing drugs or doses. We have only included the 1301 women who were in the paracetamol versus placebo arms of the studies. Of these, five studies (482 women) assessed 500 mg to 650 mg and six studies (797 women) assessed 1000 mg of paracetamol. One study assessed 650 mg and 1000 mg compared with placebo and contributed to both comparisons. We used a random-effects meta-analysis because of the clinical variability among studies. Studies were from the 1970s to the early 1990s, and there was insufficient information to assess the risk of bias adequately, hence the findings need to be interpreted within this context. The certainty of the evidence for the two primary outcomes on which data were available was assessed as low, downgraded for overall unclear risk of bias and for heterogeneity (I² statistic 60% or greater). More women may experience pain relief with paracetamol compared with placebo (average risk ratio (RR) 2.14, 95% confidence interval (CI) 1.59 to 2.89; 10 trials, 1279 women), and fewer women may need additional pain relief with paracetamol compared with placebo (average RR 0.34, 95% CI 0.21 to 0.55; 8 trials, 1132 women). However, the certainty of the evidence was low, downgraded for unclear overall risk of bias and substantial heterogeneity. One study used the higher dose of paracetamol (1000 mg) and reported maternal drug adverse effects. There may be little or no difference in the incidence of nausea (average RR 0.18, 95% CI 0.01 to 3.66; 1 trial, 232 women; low-certainty evidence), or sleepiness (average RR 0.89, 95% CI 0.18 to 4.30; 1 trial, 232 women; low-certainty evidence). No other maternal adverse events were reported. None of the studies assessed neonatal drug adverse effects. AUTHORS' CONCLUSIONS A single dose of paracetamol may improve perineal pain relief following vaginal birth, and may reduce the need for additional pain relief. Potential adverse effects for both women and neonates were not appropriately assessed. Any further trials should also address the gaps in evidence concerning maternal outcomes such as satisfaction with postnatal care, maternal functioning/well-being (emotional attachment, self-efficacy, competence, autonomy, confidence, self-care, coping skills) and neonatal drug adverse effects.
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Affiliation(s)
- Edgardo Abalos
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
| | - Yanina Sguassero
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
| | - Gillian Ml Gyte
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
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Cardaillac C, Ploteau S, Le Thuaut A, Dochez V, Winer N, Ducarme G. 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. Trials 2020; 21:522. [PMID: 32532310 PMCID: PMC7291718 DOI: 10.1186/s13063-020-04423-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 05/16/2020] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Claire Cardaillac
- Department of Obstetrics and Gynecology and Reproductive Medicine, Nantes University Hospital, 44000, Nantes, France.,Federative Pelvic Pain Centre, Nantes University Hospital, 44000, Nantes, France
| | - Stéphane Ploteau
- Department of Obstetrics and Gynecology and Reproductive Medicine, Nantes University Hospital, 44000, Nantes, France.,Federative Pelvic Pain Centre, Nantes University Hospital, 44000, Nantes, France
| | - Aurélie Le Thuaut
- Clinical Research Centre, Centre Hospitalier Departemental, 85000, La Roche sur Yon, France
| | - Vincent Dochez
- Department of Obstetrics and Gynecology and Reproductive Medicine, Nantes University Hospital, 44000, Nantes, France
| | - Norbert Winer
- Department of Obstetrics and Gynecology and Reproductive Medicine, Nantes University Hospital, 44000, Nantes, France
| | - Guillaume Ducarme
- Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, 85000, La Roche sur Yon, France.
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Ononuju CN, Ogu RN, Nyengidiki TK, Onwubuariri MI, Amadi SC, Ezeaku EC. Review of Episiotomy and the Effect of its Risk Factors on Postepisiotomy Complications at the University of Port Harcourt Teaching Hospital. Niger Med J 2020; 61:96-101. [PMID: 32675902 PMCID: PMC7357809 DOI: 10.4103/nmj.nmj_121_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 12/04/2019] [Accepted: 04/28/2020] [Indexed: 11/04/2022] Open
Abstract
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 1st and 6th 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.
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Affiliation(s)
- Chidiebere N Ononuju
- Department of Obstetrics and Gynaecology, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
| | - Rosemary N Ogu
- Department of Obstetrics and Gynaecology, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
| | - Tamunomie K Nyengidiki
- Department of Obstetrics and Gynaecology, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
| | - Michael I Onwubuariri
- Department of Obstetrics and Gynaecology, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
| | - Simeon C Amadi
- Department of Obstetrics and Gynaecology, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
| | - Elizabeth C Ezeaku
- Department of Obstetrics and Gynaecology, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
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Martínez-Galiano JM, Arredondo-López B, Molina-Garcia L, Cámara-Jurado AM, Cocera-Ruiz E, Rodríguez-Delgado M. Continuous versus discontinuous suture in perineal injuries produced during delivery in primiparous women: a randomized controlled trial. BMC Pregnancy Childbirth 2019; 19:499. [PMID: 31842788 PMCID: PMC6916034 DOI: 10.1186/s12884-019-2655-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 11/29/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The technique used in the repair of a perineal injury resulting from childbirth could avoid discomfort and morbidity during the postpartum period. Recent studies show inconsistent results and support the need for new research with the inclusion of new health parameters not yet studied. Therefore, this study aims to evaluate if the suture technique (continuous or interrupted) has an effect on pain and other postpartum problems, incidence of incontinence (urinary and/or fecal), and the restart of sexual relations. METHODS A single-blind randomized clinical trial was conducted in five hospitals in south-east Spain. The participants were primiparous women who had experienced a perineal injury during delivery (second-degree tear or episiotomy). Data was collected on sociodemographic variables, variables associated with pregnancy, labor and delivery, and the postpartum period, and outcomes during the 3 months after delivery: pain, incontinence, and restart of sexual relations. Odds ratios (OR) were calculated by binary logistic regression to assess the influence of the suture type on binary outcomes and t-test used for comparing continuous outcomes. Multivariate analyses (using logistic regression -adjusted (aOR)- and analysis of covariance) were carried out to adjust for unbalanced variables after randomization. RESULTS A total of 70 women were included in the intervention group (continuous suture) and 64 in the reference group (interrupted sutures). A negative association was observed (aOR = 0.39; 95% CI = 0.18-0.86) between a continuous suture and the need for analgesia at 24 h postpartum. Pain experienced by the women at 24 h postpartum was assessed as 4.4 ± 0.3 compared with a score of 3.4 ± 0.3 in the group with continuous sutures (p = 0.011). At 15 days postpartum, women in the intervention group experienced less pain (aOR = 0.38; 95% CI = 0.18-0.80) (p = 0.019). Urinary sphincter incontinence was also evaluated at 15 days, with 4.3% (n = 3) of the women in the intervention group presenting with urinary incontinence compared with 18.8% (n = 12) in the control group (aOR = 0.11; 95% CI = 0.03-0.47) (P = 0.003). CONCLUSIONS The women who had a continuous suture repair showed lower levels of pain from delivery to 3 months after delivery and had a lower incidence of urinary incontinence at 15 days postpartum. TRIAL REGISTRATION ClinicalTrials.gov NCT03825211 posted January 31, 2019 (retrospectively registered).
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Affiliation(s)
- Juan Miguel Martínez-Galiano
- Department of Nursing, University of Jaen, Jaen, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | | | | | | | | | - Miguel Rodríguez-Delgado
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Department of Health Sciences, University of Jaen, Jaen, Spain
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Wiseman O, Rafferty AM, Stockley J, Murrells T, Bick D. Infection and wound breakdown in spontaneous second-degree perineal tears: An exploratory mixed methods study. Birth 2019; 46:80-89. [PMID: 30136338 DOI: 10.1111/birt.12389] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 07/22/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Perineal trauma affects large numbers of women who have a vaginal birth. This study explores the incidence, etiology and women's experiences of wound infection/breakdown associated with spontaneous second degree tears. METHODS This was an exploratory mixed methods study set in an urban tertiary National Health Service hospital in 2014-2015. The study included a prospective observational study of second-degree tears using electronic patient records. Infection was defined using criteria adapted from Public Health England's Surgical Site Infection Surveillance Service. We also did a case-control study of maternity records to explore factors associated with perineal infection/wound breakdown, and semi-structured interviews with a purposeful sample of women who experienced wound infection/breakdown. RESULTS Of 2892 vaginal births during the study period, 76.8% sustained perineal trauma, with second-degree tears most commonly recorded (n = 828/28.6%). Sixteen (1.9%) had a documented infection/wound breakdown which were associated with "compromised wound status" (increased severity of wound/poor suturing; P = 0.033) Women complained of a lack of information about their perineum and poor postnatal surveillance by midwives and physicians. Diagnosis and treatment were often delayed by clinicians' reliance on external signs of wound infection. Although the sample size was small, there were no differences in rates of infection between sutured and unsutured second-degree tears. CONCLUSIONS Although second-degree tears were common after vaginal birth, wound infection/breakdown was relatively uncommon. Women who report feeling unwell or develop pyrexia postnatally should be assessed urgently. A prospective longitudinal study exploring the long-term sequelae of second-degree tears is needed.
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Affiliation(s)
- Octavia Wiseman
- Centre for Maternal and Child Health, City, University of London, London, UK
| | - Anne M Rafferty
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| | - Jane Stockley
- Department of Medical Microbiology, Worcestershire Royal Hospital, Worcester, UK
| | - Trevor Murrells
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| | - Debra Bick
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
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Agarwal MD, Resnick EL, Mhuircheartaigh JN, Mortele KJ. MR Imaging of the Female Perineum. Magn Reson Imaging Clin N Am 2017; 25:435-455. [DOI: 10.1016/j.mric.2017.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Gün İ, Doğan B, Özdamar Ö. Long- and short-term complications of episiotomy. Turk J Obstet Gynecol 2016; 13:144-148. [PMID: 28913110 PMCID: PMC5558305 DOI: 10.4274/tjod.00087] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 08/21/2016] [Indexed: 01/15/2023] Open
Abstract
Although extensively applied in obstetrics practice to facilitate delivery by increasing the vaginal birth conduit, most episiotomy studies are in the context of short- or medium-term outcomes, and the number of studies investigating the long-term effects is insufficient. Episiotomy is often considered associated with urinary and/or anal incontinence and dyspareunia; however, there is no concrete evidence for this issue. Current meta-analyses and reviews that assessed the studies available in the literature revealed that episiotomy does not decrease the rates of urinary incontinence, perineal pain, and sexual dysfunction and that routine episiotomy does not prevent pelvic floor damage; thus, the recommended use of mediolateral episiotomy is restricted, rather than routine. According to the limited number of studies on sexual function, there seems to be a linear relationship between the degree of perineal laceration and postpartum dyspareunia. It is still not clear whether episiotomy has any impact on pelvic floor relaxation, pelvic organ prolapse, and sexual dysfunction in the long term.
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Affiliation(s)
- İsmet Gün
- Gülhane Military Medical Academy, Haydarpaşa Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Bülent Doğan
- Gülhane Military Medical Academy, Haydarpaşa Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Özkan Özdamar
- İstanbul Medeniyet University Faculty of Medicine, Department of Obstetrics and Gynecology, İstanbul, Turkey
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Maguire T, Mayne C, Willars J, Tincello D. The effect of vaginal closure technique on early post-operative pain following vaginal prolapse surgery: a feasibility pilot study and qualitative assessment. SPRINGERPLUS 2014; 3:1. [PMID: 24422185 PMCID: PMC3887222 DOI: 10.1186/2193-1801-3-1] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 12/30/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND Surgery for pelvic organ prolapse is a common surgical procedure. There is little research studying post-operative pain, contrasting with extensive literature on pain after childbirth trauma which shows that suture method has a significant effect on pain. We designed a protocol for a trial comparing suture techniques and post-operative pain, and conducted a pre-protocol pilot to inform our trial design. METHODS Routine surgical data, post-operative pain scores (from 10 cm Visual Analogue Scales, VAS) and analgesic requirements were obtained from the notes of a cohort of women undergoing vaginal prolapse surgery. Median VAS scores at 4, 12 and 24 hours were compared by suture material used and method of closure (single continuous suture or interrupted sutures). The women whose data were obtained were invited to attend focus groups of up to six people in the twelve weeks following surgery. A semi structured question guide was used, and interviews were recorded, transcribed anonymously and analysed using the constant comparative method of grounded theory. Ethical approval was not sought because formal pre-protocol work is exempt for UK ethical requirements, but formal written consent on standard forms was obtained for publishing outcomes and anonymised comments from participants. RESULTS Complete VAS data and operative details were available from 41 women. Surgery was completed using absorbable polyglactin sutures with continuous suturing (17 women) or interrupted sutures (24 women). Pain scores at 4 and 12 hours were similar; pain at 24 hours was greater in the women with interrupted sutures (median VAS 3 (range 0-8) versus 1.5 (0-8) (p = 0.0513). Analgesic needs were similar. Two focus groups (nine participants) revealed that women regarded post-operative pain as insignificant and not a topic worthy of formal research. It was apparent that the use, and especially removal of, vaginal packs was a practice associated with pain which women remembered as a significant part of their post-operative experience. CONCLUSIONS Formal pre-protocol work is informative; we found a moderate difference in our proposed outcomes, suggesting a trial was feasible but women themselves were unconvinced of the need for formal research into pain following vaginal surgery.
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Affiliation(s)
- Turlough Maguire
- Leicester General Hospital, University Hospitals of Leicester NHS Trust, Gwendolen Road, Leicester, LE5 4PW UK
| | - Christopher Mayne
- Leicester General Hospital, University Hospitals of Leicester NHS Trust, Gwendolen Road, Leicester, LE5 4PW UK
| | - Janet Willars
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Douglas Tincello
- Leicester General Hospital, University Hospitals of Leicester NHS Trust, Gwendolen Road, Leicester, LE5 4PW UK ; Reproductive Sciences Section, Cancer Studies and Molecular Medicine, University of Leicester, Leicester, UK
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Ismail KMK, Kettle C, Macdonald SE, Tohill S, Thomas PW, Bick D. Perineal Assessment and Repair Longitudinal Study (PEARLS): a matched-pair cluster randomized trial. BMC Med 2013; 11:209. [PMID: 24059602 PMCID: PMC3849411 DOI: 10.1186/1741-7015-11-209] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Accepted: 08/29/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Perineal trauma during childbirth affects millions of women worldwide every year. The aim of the Perineal Assessment and Repair Longitudinal Study (PEARLS) was to improve maternal clinical outcomes following childbirth through an enhanced cascaded multiprofessional training program to support implementation of evidence-based perineal management. METHODS This was a pragmatic matched-pair cluster randomized controlled trial (RCT) that enrolled women (n = 3681) sustaining a second-degree perineal tear in one of 22 UK maternity units (clusters), organized in 11 matched pairs. Units in each matched pair were randomized to receive the training intervention either early (group A) or late (group B). Outcomes within each cluster were assessed prior to any training intervention (phase 1), and then after the training intervention was given to group A (phase 2) and group B (phase 3). Focusing on phase 2, the primary outcome was the percentage of women who had pain on sitting or walking at 10 to 12 days post-natal. Secondary outcomes included use of pain relief at 10 to 12 days post-natal, need for suture removal, uptake and duration of exclusive breastfeeding, and perineal wound infection. Practice-based measures included implementation of evidence into practice to promote effective clinical management of perineal trauma. Cluster-level paired t-tests were used to compare groups A and B. RESULTS There was no significant difference between the clusters in phase 2 of the study in the average percentage of women reporting perineal pain on sitting and walking at 10 to 12 days (mean difference 0.7%; 95% CI -10.1% to 11.4%; P = 0.89). The intervention significantly improved overall use of evidence-based practice in the clinical management of perineal trauma. Following the training intervention, group A clusters had a significant reduction in mean percentages of women reporting perineal wound infections and of women needing sutures removed. CONCLUSION PEARLS is the first RCT to assess the effects of a 'training package on implementation of evidence-based perineal trauma management. The intervention did not significantly improve the primary outcome but did significantly improve evidence-based practice and some of the relevant secondary clinical outcomes for women. TRIAL REGISTRATIONS ISRCTN28960026 NIHR UKCRN portfolio no: 4785.
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Affiliation(s)
- Khaled M K Ismail
- Professor of Obstetrics and Gynaecology, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, West Midlands, B15 2TT, UK
| | - Christine Kettle
- Professor of Women’s Health Staffordshire University, Blackheath Lane, Stafford, Staffordshire ST18 0AD, UK
| | - Sue E Macdonald
- Lead Midwife for Education, (until Dec 2012) College of Midwives, 15 Mansfield Street, London WIG 9NH, UK
| | - Sue Tohill
- Midwife, West Midlands (South) Comprehensive Local Research Network, University Hospitals Coventry and Warwickshire NHS Trust, University Hospital, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Peter W Thomas
- Professor of Healthcare Statistics and Epidemiology, Bournemouth University, Clinical Research Unit, School of Health and Social Care, R506A Royal London House, Christchurch Road, Bournemouth, Dorset BH1 3LT, UK
| | - Debra Bick
- Professor of Evidence Based Midwifery Practice, Kings College London, Florence Nightingale School of Nursing and Midwifery, 57 Waterloo Road, London SE1 8WA, UK
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Bonfill X, Roqué M, Aller MB, Osorio D, Foradada C, Vives À, Rigau D. Development of quality of care indicators from systematic reviews: the case of hospital delivery. Implement Sci 2013; 8:42. [PMID: 23574918 PMCID: PMC3626798 DOI: 10.1186/1748-5908-8-42] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 04/01/2013] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The objective of this research is to generate quality of care indicators from systematic reviews to assess the appropriateness of obstetric care in hospitals. METHODS A search for systematic reviews about hospital obstetric interventions, conducted in The Cochrane Library, clinical evidence and practice guidelines, identified 303 reviews. We selected 48 high-quality evidence reviews, which resulted in strong clinical recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The 255 remaining reviews were excluded, mainly due to a lack of strong evidence provided by the studies reviewed. RESULTS A total of 18 indicators were formulated from these clinical recommendations, on antepartum care (8), care during delivery and postpartum (9), and incomplete miscarriage (1). Authors of the systematic reviews and specialists in obstetrics were consulted to refine the formulation of indicators. CONCLUSIONS High-quality systematic reviews, whose conclusions clearly claim in favour or against an intervention, can be a source for generating quality indicators of delivery care. To make indicators coherent, the nuances of clinical practice should be considered. Any attempt made to evaluate the extent to which delivery care in hospitals is based on scientific evidence should take the generated indicators into account.
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Affiliation(s)
- Xavier Bonfill
- Service of Clinical Epidemiology, Hospital de la Santa Creu i Sant Pau, Sant Pau Biomedical Research Institute (IIB Sant Pau), c/Sant Quintí 89, Barcelona, 08026, Spain
- Iberoamerican Cochrane Centre, Hospital de la Santa Creu i Sant Pau, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
- Department of Paediatrics, Obstetrics and Gynaecology and Preventive Medicine., Universitat Autònoma de Barcelona, Bellaterra, Spain
- CIBERESP (CIBER de Epidemiología y Salud Pública), Barcelona, Spain
| | - Marta Roqué
- Iberoamerican Cochrane Centre, Hospital de la Santa Creu i Sant Pau, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
- CIBERESP (CIBER de Epidemiología y Salud Pública), Barcelona, Spain
| | - Marta Beatriz Aller
- Research Unit. Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain
| | - Dimelza Osorio
- Service of Clinical Epidemiology, Hospital de la Santa Creu i Sant Pau, Sant Pau Biomedical Research Institute (IIB Sant Pau), c/Sant Quintí 89, Barcelona, 08026, Spain
| | - Carles Foradada
- Department of Paediatrics, Obstetrics and Gynaecology and Preventive Medicine., Universitat Autònoma de Barcelona, Bellaterra, Spain
- Department of Gynaecology and Obstetrics, Corporació Sanitària Parc Taulí, Sabadell, Spain
| | - Àngels Vives
- Department of Gynaecology and Obstetrics, Consorci Sanitari de Terrassa, Terrassa, Spain
| | - David Rigau
- Service of Clinical Epidemiology, Hospital de la Santa Creu i Sant Pau, Sant Pau Biomedical Research Institute (IIB Sant Pau), c/Sant Quintí 89, Barcelona, 08026, Spain
- Iberoamerican Cochrane Centre, Hospital de la Santa Creu i Sant Pau, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
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Chou D, Abalos E, Gyte GML, Gülmezoglu AM. Paracetamol/acetaminophen (single administration) for perineal pain in the early postpartum period. Cochrane Database Syst Rev 2013:CD008407. [PMID: 23440827 DOI: 10.1002/14651858.cd008407.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Perineal pain is a common but poorly studied adverse outcome following childbirth. Pain may result from perineal trauma due to bruising, spontaneous tears, surgical incisions (episiotomies), or in association with operative births (ventouse or forceps assisted births). OBJECTIVES To determine the efficacy of a single administration of paracetamol (acetaminophen) systemic drugs used in the relief of acute postpartum perineal pain SEARCH METHODS We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 6 November 2012. SELECTION CRITERIA Randomised controlled trials (RCTs) assessing paracetamol (acetaminophen) in a single dose compared with placebo for women with early postpartum perineal pain. We excluded quasi-RCTs and cross-over studies. DATA COLLECTION AND ANALYSIS Two review authors assessed each paper for inclusion and extracted data. One review author reviewed the decisions and confirmed calculations for pain relief scores. MAIN RESULTS We did not identify any new trials from the updated search so the results remain unchanged as follows.We have included 10 studies describing two dosages of paracetamol. Of these, five studies (526 women) assessed 500 mg to 650 mg and six studies (841 women) assessed 1000 mg of paracetamol. We chose to use random-effects meta-analyses because of the heterogeneity in dosage used. Studies were from the 1970s to the early 1990s, and there was insufficient information to assess the risk of bias adequately, hence the findings need to be interpreted within this context.More women experienced pain relief with paracetamol compared with placebo (average risk ratio (RR) 2.14, 95% confidence interval (CI) 1.59 to 2.89, 10 studies, 1279 women). In addition, there were significantly fewer women having additional pain relief with paracetamol compared with placebo (RR 0.34, 95% CI 0.21 to 0.55, eight studies, 1132 women). Both the 500 mg to 650 mg and 1000 mg doses were effective in providing more pain relief than placebo.Maternal and neonatal potential adverse drug effects were not assessed in any of the included studies. Indeed few secondary outcomes were assessed. AUTHORS' CONCLUSIONS More women experienced pain relief, and fewer had additional pain relief, with paracetamol compared with placebo, although potential adverse effects were not assessed and generally the quality of studies was unclear.
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Affiliation(s)
- Doris Chou
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction,Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
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Kettle C, Dowswell T, Ismail KM. Continuous and interrupted suturing techniques for repair of episiotomy or second-degree tears. Cochrane Database Syst Rev 2012; 11:CD000947. [PMID: 23152204 PMCID: PMC7045987 DOI: 10.1002/14651858.cd000947.pub3] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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).
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Hasanpoor S, Bani S, Shahgole R, Gojazadeh M. The effects of continuous and interrupted episiotomy repair on pain severity and rate of perineal repair: a controlled randomized clinical trial. J Caring Sci 2012; 1:165-71. [PMID: 25276692 DOI: 10.5681/jcs.2012.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2012] [Accepted: 05/14/2012] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Perineal pain is the most common complaint after episiotomy. It imposes extra pressure on mothers who attempt to adapt to their new conditions. Therefore, the present study was performed to compare pain severity and perineal repair in two episiotomy repair methods. METHODS In this clinical trial, 100 primiparous women who referred to hospitals of Tabriz (Iran) for delivery were randomly allocated into two groups of 50 to undergo either continuous or interrupted episiotomy repair. A visual analogue scale (VAS) was used to evaluate pain severity 12-18 hours after episiotomy repair and also 10 days after delivery. Perineal repair rate was also assessed using the REEDA (redness, edema, ecchymosis, discharge, and approximation) scoring scale. The obtained data was analyzed in SPSS15. RESULTS Statistical tests did not show significant differences between the 2 groups in pain severity variations or REEDA scores at 12-18 hours and the 10th day after delivery. However, the mean required time for repair and the number of used threads were significantly lower in the continuous repair group (p < 0.001). CONCLUSION The results of this study showed that pain severity and episiotomy repair rate were similar in the two methods. Nevertheless, shorter time of repair and fewer threads were required using the continuous repair method. Therefore, this method would provide better services for mothers and reduce the required time, energy, and costs.
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Affiliation(s)
- Shirin Hasanpoor
- MSc, Instructor , Department of Midwifery, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Soheila Bani
- MSc, Instructor , Department of Midwifery, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Rudabe Shahgole
- MSc, Postgraduate Student, Department of Midwifery, International Aras Branch, Tabriz University of Medical Sciences Tabriz, Iran
| | - Morteza Gojazadeh
- PhD, Assistant Professor, Reproductive Women's Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Bick DE, Ismail KM, Macdonald S, Thomas P, Tohill S, Kettle C. How good are we at implementing evidence to support the management of birth related perineal trauma? A UK wide survey of midwifery practice. BMC Pregnancy Childbirth 2012; 12:57. [PMID: 22731799 PMCID: PMC3472238 DOI: 10.1186/1471-2393-12-57] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Accepted: 06/01/2012] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The accurate assessment and appropriate repair of birth related perineal trauma require high levels of skill and competency, with evidence based guideline recommendations available to inform UK midwifery practice. Implementation of guideline recommendations could reduce maternal morbidity associated with perineal trauma, which is commonly reported and persistent, with potential to deter women from a future vaginal birth. Despite evidence, limited attention is paid to this important aspect of midwifery practice. We wished to identify how midwives in the UK assessed and repaired perineal trauma and the extent to which practice reflected evidence based guidance. Findings would be used to inform the content of a large intervention study. METHODS A descriptive cross sectional study was completed. One thousand randomly selected midwives were accessed via the Royal College of Midwives (RCM) and sent a questionnaire. Study inclusion criteria included that the midwives were in clinical practice and undertook perineal assessment and management within their current role. Quantitative and qualitative data were collated. Associations between midwife characteristics and implementation of evidence based recommendations for perineal assessment and management were examined using chi-square tests of association. RESULTS 405 midwives (40.5%) returned a questionnaire, 338 (83.5%) of whom met inclusion criteria. The majority worked in a consultant led unit (235, 69.5%) and over a third had been qualified for 20 years or longer (129, 38.2%). Compliance with evidence was poor. Few (6%) midwives used evidence based suturing methods to repair all layers of perineal trauma and only 58 (17.3%) performed rectal examination as part of routine perineal trauma assessment. Over half (192, 58.0%) did not suture all second degree tears. Feeling confident to assess perineal trauma all of the time was only reported by 116 (34.3%) midwives, with even fewer (73, 21.6%) feeling confident to perform perineal repair all of the time. Two thirds of midwives (63.5%) felt confident to perform an episiotomy. Midwives qualified for 20 years or longer and those on more senior clinical grades were most likely to implement evidence based recommendations and feel confident about perineal management. CONCLUSIONS There are considerable gaps with implementation of evidence to support management of perineal trauma.
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Affiliation(s)
- Debra E Bick
- Professor of Evidence Based Midwifery Practice Kings College London, Florence Nightingale School of Nursing and Midwifery, 57 Waterloo Road, London SE1 8WA, UK
| | - Khaled M Ismail
- School of Clinical & Experimental Medicine, College of Medical & Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Sue Macdonald
- Education and Research Manager, Royal College of Midwives, 15 Mansfield Street, London WIG 9NH, UK
| | - Peter Thomas
- Centre of Postgraduate Medical Research and Education, School of Health and Social Care, Bournemouth University, R506A Royal London House, Christchurch Road, Bournemouth, Dorset BH1 3LT, UK
| | - Sue Tohill
- Research Manager West Midlands (South) Comprehensive Local Research Network, University Hospitals Coventry and Warwickshire NHS Trust, University Hospital, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Christine Kettle
- Maternity Centre, Professor of Women’s Health Staffordshire University and University Hospital of North Staffordshire, Newcastle Road, Stoke-on-Trent, Staffordshire ST4 6QG, UK
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da Silva FMB, de Oliveira SMJV, Bick D, Osava RH, Tuesta EF, Riesco MLG. Risk factors for birth-related perineal trauma: a cross-sectional study in a birth centre. J Clin Nurs 2012; 21:2209-18. [PMID: 22646921 DOI: 10.1111/j.1365-2702.2012.04133.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM AND OBJECTIVES To identify maternal, newborn and obstetric factors associated with birth-related perineal trauma in one independent birth centre. BACKGROUND Risk factors for birth-related perineal trauma include episiotomy, maternal age, ethnicity, parity and interventions during labour including use of oxytocin, maternal position at time of birth and infant birth weight. Understanding more about these factors could support the management of vaginal birth to prevent spontaneous perineal trauma, in line with initiatives to reduce routine use of episiotomy. DESIGN Cross-sectional study. METHODS Data were retrospectively collected from one independent birth centre in Brazil, during 2006-2009. The dependent variable (perineal trauma) was classified as: (1) intact perineum or first-degree laceration, (2) second-degree laceration and (3) episiotomy (right mediolateral or median). RESULTS There were 1079 births during the study period. Parity, use of oxytocin during labour, position at time of giving birth and infant birth weight were associated with second-degree lacerations and episiotomies. After adjusting for parity, oxytocin, maternal position at the expulsive stage of labour and infant birth weight influenced perineal outcomes among primiparae only. CONCLUSIONS Although the overall rate of episiotomies in this study was low compared with national data, it was observed that younger women were most vulnerable to this intervention. In this age group in particular, the use of oxytocin as well as semi-upright positions at the time of birth was associated with second-degree lacerations and episiotomies. RELEVANCE TO CLINICAL PRACTICE The use of upright alternative positions for birth and avoidance of use of oxytocin could reduce the risk of perineal trauma from lacerations and need to perform episiotomy.
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Affiliation(s)
- Flora M B da Silva
- National Council for Scientific and Technological Development (CNPq) Scholarship, University of São Paulo, São Paulo, SP, Brazil.
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Perineal pain following childbirth: Prevalence, effects on postnatal recovery and analgesia usage. Midwifery 2012; 28:93-7. [DOI: 10.1016/j.midw.2010.11.009] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Revised: 11/15/2010] [Accepted: 11/21/2010] [Indexed: 11/20/2022]
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Way S. A qualitative study exploring women's personal experiences of their perineum after childbirth: expectations, reality and returning to normality. Midwifery 2011; 28:e712-9. [PMID: 21978497 DOI: 10.1016/j.midw.2011.08.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 08/12/2011] [Accepted: 08/25/2011] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Susan Way
- Bournemouth University, Christchurch road, Bournemouth, BH1 3LT, UK.
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Impact of increasing capacity for generating and using research on maternal and perinatal health practices in South East Asia (SEA-ORCHID Project). PLoS One 2011; 6:e23994. [PMID: 21915274 PMCID: PMC3168479 DOI: 10.1371/journal.pone.0023994] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 08/03/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Maternal and neonatal mortality and morbidity remain unacceptably high in many low and middle income countries. SEA-ORCHID was a five year international collaborative project in South East Asia which aimed to determine whether health care and health outcomes for mothers and babies could be improved by developing capacity for research generation, synthesis and use. METHODS Nine hospitals in Indonesia, Malaysia, the Philippines and Thailand participated in SEA-ORCHID. These hospitals were supported by researchers from three Australian centres. Health care practices and outcomes were assessed for 1000 women at each hospital both before and after the intervention. The capacity development intervention was tailored to the needs and context of each hospital and delivered over an 18 month period. Main outcomes included adherence to forms of care likely to be beneficial and avoidance of forms of care likely to be ineffective or harmful. RESULTS We observed substantial variation in clinical practice change between sites. The capacity development intervention had a positive impact on some care practices across all countries, including increased family support during labour and decreased perineal shaving before birth, but in some areas there was no significant change in practice and a few beneficial practices were followed less often. CONCLUSION The results of SEA-ORCHID demonstrate that investing in developing capacity for research use, synthesis and generation can lead to improvements in maternal and neonatal health practice and highlight the difficulty of implementing evidence-based practice change.
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Elharmeel SM, Chaudhary Y, Tan S, Scheermeyer E, Hanafy A, van Driel ML. Surgical repair of spontaneous perineal tears that occur during childbirth versus no intervention. Cochrane Database Syst Rev 2011:CD008534. [PMID: 21833968 DOI: 10.1002/14651858.cd008534.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Suzan Ma Elharmeel
- Department of Obstetrics and Gynaecology, Gold Coast Hospital, 108 Nerang Street, Gold Coast, Queensland, Australia, 4215
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Dudley LM, Kettle C, Ismail KMK. Secondary suturing compared to non-suturing for broken down perineal wounds following childbirth. Cochrane Database Syst Rev 2011. [DOI: 10.1002/14651858.cd008977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Kokanalı D, Ugur M, Kuntay Kokanalı M, Karayalcın R, Tonguc E. Continuous versus interrupted episiotomy repair with monofilament or multifilament absorbed suture materials: a randomised controlled trial. Arch Gynecol Obstet 2010; 284:275-80. [PMID: 20680312 DOI: 10.1007/s00404-010-1620-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2010] [Accepted: 07/20/2010] [Indexed: 11/27/2022]
Abstract
PURPOSE To compare different repair techniques and different suture materials for episiotomy. METHODS 160 women having vertex delivery with right-mediolateral episiotomy were randomly allocated to four groups. In the groups where continuos technique was performed, vaginal mucosa, perineal muscles and the skin were sutured continuously. In the groups of interrupted technique, vaginal mucosa was sutured with continuous sutures, then muscle layers and skin were closed by interrupted sutures. Two different types of synthetic absorbed suture material were used: monofilament type is in form of polyglycolide-co-caprolactone and multifilament one is polyglactin 910-Rapide. Perineal pain during different activities on the first and tenth day postpartum and also during sexual intercourse 6 weeks after the delivery was questioned by visual analogous scale (VAS). Furthermore, repair time, amount of suture and episiotomy complications were investigated in each groups. RESULTS On the first day after delivery, the perineal pain scores, the repair time, the amount of suture were statistically less in the continuous technique groups. The differences between the pain at tenth day and during sexual intercourse 6 weeks after the delivery were statistically same. CONCLUSIONS The continuous suturing techniques for episiotomy closure, compared to interrupted methods, are associated with less short-term pain, are quicker and also need less suture material.
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Affiliation(s)
- Demet Kokanalı
- Dr. Zekai Tahir Burak Woman's Health Education and Research Hospital, Ankara, Turkey.
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Kettle C, Dowswell T, Ismail KMK. Absorbable suture materials for primary repair of episiotomy and second degree tears. Cochrane Database Syst Rev 2010; 2010:CD000006. [PMID: 20556745 PMCID: PMC7263442 DOI: 10.1002/14651858.cd000006.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Christine Kettle
- University Hospital of North StaffordshireMaternity CentreCity General SiteNewcastle RoadStoke‐on‐TrentStaffordshireUKST4 6QG
| | - Therese Dowswell
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, School of Reproductive and Developmental Medicine, Division of Perinatal and Reproductive MedicineFirst Floor, Liverpool Women's NHS Foundation TrustLiverpoolUKL8 7SS
| | - Khaled MK Ismail
- Keele University Medical SchoolInstitute of Science and Technology in MedicineKeeleStaffordshireUK
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Chou D, Abalos E, Gyte GM, Gülmezoglu AM. Paracetamol/acetaminophen (single administration) for perineal pain in the early postpartum period. Cochrane Database Syst Rev 2010:CD008407. [PMID: 20238369 DOI: 10.1002/14651858.cd008407] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Perineal pain is a common but poorly studied adverse outcome following childbirth. Pain may result from perineal trauma due to bruising, spontaneous tears, surgical incisions (episiotomies), or in association with operative births (ventouse or forceps assisted births). OBJECTIVES To determine the efficacy of a single administration of paracetamol (acetaminophen) systemic drugs used in the relief of acute postpartum perineal pain SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2009). SELECTION CRITERIA Randomised controlled trials (RCTs) assessing paracetamol (acetaminophen) in a single dose compared with placebo for women with early postpartum perineal pain. We excluded quasi-RCTs and cross-over studies. DATA COLLECTION AND ANALYSIS Two review authors assessed each paper for inclusion and extracted data. One review author reviewed the decisions and confirmed calculations for pain relief scores. MAIN RESULTS We have included 10 studies describing two dosages of paracetamol. Of these, five studies (526 women) assessed 500 mg to 650 mg and six studies (841 women) assessed 1000 mg of paracetamol. We chose to use random-effects meta-analyses because of the heterogeneity in dosage used. Studies were from the 1970s to the early 1990s, and there was insufficient information to assess the risk of bias adequately, hence the findings need to be interpreted within this context.More women experienced pain relief with paracetamol compared with placebo (average risk ratio (RR) 2.14, 95% confidence interval (CI) 1.59 to 2.89, 10 studies, 1279 women). In addition, there were significantly fewer women having additional pain relief with paracetamol compared with placebo (RR 0.34, 95% CI 0.21 to 0.55, eight studies, 1132 women). Both the 500 mg to 650 mg and 1000 mg doses were effective in providing more pain relief than placebo.Maternal and neonatal potential adverse drug effects were not assessed in any of the included studies. Indeed few secondary outcomes were assessed. AUTHORS' CONCLUSIONS More women experienced pain relief, and fewer had additional pain relief, with paracetamol compared with placebo, although potential adverse effects were not assessed and generally the quality of studies was unclear.
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Affiliation(s)
- Doris Chou
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, 20 Avenue Appia, Geneva, Switzerland, 1211
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Abstract
OBJECTIVE To compare the clinical outcomes of staples versus sutures in wound closure after orthopaedic surgery. DESIGN Meta-analysis. DATA SOURCES Medline, CINAHL, AMED, Embase, Scopus, and the Cochrane Library databases were searched, in addition to the grey literature, in all languages from 1950 to September 2009. Additional studies were identified from cited references. Selection criteria Two authors independently assessed papers for eligibility. Included studies were randomised and non-randomised controlled trials that compared the use of staples with suture material for wound closure after orthopaedic surgery procedures. All studies were included, and publications were not excluded because of poor methodological quality. Review methods Two authors independently reviewed studies for methodological quality and extracted data from each paper. Final data for analysis were collated through consensus. The primary outcome measure was the assessment of superficial wound infection after wound closure with staples compared with sutures. Relative risk and mean difference with 95% confidence intervals were calculated and pooled with a random effects model. Heterogeneity was assessed with I(2) and chi(2) statistical test. RESULTS Six papers, which included 683 wounds, were identified; 332 patients underwent suture closure and 351 staple closure. The risk of developing a superficial wound infection after orthopaedic procedures was over three times greater after staple closure than suture closure (relative risk 3.83, 95% confidence interval 1.38 to 10.68; P=0.01). On subgroup analysis of hip surgery alone, the risk of developing a wound infection was four times greater after staple closure than suture closure (4.79, 1.24 to 18.47; P=0.02). There was no significant difference between sutures and staples in the development of inflammation, discharge, dehiscence, necrosis, and allergic reaction. The included studies had several major methodological limitations, including the recruitment of small, underpowered cohorts, poorly randomising patients, and not blinding assessors to the allocated methods of wound closure. Only one study had acceptable methodological quality. CONCLUSIONS After orthopaedic surgery, there is a significantly higher risk of developing a wound infection when the wound is closed with staples rather than sutures. This risk is specifically greater in patients who undergo hip surgery. The use of staples for closing hip or knee surgery wounds after orthopaedic procedures cannot be recommended, though the evidence comes from studies with substantial methodological limitations. Though we advise orthopaedic surgeons to reconsider their use of staples for wound closure, definitive randomised trials are still needed to assess this research question.
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Affiliation(s)
- Toby O Smith
- Norfolk and Norwich University Hospital, Norwich NR2 7UY.
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Bick DE, Kettle C, Macdonald S, Thomas PW, Hills RK, Ismail KMK. PErineal Assessment and Repair Longitudinal Study (PEARLS): protocol for a matched pair cluster trial. BMC Pregnancy Childbirth 2010; 10:10. [PMID: 20184764 PMCID: PMC2836981 DOI: 10.1186/1471-2393-10-10] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Accepted: 02/25/2010] [Indexed: 11/24/2022] Open
Abstract
Background The Perineal Assessment and Repair Longitudinal Study (PEARLS) is a national clinical quality improvement initiative designed to improve the assessment and management of perineal trauma. Perineal trauma affects around 85% of women who have a vaginal birth in the UK each year and millions more world-wide. Continuous suturing techniques compared with traditional interrupted methods are more effective in reducing pain and postnatal morbidity, however they are not widely used by clinicians despite recommendations of evidence based national clinical guidelines. Perineal suturing skills and postnatal management of trauma remain highly variable within and between maternity units in the UK as well as worldwide. Implementation of a standardised training package to support effective perineal management practices could reduce perineal pain and other related postnatal morbidity for a substantial number of women. Methods/Design PEARLS is a matched pair cluster trial, which is being conducted in maternity units across the UK. Units within a matched pair will be randomised to implement the study intervention either early or late in the study period. The intervention will include the cascading of a multi-professional training package to enhance midwifery and obstetric skills in the assessment, repair and postnatal management of perineal trauma. Women who have had an episiotomy or second degree perineal tear will be eligible for recruitment. Prior to developing the intervention and deciding on study outcomes, a Delphi survey and a consensus conference were held to identify what women, who previously suffered perineal trauma during childbirth, considered to be important outcomes for them. Findings from this preliminary work (which will be reported elsewhere) and other outcomes including women's experiences of perineal pain and pain on activity, breastfeeding uptake and duration and psychological well-being as assessed using the Edinburgh Postnatal Depression Scale (EPDS) will be assessed at 10 days and three months post-birth. Discussion Implementation of evidence-based perineal assessment and management practices, could lead to significantly improved physical and psychological health outcomes for women in the UK and world-wide. Trial registration PEARLS is registered with the Current Controlled Trials Registry (no: ISRCTN28960026). NIHR UKCRN portfolio no: 4785.
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Affiliation(s)
- Debra E Bick
- King's College London, Florence Nightingale School of Nursing and Midwifery, James Clerk Maxwell Building, 57 Waterloo Road, London, UK.
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Navvabi S, Abedian Z, Steen-Greaves M. Effectivness of cooling gel pads and ice packs on perineal pain. ACTA ACUST UNITED AC 2009. [DOI: 10.12968/bjom.2009.17.11.45030] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Shahin Navvabi
- Zahedan University of Medical Science Nursing and Midwifery, Mashhad Iran
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Chou D, Abalos E, Gyte GML, Gülmezoglu AM. Drugs for perineal pain in the early postpartum period: generic protocol. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [DOI: 10.1002/14651858.cd007734.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Doris Chou
- World Health Organization; UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research; 20 Avenue Appia Geneva Switzerland 1211
| | - Edgardo Abalos
- Centro Rosarino de Estudios Perinatales; Pueyrredon 985 Rosario Santa Fe Argentina 2000
| | - Gillian ML Gyte
- The University of Liverpool; Cochrane Pregnancy and Childbirth Group, School of Reproductive and Developmental Medicine, Division of Perinatal and Reproductive Medicine; First Floor, Liverpool Women's NHS Foundation Trust Crown Street Liverpool UK L8 7SS
| | - A Metin Gülmezoglu
- World Health Organization; UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research; 20 Avenue Appia Geneva Switzerland 1211
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Valenzuela P, Saiz Puente MS, Valero JL, Azorín R, Ortega R, Guijarro R. Continuous versus interrupted sutures for repair of episiotomy or second-degree perineal tears: a randomised controlled trial. BJOG 2009; 116:436-41. [PMID: 19187377 DOI: 10.1111/j.1471-0528.2008.02056.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the repair techniques of continuous and interrupted methods for episiotomy or perineal tears. DESIGN A randomised controlled trial. SETTING The Hospital Universitario Principe de Asturias, a state hospital belonging to the community of Madrid. SAMPLE Four hundred forty-five women who had undergone vaginal deliveries with episiotomies or second-grade tearing of the perineum between September 2005 and July 2007. METHODS One group was repaired with continuous, nonlocking sutures involving the vagina, perineum, and subcutaneous tissues. The other group had continuous, locking sutures of the vagina, interrupted sutures in the perineal muscles, and interrupted transcutaneous sutures. The threads used for stitching were identical in both groups. MAIN OUTCOME MEASURES The participants were questioned regarding the sensation of pain and the use of painkillers on the second and the tenth days, and 3 months postpartum. RESULTS When comparing the group with continuous suture to the group with interrupted sutures, the differences included less repair time (1 minute; P= 0.017) and less suture material used (relative risk [RR], 3.2, 95% CI: 2.6-4.0). The comparison of pain on the second and tenth days, and 3 months postpartum were not statistically different between the two techniques (RR, 1.08, 95% CI: 0.74-1.57; RR, 0.96, 95% CI: 0.59-1.55; and RR, 0.68, 95% CI: 0.19-2.46, respectively). CONCLUSIONS Although we did not demonstrate that one technique was better than the other in the incidence of pain in the short or long term, we showed that episiotomy and perineal tear repairs with continuous suturing were quicker and used less suture material without an increase in complication than interrupted suturing.
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Affiliation(s)
- P Valenzuela
- Department of Medical Specialties, Alcalá de Henares University, Madrid, Spain.
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Chou D, Abalos E, Gyte GML, Gülmezoglu AM. Drugs for perineal pain in the early postpartum period. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [DOI: 10.1002/14651858.cd007734] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
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.
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Affiliation(s)
- Guillermo Carroli
- Centro Rosarino de Estudios Perinatales, Pueyrredon 985, Rosario, Santa Fe, Argentina, 2000.
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Kindberg S, Klünder L, Strøm J, Henriksen TB. Ear acupuncture or local anaesthetics as pain relief during postpartum surgical repair: a randomised controlled trial. BJOG 2008; 116:569-76. [PMID: 19120322 DOI: 10.1111/j.1471-0528.2008.02016.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate two methods of pain relief during postpartum surgical repair in regard to effectiveness, wound healing and patient evaluation. DESIGN A randomised controlled trial testing a pragmatic set-up of brief training of clinicians. SETTING Delivery ward at a Danish district hospital with approximately 1600 annual deliveries. POPULATION Primiparous women with a vaginal delivery at term who needed surgical repair of lacerations to the labia or the vagina, perineal lacerations of first or second degree or mediolateral episiotomies. METHODS The trial was set up to evaluate the effect of a brief 2-hour hands-on training in the use of ear acupuncture. All midwives (n = 36) in the department had previous experience in using acupuncture for obstetric pain relief. Pain and wound healing were evaluated using validated scores. Data collection was performed by research assistants blinded towards treatment allocation. Randomisation was computer assisted. A total of 207 women were randomised to receive ear acupuncture (105) and local anaesthetics (102), respectively. MAIN OUTCOME MEASURES The primary outcome was pain during surgical repair. Secondary outcomes were wound healing at 24-48 hours and 14 days postpartum, participant satisfaction, revision of wound or dyspareunia reported 6 months postpartum. RESULTS Pain during surgical repair was more frequently reported by participants allocated to ear acupuncture compared with participants receiving local anaesthetics (89 versus 54%, P < 0.01). Pain intensity during surgical repair was also reported higher (Visual Analogue Scale score 3.5 versus 1.5, P < 0.01). The ear acupuncture group received more additional pain relief during repair (53 versus 19%, P < 0.01). No difference was observed in wound healing at 24-48 hours or 14 days postpartum. Revision of wounds was rare, and no difference occurred in this trial. Comparable proportions of participants reported dyspareunia at 6 months. Patient satisfaction with the allocated pain-relief method was lower in the ear acupuncture group (69 versus 91%, P < 0.01) and fewer women would recommend the method to a friend (74 versus 91%, P < 0.01). CONCLUSIONS Ear acupuncture as used in this trial was less effective for pain relief compared with a local anaesthetic. No difference was observed in wound healing, need for revision of wound or dyspareunia. Patient satisfaction with allocated pain-relief method was lower in the ear acupuncture group.
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Affiliation(s)
- S Kindberg
- Department of Research and Medical Education, Sønderborg Hospital, Denmark.
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