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Effect of Prenatal Perineal Massage on Postpartum Perineal Injury and Postpartum Complications: A Meta-Analysis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:3315638. [PMID: 35872935 PMCID: PMC9303122 DOI: 10.1155/2022/3315638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/25/2022] [Accepted: 06/29/2022] [Indexed: 11/17/2022]
Abstract
Background The efficacy of perineal massage is controversial. The study was aimed at comparing the effects of perineal massage on perineal injury and complications. Methods PubMed, Embase, the Cochrane Library, and ISI Web of Science were searched for literature on the relationship between prenatal perineal massage and postpartum perineal injury and complications until April 2022. Indicators included postpartum perineal tears, perineotomy, postpartum perineal pain, natural labour, and postpartum incontinence. Finally, RevMan5.4 software was used to analyze the extracted data. Results A total of 6487 subjects in 16 studies were included, with 3211 who received perineal massage and 3276 did not. There was no significant difference in 1-2 degree perineal tearing between the intervention group and the control group (RR = 0.96, 95% CI [0.90, 1.03], P = 0.30), and there was no heterogeneity between studies (P = 0.62, I2 = 0%), indicating publication bias. Compared with the control group, prenatal perineal massage significantly reduced the incidence of 3-4 degree perineal tears (RR = 0.56, 95% CI [0.47, 0.67], P < 0.00001), and there was no heterogeneity between studies (P = 0.16, I2 = 30%), indicating publication bias. Compared with the control group, prenatal perineal massage reduced the risk of lateral perineal resection (RR = 0.87, 95% CI [0.80, 0.95], P = 0.001), and there was no heterogeneity between studies (P = 0.14, I2 = 31%), and there was no publication bias. Compared with the control group, prenatal perineal massage reduced the risk of postpartum pain at 3 months (RR = 0.64, 95% CI [0.51, 0.81], P = 0.0002). There was no significant heterogeneity among studies (P = 0.23, I2 = 31%). Conclusion Compared with no prenatal perineal massage, prenatal perineal massage can reduce the risk of perineal injury, the incidence of lateral perineal resection, and the incidence of long-term pain.
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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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Gluck O, Ganer Herman H, Tal O, Grinstein E, Bar J, Kovo M, Ginath S, Weiner E. The association between the number of vaginal examinations during labor and perineal trauma: a retrospective cohort study. Arch Gynecol Obstet 2020; 301:1405-1410. [PMID: 32328711 DOI: 10.1007/s00404-020-05552-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 04/11/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To study the association between the number of vaginal examinations (VEs) performed during labor and subsequent severe perineal trauma. METHODS This is a retrospective cohort study. We included all women admitted to the delivery ward between 2008 and 2017, in active labor. Exclusion criteria included preterm deliveries (< 37 weeks), Cesarean deliveries and episiotomy during delivery. The primary outcome, severe perineal trauma, was defined as perineal tears grades 3-4. The cohort was divided into 4 groups, based on the number of VEs performed during labor: Group 1-up to two VEs (n = 4588), Group 2-three to four VEs (n = 5815), Group 3-five to six VEs (n = 4687), and Group 4-seven or more VEs (n = 7297). RESULTS Overall, 22,387 women were included in the study. The rate of severe perineal trauma in groups 1, 2, 3 and 4 was 0.4%, 0.1%, 0.8%, and 0.4%, respectively (p < 0.001). Performing five or more VEs during labor was associated with a higher risk of severe perineal trauma (0.26% vs. 0.53%, p < 0.01), as compared to four VEs or less. Using a logistic regression model, we found that performing five or more VEs during labor (aOR = 1.72 CI 95% (1.21-2.47), p < 0.001) or performing an instrumental delivery (aOR = 2.65 CI 95% (1.72-4.07), p < 0.001) were directly associated with the risk for severe perineal trauma. Applying epidural anesthesia showed an inverse association with severe perineal trauma (aOR = 0.54 CI 95% (0.38-0.77), p < 0.001). CONCLUSION Performing five or more VEs during active labor is associated with an increased risk for severe perineal trauma.
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Affiliation(s)
- Ohad Gluck
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Holon, and Sackler School of Medicine, Tel Aviv University, P.O. Box 5, 58100, Holon, Israel.
| | - Hadas Ganer Herman
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Holon, and Sackler School of Medicine, Tel Aviv University, P.O. Box 5, 58100, Holon, Israel
| | - Ori Tal
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Holon, and Sackler School of Medicine, Tel Aviv University, P.O. Box 5, 58100, Holon, Israel
| | - Ehud Grinstein
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Holon, and Sackler School of Medicine, Tel Aviv University, P.O. Box 5, 58100, Holon, Israel
| | - Jacob Bar
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Holon, and Sackler School of Medicine, Tel Aviv University, P.O. Box 5, 58100, Holon, Israel
| | - Michal Kovo
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Holon, and Sackler School of Medicine, Tel Aviv University, P.O. Box 5, 58100, Holon, Israel
| | - Shimon Ginath
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Holon, and Sackler School of Medicine, Tel Aviv University, P.O. Box 5, 58100, Holon, Israel
| | - Eran Weiner
- Department of Obstetrics and Gynecology, The Edith Wolfson Medical Center, Holon, and Sackler School of Medicine, Tel Aviv University, P.O. Box 5, 58100, Holon, Israel
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Shahoei R, Zaheri F, Nasab LH, Ranaei F. The effect of perineal massage during the second stage of birth on nulliparous women perineal: A randomization clinical trial. Electron Physician 2017; 9:5588-5595. [PMID: 29238501 PMCID: PMC5718865 DOI: 10.19082/5588] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 08/18/2017] [Indexed: 01/22/2023] Open
Abstract
Background Childbirth and puerperium are of the most important periods in women's lives and can affect different aspects of their lives. Objective To determine the effect of perineal massage in the second stage of labor on perineal lacerations, episiotomy, and perineal pain in nulliparous women. Methods This randomization clinical trial was conducted at Be'sat Hospital in Sanandaj, Iran, from 2013 to 2014. A total of 195 nulliparous women were included in the study. The participants were selected through convenience sampling, and randomly assigned to two groups: intervention and control groups. The intervention group received 30-minute perineal massage during second stage of labor. Subsequently, we analyzed perineal laceration, episiotomy, and perineal pain among the two groups. All of them were taught about postpartum perineal pain and its severity, and the researcher followed them up 3 days, 10 days, and 3 months after childbirth by telephone. The data were analyzed using SPSS version 18. We used descriptive statistics and analytical statistics, including t test, Chi-square test, and Fisher's test. Results Frequency of episiotomy was 69.47% in the intervention group and 92.31% in the control group, and the difference was statistically significant (p<0.05). The results revealed 23.16% of first-degree perineal laceration and 2.11% of second-degree perineal laceration in the intervention group, and no vestibular laceration or third- and fourth-degree lacerations in the intervention group. However, there were 5.13% of vestibular laceration, 7.69% of first-degree laceration, 2.56% of second-degree laceration, and 1.05% of third-degree laceration (one woman) in the control group. Based on the results, the postpartum perineal pain was significantly different in both groups. Conclusion Regarding the results of this study and those of other studies, perineal massage during the second stage of labor can reduce the need to episiotomy, perineal injuries, and perineal pain. Trial registration The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the Irct.ID: IRCT2013090314556N1. Funding This study received by financial support of Kurdistan University of Medical Sciences, Sanandaj, Iran.
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Affiliation(s)
- Roonak Shahoei
- Ph.D. of Midwifery, Associate Professor, Clinical Care Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran.,Department of Midwifery, Faculty of Nursing & Midwifery, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Farzaneh Zaheri
- Ph.D. Student, Lecturer, Department of Midwifery, Faculty of Nursing & Midwifery, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Lila Hashemi Nasab
- M.Sc. of Midwifery, Faculty Member, Department of Midwifery, Faculty of Nursing & Midwifery, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Fariba Ranaei
- M.Sc. of Midwifery, Faculty Member, Department of Midwifery, Faculty of Nursing & Midwifery, Kurdistan University of Medical Sciences, Sanandaj, Iran
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Aasheim V, Nilsen ABV, Reinar LM, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 2017; 6:CD006672. [PMID: 28608597 PMCID: PMC6481402 DOI: 10.1002/14651858.cd006672.pub3] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Most vaginal births are associated with trauma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including perineal massage, warm or cold compresses, and perineal management techniques have been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011. OBJECTIVES To assess the effect of perineal techniques during the second stage of labour on the incidence and morbidity associated with perineal trauma. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (26 September 2016) and reference lists of retrieved studies. SELECTION CRITERIA Published and unpublished randomised and quasi-randomised controlled trials evaluating perineal techniques during the second stage of labour. Cross-over trials were not eligible for inclusion. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. We checked data for accuracy. MAIN RESULTS Twenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Overall, trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques.Most studies did not report data on our secondary outcomes. We downgraded evidence for risk of bias, inconsistency, and imprecision for all comparisons. Hands off (or poised) compared to hands onHands on or hands off the perineum made no clear difference in incidence of intact perineum (average risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.12, two studies, Tau² 0.00, I² 37%, 6547 women; moderate-quality evidence), first-degree perineal tears (average RR 1.32, 95% CI 0.99 to 1.77, two studies, 700 women; low-quality evidence), second-degree tears (average RR 0.77, 95% CI 0.47 to 1.28, two studies, 700 women; low-quality evidence), or third- or fourth-degree tears (average RR 0.68, 95% CI 0.21 to 2.26, five studies, Tau² 0.92, I² 72%, 7317 women; very low-quality evidence). Substantial heterogeneity for third- or fourth-degree tears means these data should be interpreted with caution. Episiotomy was more frequent in the hands-on group (average RR 0.58, 95% CI 0.43 to 0.79, Tau² 0.07, I² 74%, four studies, 7247 women; low-quality evidence), but there was considerable heterogeneity between the four included studies.There were no data for perineal trauma requiring suturing. Warm compresses versus control (hands off or no warm compress)A warm compress did not have any clear effect on the incidence of intact perineum (average RR 1.02, 95% CI 0.85 to 1.21; 1799 women; four studies; moderate-quality evidence), perineal trauma requiring suturing (average RR 1.14, 95% CI 0.79 to 1.66; 76 women; one study; very low-quality evidence), second-degree tears (average RR 0.95, 95% CI 0.58 to 1.56; 274 women; two studies; very low-quality evidence), or episiotomy (average RR 0.86, 95% CI 0.60 to 1.23; 1799 women; four studies; low-quality evidence). It is uncertain whether warm compress increases or reduces the incidence of first-degree tears (average RR 1.19, 95% CI 0.38 to 3.79; 274 women; two studies; I² 88%; very low-quality evidence).Fewer third- or fourth-degree perineal tears were reported in the warm-compress group (average RR 0.46, 95% CI 0.27 to 0.79; 1799 women; four studies; moderate-quality evidence). Massage versus control (hands off or routine care)The incidence of intact perineum was increased in the perineal-massage group (average RR 1.74, 95% CI 1.11 to 2.73, six studies, 2618 women; I² 83% low-quality evidence) but there was substantial heterogeneity between studies). This group experienced fewer third- or fourth-degree tears (average RR 0.49, 95% CI 0.25 to 0.94, five studies, 2477 women; moderate-quality evidence).There were no clear differences between groups for perineal trauma requiring suturing (average RR 1.10, 95% CI 0.75 to 1.61, one study, 76 women; very low-quality evidence), first-degree tears (average RR 1.55, 95% CI 0.79 to 3.05, five studies, Tau² 0.47, I² 85%, 537 women; very low-quality evidence), or second-degree tears (average RR 1.08, 95% CI 0.55 to 2.12, five studies, Tau² 0.32, I² 62%, 537 women; very low-quality evidence). Perineal massage may reduce episiotomy although there was considerable uncertainty around the effect estimate (average RR 0.55, 95% CI 0.29 to 1.03, seven studies, Tau² 0.43, I² 92%, 2684 women; very low-quality evidence). Heterogeneity was high for first-degree tear, second-degree tear and for episiotomy - these data should be interpreted with caution. Ritgen's manoeuvre versus standard careOne study (66 women) found that women receiving Ritgen's manoeuvre were less likely to have a first-degree tear (RR 0.32, 95% CI 0.14 to 0.69; very low-quality evidence), more likely to have a second-degree tear (RR 3.25, 95% CI 1.73 to 6.09; very low-quality evidence), and neither more nor less likely to have an intact perineum (RR 0.17, 95% CI 0.02 to 1.31; very low-quality evidence). One larger study reported that Ritgen's manoeuvre did not have an effect on incidence of third- or fourth-degree tears (RR 1.24, 95% CI 0.78 to 1.96,1423 women; low-quality evidence). Episiotomy was not clearly different between groups (RR 0.81, 95% CI 0.63 to 1.03, two studies, 1489 women; low-quality evidence). Other comparisonsThe delivery of posterior versus anterior shoulder first, use of a perineal protection device, different oils/wax, and cold compresses did not show any effects on perineal outcomes. Only one study contributed to each of these comparisons, so data were insufficient to draw conclusions. AUTHORS' CONCLUSIONS Moderate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent. Poor-quality evidence suggests hands-off techniques may reduce episiotomy, but this technique had no clear impact on other outcomes. There were insufficient data to show whether other perineal techniques result in improved outcomes.Further research could be performed evaluating perineal techniques, warm compresses and massage, and how different types of oil used during massage affect women and their babies. It is important for any future research to collect information on women's views.
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Affiliation(s)
- Vigdis Aasheim
- Western Norway University of Applied SciencesFaculty of Health and Social SciencesBergenNorway
| | - Anne Britt Vika Nilsen
- Western Norway University of Applied SciencesFaculty of Health and Social SciencesBergenNorway
| | - Liv Merete Reinar
- Norwegian Institute of Public HealthDivision for Health ServicesPO Box 4404NydalenOsloNorway0403
| | - Mirjam Lukasse
- University College of Southeast NorwayFaculty of Health and Social SciencesOsloNorway
- Oslo and Akershus University CollegeFaculty of Health SciencesPB4St.Olavs plassOsloNorwayN‐0130
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Harvey MA, Pierce M, Alter JEW, Chou Q, Diamond P, Epp A, Geoffrion R, Harvey MA, Larochelle A, Maslow K, Neustaedter G, Pascali D, Pierce M, Schulz J, Wilkie D, Sultan A, Thakar R. Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 37:1131-48. [PMID: 26637088 DOI: 10.1016/s1701-2163(16)30081-0] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To review the evidence relating to obstetrical anal sphincter injuries (OASIS) with respect to diagnosis, repair techniques and outcomes. To formulate recommendations as to patient counselling regarding route of delivery for subsequent pregnancy after OASIS. OPTIONS Obstetrical care providers caring for women with OASIS have the option of repairing the anal sphincter using end-to-end or overlapping techniques. They may also be involved in counselling women with prior OASIS regarding the route of delivery for future pregnancies. OUTCOMES The outcome measured is anal continence following primary OASIS repair and after subsequent childbirth. EVIDENCE Published literature was retrieved through searches of Medline, EMBASE, and The Cochrane Library in May 2011 using appropriate controlled vocabulary (e.g., anal canal, obstetrics, obstetric labour complication, pregnancy complication, treatment outcome, surgery, quality of life) and key words (obstetrical anal sphincter injur*, anus sphincter, anus injury, delivery, obstetrical care, surgery, suturing method, overlap, end-to-end, feces incontinence). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS Benefits from implementation of these guidelines include: improved diagnosis of OASIS, optimal functional outcomes following repair, and evidence-based counselling of women for future childbirth.
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Dönmez S, Kavlak O. Effects of Prenatal Perineal Massage and Kegel Exercises on the Integrity of Postnatal Perine. Health (London) 2015. [DOI: 10.4236/health.2015.74059] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Renfrew MJ, McFadden A, Bastos MH, Campbell J, Channon AA, Cheung NF, Silva DRAD, Downe S, Kennedy HP, Malata A, McCormick F, Wick L, Declercq E. Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet 2014; 384:1129-45. [PMID: 24965816 DOI: 10.1016/s0140-6736(14)60789-3] [Citation(s) in RCA: 742] [Impact Index Per Article: 74.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In this first paper in a series of four papers on midwifery, we aimed to examine, comprehensively and systematically, the contribution midwifery can make to the quality of care of women and infants globally, and the role of midwives and others in providing midwifery care. Drawing on international definitions and current practice, we mapped the scope of midwifery. We then developed a framework for quality maternal and newborn care using a mixed-methods approach including synthesis of findings from systematic reviews of women's views and experiences, effective practices, and maternal and newborn care providers. The framework differentiates between what care is provided and how and by whom it is provided, and describes the care and services that childbearing women and newborn infants need in all settings. We identified more than 50 short-term, medium-term, and long-term outcomes that could be improved by care within the scope of midwifery; reduced maternal and neonatal mortality and morbidity, reduced stillbirth and preterm birth, decreased number of unnecessary interventions, and improved psychosocial and public health outcomes. Midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed, and regulated. Our findings support a system-level shift from maternal and newborn care focused on identification and treatment of pathology for the minority to skilled care for all. This change includes preventive and supportive care that works to strengthen women's capabilities in the context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, and in which first-line management of complications and accessible emergency treatment are provided when needed. Midwifery is pivotal to this approach, which requires effective interdisciplinary teamwork and integration across facility and community settings. Future planning for maternal and newborn care systems can benefit from using the quality framework in planning workforce development and resource allocation.
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Affiliation(s)
- Mary J Renfrew
- Mother and Infant Research Unit, School of Nursing and Midwifery, College of Medicine, Dentistry and Nursing, University of Dundee, Dundee, UK.
| | - Alison McFadden
- Mother and Infant Research Unit, School of Nursing and Midwifery, College of Medicine, Dentistry and Nursing, University of Dundee, Dundee, UK
| | | | - James Campbell
- Instituto de Cooperación Social Integrare, Barcelona, Spain
| | - Andrew Amos Channon
- Division of Social Statistics and Demography, Faculty of Social and Human Sciences, University of Southampton, Southampton, UK
| | - Ngai Fen Cheung
- Midwifery Expert Committee of the Maternal and Child Health Association of China, Beijing, China
| | | | - Soo Downe
- School of Health, University of Central Lancashire, Preston, Lancashire, UK
| | | | - Address Malata
- Kamuzu College of Nursing University of Malawi, Lilongwe, Malawi
| | - Felicia McCormick
- Department of Health Sciences, University of York, Heslington West, York, UK
| | - Laura Wick
- Institute of Community and Public Health, Birzeit University, Birzeit, Palestine
| | - Eugene Declercq
- Community Health Sciences, Boston University School of Public Health, Boston, MD, USA
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Abstract
BACKGROUND Perineal trauma following vaginal birth can be associated with significant short-term and long-term morbidity. Antenatal perineal massage has been proposed as one method of decreasing the incidence of perineal trauma. OBJECTIVES To assess the effect of antenatal digital perineal massage on the incidence of perineal trauma at birth and subsequent morbidity. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (22 October 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 10), PubMed (1966 to October 2012), EMBASE (1980 to October 2012) and reference lists of relevant articles. SELECTION CRITERIA Randomised and quasi-randomised controlled trials evaluating any described method of antenatal digital perineal massage undertaken for at least the last four weeks of pregnancy. DATA COLLECTION AND ANALYSIS Both review authors independently applied the selection criteria, extracted data from the included studies and assessed study quality. We contacted study authors for additional information. MAIN RESULTS We included four trials (2497 women) comparing digital perineal massage with control. All were of good quality. Antenatal digital perineal massage was associated with an overall reduction in the incidence of trauma requiring suturing (four trials, 2480 women, risk ratio (RR) 0.91 (95% confidence interval (CI) 0.86 to 0.96), number needed to treat to benefit (NNTB) 15 (10 to 36)) and women practicing perineal massage were less likely to have an episiotomy (four trials, 2480 women, RR 0.84 (95% CI 0.74 to 0.95), NNTB 21 (12 to 75)). These findings were significant for women without previous vaginal birth only. No differences were seen in the incidence of first- or second-degree perineal tears or third-/fourth-degree perineal trauma. Only women who have previously birthed vaginally reported a statistically significant reduction in the incidence of pain at three months postpartum (one trial, 376 women, RR 0.45 (95% CI 0.24 to 0.87) NNTB 13 (7 to 60)). No significant differences were observed in the incidence of instrumental deliveries, sexual satisfaction, or incontinence of urine, faeces or flatus for any women who practised perineal massage compared with those who did not massage. AUTHORS' CONCLUSIONS Antenatal digital perineal massage reduces the likelihood of perineal trauma (mainly episiotomies) and the reporting of ongoing perineal pain, and is generally well accepted by women. As such, women should be made aware of the likely benefit of perineal massage and provided with information on how to massage.
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Kataoka Y, Eto H, Iida M. Outcomes of independent midwifery attended births in birth centres and home births: a retrospective cohort study in Japan. Midwifery 2013; 29:965-72. [PMID: 23415360 DOI: 10.1016/j.midw.2012.12.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 06/13/2012] [Accepted: 12/17/2012] [Indexed: 11/27/2022]
Abstract
OBJECTIVE the objective of this study was to describe and compare perinatal and neonatal outcomes of women who received care from independent midwives practicing home births and at birth centres in Tokyo. DESIGN a retrospective cohort study. SETTINGS birth centres and homes serviced by independent midwives in Tokyo. PARTICIPANTS of the 43 eligible independent midwives 19 (44%) (10 assisted birth at birth centres, nine assisted home birth) participated in the study. A total of 5477 women received care during their pregnancy and gave birth assisted by these midwives between 2001 and 2006. METHODS researchers conducted a retrospective chart review of women's individual data. Collected data included demographic characteristics, process of pregnancy and perinatal and neonatal outcomes. We also collected data about independent midwives and their practice. FINDINGS of the 5477 women, 83.9% gave birth at birth centres and 16.1% gave birth at home. The average age was 31.7 years old and the majority (70.6%) were multiparas. All women had vaginal spontaneous deliveries, with no vacuum, forceps or caesarean section interventions. No maternal fatalities were reported, nor were breech or multiple births. The average duration of the first and second stages of labour was 14.9 hours for primiparas and 6.2 hours for multiparas. Most women (97.1%) gave birth within 24 hours of membrane rupture. Maternal position during labour varied and family attended birth was common. The average blood loss was 371.3mL, while blood loss over 500mL was 22.6% and over 1000mL was 3.6%. Nearly 60% of women had intact perinea. There were few preterm births (0.6%) and post mature births (1.3%). Infant's average birth weight was 3126g and 0.5% were low-birthweight-infants, while 3.3% had macrosomia. Among primiparas, the birth centre group had more women experiencing an excess of 500mL blood loss compared to the home birth group (27.2% versus 17.6% respectively; RR 1.54; 95%CI 1.10 to 2.16). Multiparas delivering at birth centres were more likely to have a blood loss over 500mL (RR1.28; 95%CI 1.07 to 1.53) and over 1000mL (RR1.75; 95%CI 1.04 to 2.82) compared to women birthing at home. CONCLUSION our results for birth outcomes with independent midwives at birth centres and home births in Japan indicated a high degree of safety and evidence-based practice. This study had some limitations because of its incomplete data and low response rate. However, this is one of the few studies that reported outcomes of Japanese independent midwives and the safety of their practice. A birth registry system would provide us with more accurate and complete information of all childbirths with which to evaluate the safety of independent Japanese midwives.
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Affiliation(s)
- Yaeko Kataoka
- St. Luke's College of Nursing, 10-1 Akashi-cho Chuo-ku, Tokyo, Japan.
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11
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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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12
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Hofmeyr GJ, Novikova N. Perineal dilators for facilitating the second stage of labour. Hippokratia 2012. [DOI: 10.1002/14651858.cd010197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- G Justus Hofmeyr
- University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health; Department of Obstetrics and Gynaecology, East London Hospital Complex; Frere and Cecilia Makiwane Hospitals Private Bag X 9047 East London Eastern Cape South Africa 5200
| | - Natalia Novikova
- Walter Sisulu University; Department of Obstetrics and Gynaecology, East London Hospital Complex; Private Bag X9047 East London South Africa 5200
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East CE, Begg L, Henshall NE, Marchant PR, Wallace K. Local cooling for relieving pain from perineal trauma sustained during childbirth. Cochrane Database Syst Rev 2012:CD006304. [PMID: 22592710 DOI: 10.1002/14651858.cd006304.pub3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Perineal trauma is common during childbirth and may be painful. Contemporary maternity practice includes offering women numerous forms of pain relief, including the local application of cooling treatments. OBJECTIVES To evaluate the effectiveness and side effects of localised cooling treatments compared with no treatment, other forms of cooling treatments and non-cooling treatments. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (10 January 2012), CINAHL (1982 to 10 January 2012), the Australian New Zealand Clinical Trials Register (10 January 2012) and contacted experts in the field. SELECTION CRITERIA Published and unpublished randomised and quasi-randomised trials (RCTs) that compared localised cooling treatment applied to the perineum with no treatment or other treatments applied to relieve pain related to perineal trauma sustained during childbirth. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed trials for inclusion, assessed trial quality and extracted data. A sub-set of data were double checked for accuracy. Analyses were performed on an intention-to-treat basis where data allowed. We sought additional information from the authors of three trials. MAIN RESULTS Ten published RCTs were included (involving 1825 women). Comparisons were local cooling treatments (ice packs, cold gel pads (with or without compression) or cold/iced baths) with no treatment, gel pads with compression, hamamelis water (witch hazel), pulsed electromagnetic energy (PET), hydrocortisone/pramoxine foam (Epifoam), oral paracetamol or warm baths. Ice packs provided improved pain relief 24 to 72 hours after birth compared with no treatment (risk ratio (RR) 0.61; 95% confidence interval (CI) 0.41 to 0.91; one study, n = 208). Women preferred the utility of the gel pads compared with ice packs or no treatment (RR 0.82; 95% CI 0.73, 0.92). Differences detected in a composite of perineal oedema and bruising and overall wound healing were noted in one small study, favouring cold gel pads (n = 37) over ice (n = 35, mean difference (MD) 0.63 on a scale of 0 to 15; 95% CI 0.20 to 1.06) or no treatment (n = 39, MD -2.10; 95% CI -3.80 to -0.40) three to 14 days after giving birth. Women reported more pain (RR 5.60; 95% CI 2.35 to 13.33; one study, 100 women) and used more additional analgesia (RR 4.00; 95% CI 1.44 to 11.13; one study, 100 women) following the application of ice packs compared with PET. AUTHORS' CONCLUSIONS There is only limited evidence to support the effectiveness of local cooling treatments (ice packs, cold gel pads, cold/iced baths) applied to the perineum following childbirth to relieve pain.
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Affiliation(s)
- Christine E East
- Department ofObstetrics and Gynaecology, University ofMelbourne, Pregnancy Research Centre,Department of PerinatalMedicine,RoyalWomen’sHospital, Parkville, Australia.
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14
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Abstract
Midwifery offers concepts and techniques for intrapartum care that could be integrated into the practice of a family physician. Normal birth has virtually been replaced by a medicalized model of maternity care in the American health care system, despite research indicating that many interventions are not necessary and even harmful. A low-tech, high-touch approach to low-risk women in labor is evidence based and results in improved perinatal outcomes as well as higher patient satisfaction with the birth experience.
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Affiliation(s)
- Anita C Jaynes
- Department of Obstetrics and Gynecology, University of Nebraska Medical Center, 983255 Nebraska Medical Center, Omaha, NE 68198-3255, USA.
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15
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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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16
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Ensayo clínico controlado y aleatorizado para determinar los efectos del uso de pelotas de parto durante el trabajo de parto. ENFERMERIA CLINICA 2012; 22:35-40. [DOI: 10.1016/j.enfcli.2011.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 06/04/2011] [Accepted: 07/11/2011] [Indexed: 11/19/2022]
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17
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Jing D, Ashton-Miller JA, DeLancey JOL. A subject-specific anisotropic visco-hyperelastic finite element model of female pelvic floor stress and strain during the second stage of labor. J Biomech 2011; 45:455-60. [PMID: 22209507 DOI: 10.1016/j.jbiomech.2011.12.002] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Revised: 11/30/2011] [Accepted: 12/01/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To develop an improved model representation of the biomechanics of the levator muscles during the second stage of labor and to use a sensitivity analysis to explore the pathomechanics of levator muscle injury. METHODS A subject-specific finite element model of human pelvic floor and fetal head was developed based on in vivo MRI data of a fetal head and maternal pelvis. An anisotropic visco-hyperelastic constitutive model employed material parameters estimated from biaxial tests on pelvic floor tissues. Boundary conditions reflected both anatomic constraints and the curve of Carus. A short second stage of labor, scaled to 10 min, was then simulated using a single expulsive push made in the absence of levator co-contraction. RESULTS Large levator stresses occurred near the levator hiatus reaching 9 MPa at the pubovisceral muscle enthesis. The dominant principal stresses were located at, and aligned with, the edge of the hiatus. Muscle stretch bordering the levator hiatus was inhomogeneous: the average levator stretch was 3.55 with a high of 4.64 at the pubovisceral muscle enthesis. Decreasing perineal body stiffness by 40%, 50%, and 60% led to reductions in the maximum principal stretch ratio at the pubovisceral muscle enthesis of 8%, 13%, and 18%, respectively. CONCLUSIONS The pubovisceral muscle enthesis and the muscle near the perineal body are the regions of greatest strain thereby placing them at highest risk for stretch-related injury. Decreasing perineal body tissue stiffness significantly reduced tissue stress and strain, and therefore injury risk, in those regions.
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Affiliation(s)
- Dejun Jing
- Department of Mechanical Engineering, Biomechanics Research Laboratory, The University of Michigan, Ann Arbor, MI 48109-2125, USA
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18
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Aasheim V, Nilsen ABV, Lukasse M, Reinar LM. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 2011:CD006672. [PMID: 22161407 DOI: 10.1002/14651858.cd006672.pub2] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Most vaginal births are associated with some form of trauma to the genital tract. The morbidity associated with perineal trauma is significant, especially when it comes to third- and fourth-degree tears. Different perineal techniques and interventions are being used to prevent perineal trauma. These interventions include perineal massage, warm compresses and perineal management techniques. OBJECTIVES The objective of this review was to assess the effect of perineal techniques during the second stage of labour on the incidence of perineal trauma. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 May 2011), the Cochrane Central Register of ControlledTrials (The Cochrane Library 2011, Issue 2 of 4), MEDLINE (January 1966 to 20 May 2011) and CINAHL (January 1983 to 20 May 2011). SELECTION CRITERIA Published and unpublished randomised and quasi-randomised controlled trials evaluating any described perineal techniques during the second stage. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trails for inclusion, extracted data and evaluated methodological quality. Data were checked for accuracy. MAIN RESULTS We included eight trials involving 11,651 randomised women. There was a significant effect of warm compresses on reduction of third- and fourth-degree tears (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.28 to 0.84 (two studies, 1525 women)). There was also a significant effect towards favouring massage versus hands off to reduce third- and fourth-degree tears (RR 0.52, 95% CI 0.29 to 0.94 (two studies, 2147 women)). Hands off (or poised) versus hand on showed no effect on third- and fourth-degree tears, but we observed a significant effect of hands off on reduced rate of episiotomy (RR 0.69, 95% CI 0.50 to 0.96 (two studies, 6547 women)). AUTHORS' CONCLUSIONS The use of warm compresses on the perineum is associated with a decreased occurrence of perineal trauma. The procedure has shown to be acceptable to women and midwives. This procedure may therefore be offered to women.
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Affiliation(s)
- Vigdis Aasheim
- Department of Postgraduate Studies, Bergen University College, Møllendalsveien 6, PO Box7030, Bergen, Norway, 5020
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19
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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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20
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Lai NM, Teng CL, Lee ML. Interpreting systematic reviews: are we ready to make our own conclusions? A cross-sectional study. BMC Med 2011; 9:30. [PMID: 21450083 PMCID: PMC3100234 DOI: 10.1186/1741-7015-9-30] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Accepted: 03/30/2011] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Independent evaluation of clinical evidence is advocated in evidence-based medicine (EBM). However, authors' conclusions are often appealing for readers who look for quick messages. We assessed how well a group of Malaysian hospital practitioners and medical students derived their own conclusions from systematic reviews (SRs) and to what extent these were influenced by their prior beliefs and the direction of the study results. METHODS We conducted two cross-sectional studies: one with hospital practitioners (n = 150) attending an EBM course in June 2008 in a tertiary hospital and one with final-year medical students (n = 35) in November 2008. We showed our participants four Cochrane SR abstracts without the authors' conclusions. For each article, the participants chose a conclusion from among six options comprising different combinations of the direction of effect and the strength of the evidence. We predetermined the single option that best reflected the actual authors' conclusions and labelled this as our best conclusion. We compared the participants' choices with our predetermined best conclusions. Two chosen reviews demonstrated that the intervention was beneficial ("positive"), and two others did not ("negative"). We also asked the participants their prior beliefs about the intervention. RESULTS Overall, 60.3% correctly identified the direction of effect, and 30.1% chose the best conclusions, having identified both the direction of effect and the strength of evidence. More students (48.2%) than practitioners (22.2%) chose the best conclusions (P < 0.001). Fewer than one-half (47%) correctly identified the direction of effect against their prior beliefs. "Positive" SRs were more likely than "negative" SRs to change the participants' beliefs about the effect of the intervention (relative risk (RR) 1.8, 95% confidence interval 1.3 to 2.6) and "convert" those who were previously unsure by making them choose the appropriate direction of effect (RR 1.9, 95% confidence interval 1.3 to 2.8). CONCLUSIONS The majority of our participants could not generate appropriate conclusions from SRs independently. Judicious direction from the authors' conclusions still appears crucial to guiding our health care practitioners in identifying appropriate messages from research. Authors, editors and reviewers should ensure that the conclusions of a paper accurately reflect the results. Similar studies should be conducted in other settings where awareness and application of EBM are different.
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Affiliation(s)
- Nai Ming Lai
- Department of Paediatrics, Monash University Sunway Campus, Jeffrey Cheah School of Medicine and Health Sciences, JKR 1235, Bukit Azah, 80100, Johor Bahru, Johor, Malaysia.
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21
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Affiliation(s)
- Mary Steen
- Midwifery Department, Faculty of Health and Social Care, University of Chester
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22
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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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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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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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25
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Tsu VD, Coffey PS. New and underutilised technologies to reduce maternal mortality and morbidity: what progress have we made since Bellagio 2003? BJOG 2009; 116:247-56. [PMID: 19076957 DOI: 10.1111/j.1471-0528.2008.02046.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In 2003, maternal health experts met in Bellagio, to consider new and underutilised technologies vital to pregnancy-related health services in low-resource settings. Five years later, we examine what progress has been made and what new opportunities may be on the horizon. Based on a review of literature and consultation with experts, we consider technologies addressing the five leading causes of maternal mortality: postpartum haemorrhage, eclampsia, obstructed labour, puerperal sepsis, and unsafe abortion (pregnancy termination and miscarriage). In addition, we consider technologies related to obstetric fistula, which has received more attention in recent years.
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Affiliation(s)
- V D Tsu
- PATH, Seattle, WA 98107, USA.
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Berghella V, Baxter JK, Chauhan SP. Evidence-based labor and delivery management. Am J Obstet Gynecol 2008; 199:445-54. [PMID: 18984077 DOI: 10.1016/j.ajog.2008.06.093] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2008] [Revised: 04/21/2008] [Accepted: 06/30/2008] [Indexed: 11/16/2022]
Abstract
Our objective was to provide evidence-based guidance for management decisions during labor and delivery. We performed MEDLINE, PubMed, and COCHRANE searches with the terms labor, delivery, pregnancy, randomized trials, plus each management aspect of labor and delivery (eg, early admission). Each management step of labor and delivery was reviewed separately. Evidence-based good quality data favor hospital births, delayed admission, support by doula, training birth assistants in developing countries, and upright position in the second stage. Home-like births, enema, shaving, routine vaginal irrigation, early amniotomy, "hands-on" method, fundal pressure, and episiotomy can be associated with complications without sufficient benefits and should probably be avoided. We conclude that labor and delivery interventions supported by good quality data as just described should be routinely performed. All aspects with lower data quality should be researched with adequately powered and designed trials.
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Affiliation(s)
- Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA, USA
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Dahlen HG, Homer CSE, Cooke M, Upton AM, Nunn R, Brodrick B. Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labor: a randomized controlled trial. Birth 2007; 34:282-90. [PMID: 18021143 DOI: 10.1111/j.1523-536x.2007.00186.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Perineal warm packs are widely used during childbirth in the belief that they reduce perineal trauma and increase comfort during late second stage of labor. The aim of this study was to determine the effects of applying warm packs to the perineum on perineal trauma and maternal comfort during the late second stage of labor. METHODS A randomized controlled trial was undertaken. In the late second stage of labor, nulliparous women (n = 717) giving birth were randomly allocated to have warm packs (n = 360) applied to their perineum or to receive standard care (n = 357). Standard care was defined as any second-stage practice carried out by midwives that did not include the application of warm packs to the perineum. Analysis was on an intention-to-treat basis, and the primary outcome measures were requirement for perineal suturing and maternal comfort. RESULTS The difference in the number of women who required suturing after birth was not significant. Women in the warm pack group had significantly fewer third- and fourth-degree tears and they had significantly lower perineal pain scores when giving birth and on "day 1" and "day 2" after the birth compared with the standard care group. At 3 months, they were significantly less likely to have urinary incontinence compared with women in the standard care group. CONCLUSIONS The application of perineal warm packs in late second stage does not reduce the likelihood of nulliparous women requiring perineal suturing but significantly reduces third- and fourth-degree lacerations, pain during the birth and on days 1 and 2, and urinary incontinence. This simple, inexpensive practice should be incorporated into second stage labor care.
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Affiliation(s)
- Hannah G Dahlen
- Sydney South Western Area Health Service, Sydney, New South Wales, Australia
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East CE, Begg L, Henshall NE, Marchant P, Wallace K. Local cooling for relieving pain from perineal trauma sustained during childbirth. Cochrane Database Syst Rev 2007:CD006304. [PMID: 17943903 DOI: 10.1002/14651858.cd006304.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Perineal trauma is common during childbirth and may be painful. Contemporary maternity practice includes offering women numerous forms of pain relief, including the local application of cooling treatments. OBJECTIVES To evaluate the effectiveness and side effects of localised cooling treatments compared with no treatment, other forms of cooling treatments and non-cooling treatments. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2007), CINAHL (1982 to January 2007) and contacted experts in the field. SELECTION CRITERIA Published and unpublished randomised and quasi-randomised trials (RCTs) that compared localised cooling treatment applied to the perineum with no treatment or other treatments applied to relieve pain related to perineal trauma sustained during childbirth. DATA COLLECTION AND ANALYSIS At least two independent authors performed data extraction for each study. Analyses were performed on an intention-to-treat basis where data allowed. We sought additional information from the authors of three trials. MAIN RESULTS Seven published RCTs were included, comparing local cooling treatments (ice packs, cold gel pads or cold/iced baths) with no treatment, hamamelis water (witch hazel), pulsed electromagnetic energy (PET), hydrocortisone/pramoxine foam [Epifoam] or warm baths. The RCTs reported on a total of 859 women. Ice packs provided improved pain relief 24 to 72 hours after birth compared with no treatment (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.41 to 0.91). Women preferred the utility of the gel pads compared with ice packs or no treatment, although no differences in pain relief were detected between the treatments. None of our comparisons of treatments resulted in differences detected in perineal oedema or bruising. Women reported more pain (RR 5.60, 95% CI 2.35 to 13.33) and used more additional analgesia (RR 4.00, 95% CI 1.44 to 11.13) following the application of ice packs compared with PET. AUTHORS' CONCLUSIONS There is only limited evidence to support the effectiveness of local cooling treatments (ice packs, cold gel pads, cold/iced baths) applied to the perineum following childbirth to relieve pain.
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Affiliation(s)
- C E East
- University of Queensland, Perinatal Research Centre, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Queensland, Australia, 4029.
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Aasheim V, Nilsen ABV, Lukasse M, Reinar LM. Perineal techniques during the second stage of labour for reducing perineal trauma. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2007. [DOI: 10.1002/14651858.cd006672] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Marchisio S, Ferraccioli K, Barbieri A, Porcelli A, Panella M. Care pathways in obstetrics: the effectiveness in reducing the incidence of episiotomy in childbirth. J Nurs Manag 2006; 14:538-43. [PMID: 17004964 DOI: 10.1111/j.1365-2934.2006.00704.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM To develop a care pathway for childbirth. BACKGROUND Care pathways are emerging as an effective tool to improve clinical and organizational performance. METHODS A pre- and postimplementation analysis model was used to evaluate the effect of introducing a care pathway for childbirth. Key outcome indicators and costs were reviewed to compare the traditional care processes with those of the care pathway. The study involved 380 women. RESULTS There was a significant reduction in episiotomy rate (from 14.90% to 8.6%, P = 0.02) in patients being cared for using a care pathway approach; however, there were no differences in caesarean section and in perineal wound rates. The average costs per patient on the care pathway were euro 1278.42 ( pound 873.64) compared with euro 1,146.87 ( pound 783.74) preimplementation. The study also demon- strated an increase in patient satisfaction for women cared for using the care pathway approach. CONCLUSIONS The care pathway proved to be a valid methodological approach to childbirth, allowing healthcare workers to efficiently share the care of the women, guaranteeing safe and effective care.
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