Antenatal perineal massage for reducing perineal trauma

Effects of perineal massage at different stages on perineal and postpartum pelvic floor function in primiparous women: a systematic review and meta-analysis

BACKGROUND

Perineal massage, as a preventive intervention, has been shown to reduce the risk of perineal injuries and may have a positive impact on pelvic floor function in the early postpartum period. However, there is still debate concerning the best period to apply perineal massage, which is either antenatal or in the second stage of labor, as well as its safety and effectiveness. Meta-analysis was used to evaluate the effect of implementing perineal massage in antenatal versus the second stage of labor on the prevention of perineal injuries during labor and early postpartum pelvic floor function in primiparous women.

METHODS

We searched nine different electronic databases from inception to April 16, 2024. The randomized controlled trials (RCTs) we included assessed the effects of antenatal and second-stage labor perineal massage in primiparous women. All data were analyzed with Revman 5.3, Stata Statistical Software, and Risk of Bias 2 was used to assess the risk of bias. Subgroup analyses were performed based on the different periods of perineal massage. The primary outcomes were the incidence of perineal integrity and perineal injury. Secondary outcomes were perineal pain, duration of the second stage of labor, postpartum hemorrhage, urinary incontinence, fecal incontinence, and flatus incontinence.

RESULTS

This review comprised a total of 10 studies that covered 1057 primigravid women. The results of the analysis showed that perineal massage during the second stage of labor reduced the perineal pain of primigravid women in the immediate postpartum period compared to the antenatal period, with a statistical value of (MD = -2.29, 95% CI [-2.53, -2.05], P < 0.001). Additionally, only the antenatal stage reported that perineal massage reduced fecal incontinence (P = 0.04) and flatus incontinence (P = 0.01) in primiparous women at three months postpartum, but had no significant effect on urinary incontinence in primiparous women at three months postpartum (P = 0.80).

CONCLUSIONS

Reducing perineal injuries in primiparous women can be achieved by providing perineal massage both antenatally and during the second stage of labor. Pelvic floor function is improved in the postnatal phase by perineal massage during the antenatal stage.

TRIAL REGISTRATION

CRD42023415996 (PROSPERO).

Pregnancy, parturition and postpartum considerations among patients with vulvar lichen sclerosus: A retrospective cross-sectional online survey

OBJECTIVE

Characterise VLS and obstetric considerations among women during pregnancy, parturition and postpartum.

DESIGN

Retrospective cross-sectional online survey, 2022.

SETTING

International, English-speakers.

POPULATION

Self-identified individuals aged 18-50 diagnosed with VLS with symptom onset prior to pregnancy.

METHODS

Participants recruited from social media support groups and accounts, completed a 47-question survey including yes/no, multiple answer, and free-text responses. Data were analysed with frequency, means and the Chi-square test.

MAIN OUTCOME MEASURES

VLS symptom severity, mode of delivery, perineal laceration, source and sufficiency of information provided about VLS and obstetrics, anxiety about delivery, and postpartum depression.

RESULTS

Of 204 responses, 134 met inclusion criteria, encompassing 206 pregnancies. Mean respondent age was 35 years (SD 6) and mean age of VLS symptom onset, diagnosis and birth, was 22 (SD 8), 29 (SD 7) and 31 (SD 4) years, respectively. Symptoms decreased in 44% (n = 91) of pregnancies and increased during the postpartum period in 60% (n = 123). In all, 67% (n = 137) of pregnancies resulted in vaginal birth and 33% (n = 69) in caesarean birth. Anxiety for delivery due to VLS symptoms was reported by 50% (n = 103); 31% (n = 63) experienced postpartum depression. Of respondents previously diagnosed with VLS, 60% (n = 69) used topical steroids prior to pregnancy, 40% (n = 45) were treated during pregnancy and 65% (n = 75) postpartum. In all, 94% (n = 116) reported receiving an insufficient amount of information on the topic.

CONCLUSION

In this online survey, we found reported symptom severity remained unchanged or decreased during pregnancy, but increased postpartum. Use of topical corticosteroids decreased during pregnancy compared with before and after pregnancy. Half of the respondents reported anxiety regarding VLS and delivery.

Antenatal, Intrapartum and Postpartum Interventions for Preventing Postpartum Urinary and Faecal Incontinence: An Umbrella Overview of Cochrane Systematic Reviews

Post-partum, women can suffer from urinary and faecal incontinence. It is important to assess interventions to prevent this problem. Cochrane systematic reviews summarize the data available from systematic reviews of randomized trials assessing interventions. We conducted an umbrella overview of Cochrane systematic reviews encompassing antenatal, intrapartum and postpartum interventions for preventing postpartum urinary and faecal incontinence. We searched the Cochrane Database of Systematic Reviews on the 9 May 2023. Results: Our search identified nine Cochrane reviews providing results. Data for urinary and faecal incontinence were available from 77 (72%) trials and included 51,113 women. The reviews assessed antenatal digital perineal massage, pelvic floor muscle training, techniques for repairing anal sphincter tears, routine use of episiotomy, use of endoanal ultrasound prior to repairing perineal tears, caesarean versus vaginal delivery (overall, for breech and for twins), and vaginal delivery with forceps or vacuum. Only the use of a vacuum instead of forceps if an assisted vaginal delivery is needed, the use of an endo-anal ultrasound prior to repairing perineal tears and postpartum pelvic floor muscle training suggest a reduction in postpartum incontinence. Due to the small number of relevant reviews, a consequence of the relatively small number of primary studies, the effect of almost all the tested interventions was found to be imprecise.

Effect of Prenatal Perineal Massage on Postpartum Perineal Injury and Postpartum Complications: A Meta-Analysis

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.

Vocalization during the second stage of labor to prevent perineal trauma: A randomized controlled trial

BACKGROUND AND PURPOSE

Most women suffer some degree of perineal trauma during vaginal delivery. Second stage management strategies, including vocalization, to protect the perineum have been investigated.

OBJECTIVE

To compare the frequency and degree of perineal trauma at vaginal delivery, with and without use of the vocalization maneuver during the second stage of labor.

MATERIALS AND METHODS

This is an open-label, randomized controlled trial. We conducted the study at the Center for Normal Deliveries of IMIP. We included low-risk women without prior cesarean deliveries. Women who met the inclusion criteria and signed the informed consent form were randomized to one of two groups: Group A (experimental) and Group B (control). A physical therapist encouraged women in Group A to maintain an open glottis during pushing and to emit sounds when exhaling (vocalization). Women in Group B underwent routine humanized vaginal deliveries. The outcomes of the study were perineal integrity and degree of perineal laceration. These were measured by the study team immediately after completion of the third stage of labor.

RESULTS

Women in Group A tended to have less severe perineal tear (less second and third degree lacerations) and smaller lacerations than women in group B. The vocalization maneuver reduced the risk of a perineal tear greater than 2 cm by 68% (NNT 2.2). There was no difference in other outcomes.

CONCLUSION

Encouraging women to follow a vocalization protocol coached by a physical therapist during the second stage of labor can be a helpful labor assistance technique, since this study showed that vocalization is associated with less extensive perineal tears.

CLINICAL TRIAL REGISTRATION

This study was registered on ClinicalTrials.gov (www.

CLINICALTRIAL

gov) registration number: NCT03605615.

Prevalence of Perineal Tear Peripartum after Two Antepartum Perineal Massage Techniques: A Non-Randomised Controlled Trial

Perineal massage increases elasticity of myofascial perineal tissue and decreases the burning and perineal pain during labour, thus optimising child birth, although an application protocol has not been standardised yet. The objective of this study is to determine the efficiency of massage in perineal tear prevention and identification of possible differences in massage application. Total of 90 pregnant participants were divided into three groups: perineal massage and EPI-NO^® device group, applied by an expert physiotherapist, self-massage group, where women were instructed to apply perineal massage in domestic household, and a control group, which received ordinary obstetric attention. Results: The results showed significant differences among the control group and the two perineal massage groups in perineal postpartum pain. Correlations in perineal postpartum pain, labour duration and the baby's weight were not statistically significant. Lithotomy posture was significantly less prevalent in the massage group than in the other two; this variable is known to have a direct effect on episiotomy incidence and could act as a causal covariate of the different incidence of episiotomy in the groups. Perineal massage reduces postpartum perineal pain, prevalence and severity of perineal tear during delivery.

A Simulation Analysis of Maternal Pelvic Floor Muscle

Pelvic floor disorder (PFD) is a common disease affecting the quality of life of middle-aged and elderly women. Pelvic floor muscle (PFM) damage is related to delivery mode, fetal size, and parity. Spontaneous vaginal delivery causes especially great damage to PFM. The purpose of this study was to summarize the characteristics of PFM action during the second stage of labor by collecting female pelvic MRI (magnetic resonance imaging) data and, further, to try to investigate the potential pathogenetic mechanism of PFD. A three-dimensional model was established to study the influence factors and characteristics of PFM strength. In the second stage of labor, the mechanical responses, possible damage, and the key parts of postpartum lesions of PFM due to the different fetal biparietal diameter (BPD) sizes were analyzed by finite element simulations. The research results showed that the peak stress and strain of PFM appeared at one-half of the delivery period and at the attachment point of the pubococcygeus to the skeleton. In addition, during the simulation process, the pubococcygeus was stretched by about 1.2 times and the levator ani muscle was stretched by more than two-fold. There was also greater stress and strain in the middle area of the levator ani muscle and pubococcygeus. According to the statistics, either being too young or in old maternal age will increase the probability of postpartum PFM injury. During delivery, the entire PFM underwent the huge deformation, in which the levator ani muscle and the pubococcygeus were seriously stretched and the attachment point between the pubococcygeus and the skeleton were the places with the highest probability of postpartum lesions.

Obstetric anal sphincter injuries: strategies for prevention, diagnosis, and management

Obstetric anal sphincter injuries (OASIS) are one of the most common causes of anal incontinence (AI) in women of reproductive age and can have a significant impact on quality of life. However, many women do not report symptoms to their physicians because of embarrassment and shame. Therefore, prevention and diagnosis of the tear is essential. Diagnostic strategies have evolved considerably in recent years, with an increase in prevalence of OASIS as a consequence. The use of 3D endoanal (3D-EAUS) and 4D transperineal ultrasound (4D-TPUS), in addition to standard clinical examination have enhanced the detection of OASIS. Once identified, adequate repair by a skilled practitioner and optimal postpartum management should be ensured in order to reduce the risk of anal incontinence. This review presents the available evidence on strategies for prevention, diagnosis, and management of OASIS.

Feasibility and safety of antepartum tactile imaging

Introduction and hypothesis

Quantitative characterization of the birth canal and critical structures before delivery may provide risk assessment for maternal birth injury. The objective of this study was to explore imaging capability of an antepartum tactile imaging (ATI) probe.

Methods

Twenty randomly selected women older than 21 years with completed 35th week of pregnancy and a premise of vaginal delivery were enrolled in the feasibility study. The biomechanical data were acquired using the ATI probe with a double-curved surface, shaped according to the fetal skull and equipped with 168 tactile sensors and an electromagnetic motion tracking sensor. Software package COMSOL Multiphysics was used for finite element modeling. Subjects were asked for assessment of pain and comfort levels experienced during the ATI examination.

Results

All 20 nulliparous women were successfully examined with the ATI. Mean age was 27.8 ± 4.1 years, BMI 30.7 ± 5.8, and week of pregnancy 38.8 ± 1.4. Biomechanical mapping with the ATI allowed real-time observation of the probe location, applied load to the vaginal walls, and a 3D tactile image composition. The nonlinear finite element model describing the stress–strain relationship of the pelvic tissue was developed and used for calculation of Young’s modulus (E). Average perineal elastic modulus was 11.1 ± 4.3 kPa, levator ani 4.8 ± 2.4 kPa, and symphysis–perineum distance was 30.1 ± 6.9 mm. The pain assessment level for the ATI examination was 2.1 ± 0.8 (scale 1–4); the comfort level was 2.05 ± 0.69 (scale 1–3).

Conclusions

The antepartum examination with the ATI probe allowed measurement of the tissue elasticity and anatomical distances. The pain level was low and the comfort level was comparable with manual palpation.

Aspirin (single dose) for perineal pain in the early postpartum period

BACKGROUND

Perineal trauma, due to spontaneous tears, surgical incision (episiotomy), or in association with operative vaginal birth, is common after vaginal birth, and is often associated with postpartum perineal pain. Birth over an intact perineum may also lead to perineal pain. There are adverse health consequences associated with perineal pain for the women and their babies in the short- and long-term, and the pain may interfere with newborn care and the establishment of breastfeeding. Aspirin has been used in the management of postpartum perineal pain, and its effectiveness and safety should be assessed. This is an update of the review, last published in 2017.

OBJECTIVES

To determine the effects of a single dose of aspirin (acetylsalicylic acid), including at different doses, in the relief of acute postpartum perineal pain.

SEARCH METHODS

For this update, we searched the Cochrane Pregnancy and Childbirth's Trials Register (4 October 2019), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (4 October 2019) and screened reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs), assessing single dose aspirin compared with placebo, no treatment, a different dose of aspirin, or single dose paracetamol or acetaminophen, for women with perineal pain in the early postpartum period. We planned to include cluster-RCTs, but none were identified. We excluded quasi-RCTs and cross-over studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of the included RCTs. Data were checked for accuracy. The certainty of the evidence for the main comparison (aspirin versus placebo) was assessed using the GRADE approach.

MAIN RESULTS

We included 17 RCTs, 16 of which randomised 1132 women to aspirin or placebo; one RCT did not report numbers of women. Two RCTs (of 16) did not contribute data to meta-analyses. All women had perineal pain post-episiotomy, and were not breastfeeding. Studies were published between 1967 and 1997, and the risk of bias was often unclear, due to poor reporting. We included four comparisons: aspirin versus placebo (15 RCTs); 300 mg versus 600 mg aspirin (1 RCT); 600 mg versus 1200 mg aspirin (2 RCTs); and 300 mg versus 1200 mg aspirin (1 RCT). Aspirin versus placebo Aspirin may result in more women reporting adequate pain relief four to eight hours after administration compared with placebo (risk ratio (RR) 2.03, 95% confidence interval (CI) 1.69 to 2.42; 13 RCTs, 1001 women; low-certainty evidence). It is uncertain whether aspirin compared with placebo has an effect on the need for additional pain relief (RR 0.25, 95% CI 0.17 to 0.37; 10 RCTs, 744 women; very low-certainty evidence), or maternal adverse effects (RR 1.08, 95% CI 0.57 to 2.06; 14 RCTs, 1067 women; very low-certainty evidence), four to eight hours after administration. Analyses based on dose did not reveal any clear subgroup differences. 300 mg versus 600 mg aspirin It is uncertain whether over four hours after administration, 300 mg compared with 600 mg aspirin has an effect on adequate pain relief (RR 0.82, 95% CI 0.36 to 1.86; 1 RCT, 81 women) or the need for additional pain relief (RR 0.68, 95% CI 0.12 to 3.88; 1 RCT, 81 women). There were no maternal adverse effects in either aspirin group. 600 mg versus 1200 mg aspirin It is uncertain whether over four to eight hours after administration, 600 mg compared with 1200 mg aspirin has an effect on adequate pain relief (RR 0.85, 95% CI 0.52 to 1.39; 2 RCTs, 121 women), the need for additional pain relief (RR 1.32, 95% CI 0.30 to 5.68; 2 RCTs, 121 women), or maternal adverse effects (RR 3.00, 95% CI 0.13 to 69.52; 2 RCTs, 121 women). 300 mg versus 1200 mg aspirin It is uncertain whether over four hours after administration, 300 mg compared with 1200 mg aspirin has an effect on adequate pain relief (RR 0.62, 95% CI 0.29 to 1.32; 1 RCT, 80 women) or need for additional pain relief (RR 2.00, 95% CI 0.19 to 21.18; 1 RCT, 80 women). There were no maternal adverse effects in either aspirin group. None of the included RCTs reported on neonatal adverse effects. No RCTs reported on secondary review outcomes of: prolonged hospitalisation due to perineal pain; re-hospitalisation due to perineal pain; fully breastfeeding at discharge; mixed feeding at discharge; fully breastfeeding at six weeks; mixed feeding at six weeks; perineal pain at six weeks; maternal views; or maternal postpartum depression.

AUTHORS' CONCLUSIONS

Single dose aspirin may increase adequate pain relief in women with perineal pain post-episiotomy compared with placebo. It is uncertain whether aspirin has an effect on the need for additional analgesia, or on maternal adverse effects, compared with placebo. We downgraded the certainty of the evidence because of study limitations (risk of bias), imprecision, and publication bias. Aspirin may be considered for use in non-breastfeeding women with post-episiotomy perineal pain. Included RCTs excluded breastfeeding women, so there was no evidence to assess the effects of aspirin on neonatal adverse effects or breastfeeding. Future RCTs should be designed to ensure low risk of bias, and address gaps in the evidence, such as the secondary outcomes established for this review. Current research has focused on women with post-episiotomy pain; future RCTs could be extended to include women with perineal pain associated with spontaneous tears or operative birth.

Factors Influencing Quality of Life during the First Trimester of Pregnancy: A Prospective Cohort Study

Introduction: Pregnancy, delivery and postpartum periods are associated with fast changes leading to decreased self-confidence, anxiety, stress or even maternal depression impairing their quality of life (QOL). Although considered important, QOL of women during pregnancy is poorly understood. The aim of our study was to assess factors influencing QOL during first trimester of pregnancy. The secondary goal of our study was to evaluate whether QOL during first trimester of pregnancy is associated with newborn weight. Materials and methods: A prospective cohort study was performed including pregnant women during the first trimester visit. Our questionnaire consisted of the SF-36 QOL questionnaire, Wexner fecal incontinence scale, and other additional information. The SF-36 questionnaire mental (MCS) and physical (PCS) health scores were used in order to evaluate QOL of women during first trimester of pregnancy. Two multiple logistic regression models were created in order to determine independent variables that influence the QOL. Results: 440 pregnant women were included in the study. The two main domains that were used in the study were MCS and PCS, their medians were 50.0 (25.0; 50.0) and 50.1 (39.4; 59.0) points respectively. From the two logistic regression models we determined several independent factors that influence QOL of women during the first trimester of pregnancy. Additionally, we determined that women who reported worse QOL tended to give birth to newborns large for their gestational age. Conclusions: We found several significant variables that influence QOL of women during the first trimester of pregnancy. We also found that that lower MCS and PCS scores during the first trimester are associated with newborns large for gestational age.

Perineal massage and training reduce perineal trauma in pregnant women older than 35 years: a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

The aim of this study was to evaluate the effectiveness of perineal massage, pelvic floor muscle training (PFMT) and a pelvic floor dysfunction (PFD) prevention educational program in pregnant women above the age of 35 years to prevent perineal tear and episiotomy.

METHODS

A randomized parallel assignment study involved two groups of pregnant women at the obstetrics outpatient clinic 4 weeks prior to their due date. The first group (n = 200) was educated to do digital perineal massage and pelvic floor muscle training and received an educational PFD prevention program. The second group (n = 200) received only the prevention education program. Occurrence of perineal laceration was reported at time of delivery as a primary outcome. Statistical analysis was done using the IBM SPSS computer program (Statistical Package for the Social Sciences; IBM Corp, Armonk, NY, USA), release 22 for Microsoft Windows.

RESULTS

Delivery was significantly less complicated by perineal tear, episiotomy and postnatal pain in the first than in the second group (p < 0.05). Grades of perineal tear were mostly of first and second degree in the first group compared with the second group. We found a significantly lower need for analgesia and fewer ampoules required during the hospital stay in the first group (p < 0.001, 0.002, respectively).

CONCLUSIONS

Performing antenatal digital perineal massage and PFMT in addition to health education is recommended to reduce perineal complications.

Birth of Lasya: Emphasizing the Need for Support in Home Births

This article explores the support structures required for home births. Written by a first-time mother who is a physician, it details her journey toward having a home birth and how these support structures shaped her confidence in having a natural birth. She also elaborates on her preparations during pregnancy, her labor, and the insights she gained during this process.

Pharmacological and Non-Pharmacological Methods of Labour Pain Relief-Establishment of Effectiveness and Comparison

Background: To evaluate the effectiveness of pharmacological and non-pharmacological pain relief methods and to compare them. Materials and methods: 258 women were included in the study and interviewed using a questionnaire and the visual analogue scale for pain. They were divided into six groups depending on chosen method of labour pain relief: epidural anaesthesia (EA; n = 42), water immersion and water birth (WB; n = 40), nitrous oxide gas for pain control (G; n = 40), transcutaneous electrical nerve stimulation (TENS) (n = 50), multiple management (MM; n = 42), none (N; n = 44). Results: The average age of the women was 29.4 ± 3.74 years and 60.47% of them were nulliparous (n = 156). Mean values of labour pain intensity were 6.81 ± 2.26 during the first stage of labour; 7.86 ± 2.06 during the second stage, and 3.22 ± 2.46 during the third stage. There was no significant difference in pain level between epidural analgesia and gas groups in the first stage of labour (p = 0.74). Nevertheless, epidural analgesia reduced pain level during the second and third stage (both p < 0.01). The highest satisfaction level pertains to water immersion (n = 38; 95%). Conclusion: Epidural analgesia is the gold standard of labour pain relief, however water birth was found to be associated with the highest satisfaction level of the parturient women. The contentment of childbirth depends not only on the level of experienced pain, but also on the care provided to the parturient during pregnancy and labour.

[Methods of preventing perineal injury and dysfunction during pregnancy: CNGOF Perineal prevention and protection in obstetrics]

OBJECTIVE

Several interventions during pregnancy have been described that might prevent the risk of postnatal perineal injury or dysfunction; these include prenatal perineal massage, use of the Epi-No device, and pelvic floor muscle training exercises. Our objective was to evaluate the effectiveness of these different interventions during pregnancy.

METHODS

A systematic review of the literature was conducted on PubMed, including articles in French and English published before May 2018, to evaluate the effectiveness of these different interventions on perineal protection in the post-partum period.

RESULTS

Perineal massage during pregnancy diminishes the episiotomy rate (LE1) as well as post-partum perineal pain and flatus (LE2). It does not reduce the rate of either OASIS (LE1) or post-partum urinary incontinence (LE2). The Epi-No device does not provide benefits for perineal protection (LE1). Prenatal pelvic floor muscle training exercises do not reduce the risk of perineal lacerations (LE2); they reduce the prevalence of post-partum urinary incontinence at 3 to 6 months but not at 12 months post-partum (LE2).

CONCLUSION

Perineal massage during pregnancy must be encouraged among women who want it (Grade B). The use of the Epi-No device during pregnancy is not recommended for the prevention of OASIS (grade B). Pelvic floor muscle training during pregnancy is not recommended for the prevention of OASIS (grade B); moreover, its absence of effect in the medium term does not allow us to recommend it for urinary incontinence (professional consensus).

Effects of perineal preparation techniques on tissue extensibility and muscle strength: a pilot study

INTRODUCTION AND HYPOTHESIS

Perineal preparation techniques for childbirth have been used with the aim of reducing perineal tears during the expulsive phase of labor. However, no studies were found to investigate the effects of instrument-assisted stretching versus perineal massage on pelvic floor muscle (PFM) variables. Therefore, the aim of this study was to evaluate the effect of instrument-assisted stretching versus perineal massage on the extensibility and strength of the PFMs.

METHODS

Primiparous women were randomized to the instrument-assisted stretching (IStr) group (n = 13) and perineal massage (PnM) group (n = 14). The groups participated in eight sessions, twice weekly, beginning at the 34th gestational week. The IStr group underwent the intervention for 15 min using EPI-NO®. The PnM group underwent a perineal massage protocol for 10 min. Each woman was evaluated by a blinded physiotherapist before, after four and after eight sessions for primary (PFM extensibility using the EPI-NO® circumference) and secondary (PFM strength using a manometer) outcomes. Covariate analysis (ANCOVA) was used to compare the groups using the baseline values as a covariate.

RESULTS

Both groups showed an increase in PFM extensibility compared with the evaluations before and after four and eight sessions (PnM group from 17.6 ± 1.8 to 20.2 ± 1.9 cm; IStr group from 19.9 ± 1.6 to 22.9 ± 1.6 cm;p < 0.001). There was no difference between groups. Regarding muscle strength, no statistical differences were observed between evaluations or between groups.

CONCLUSIONS

Instrument-assisted stretching and perineal massage increase extensibility and do not alter the strength of PFMs in pregnant women.

Prospective evaluation of the safety and feasibility of a pelvic floor dilator during active labor

INTRODUCTION AND HYPOTHESIS

The objective was to assess the safety and feasibility of using a pelvic floor dilator during active labor to prevent injuries to the levator ani muscle (LAM) and perineum.

METHODS

In a prospective pilot study, a pelvic floor dilator using soft pads was introduced into the vaginal canal to gradually expand the vagina, in 30 nulliparous women and in 10 controls. The primary outcomes were adverse events related to the device. Secondary outcomes were perineal lacerations after delivery, sonographically defined levator ani injury, hiatal area dimensions, and anal sphincter disruption, all at 12-20 weeks postpartum, and maximum pelvic floor dilation, time to achieve maximum dilation, and device retention rate.

RESULTS

From October 2014 through November 2016, a total of 494 women were screened, and 61 consented to the study. Thirty women used the device and 27 returned for follow-up. No maternal or neonatal injuries were related to use of the dilator. The average maximum dilation of the vaginal canal was 7.4 cm (SD 0.7, range 5.5-8.0). Dilation time averaged 27 min (SD 13, range 5-60). Device insertion adjustment was needed in 13 out of 30 cases (43%). Similar rates of 3th-4th degree perineal lacerations were seen in both groups. Levator ani avulsion was diagnosed in 2 out of 27 (7%) in the device group and in 1 out of 9 (11%) in the control group (p = 0.2). The rate of partial injury in the device group was 2 out of 27 (7%) vs 2 out of 9 (22%) in the comparison group (p = 0.2).

CONCLUSION

The use of the pelvic floor dilator during active labor is feasible. No safety issues were identified.

Antenatal maternal education for improving postnatal perineal healing for women who have birthed in a hospital setting

BACKGROUND

The female perineum becomes suffused and stretched during pregnancy, and further strain during vaginal childbirth contributes to approximately 85% of women experiencing some degree of trauma to the perineal region. Multiple factors play a role in the type and severity of trauma experienced, including parity, delivery method, and local practices. There is ongoing debate about best midwifery practice to reduce perineal trauma. Once perineal trauma has occurred, treatment also varies greatly, depending on its degree and severity, local practice and customs, and personal preference. In order to optimise wound-healing outcomes, it is important that wounds are assessed and managed in an appropriate and timely manner. A perineal wound may cause significant physical and/or psychological impact in the short or long term, however little evidence is available on this subject.Antenatal education serves to prepare women and their partners for pregnancy, delivery and the postpartum period. The delivery of this education varies widely in type, content, and nature. This review examined antenatal education which is specifically tailored towards perineal care and wound healing in the postnatal period via formal channels. Appropriate patient education positively impacts on wound-healing rates and compliance with wound care. Risk factors that contribute to the breakdown of wounds and poor healing rates may be addressed antenatally in order to optimise postnatal wound healing. It is important to assess whether or not antenatal wound-care education positively affects perineal healing, in order to empower women to incorporate best practice, evidence-based treatment with this important aspect of self-care in the immediate postnatal period.

OBJECTIVES

To evaluate the effects of antenatal education on perineal wound healing in postnatal women who have birthed in a hospital setting, and who have experienced a break in the skin of the perineum as a result of a tear or episiotomy, or both.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2017), ClinicalTrials.gov (8th September 2017), the WHO International Clinical Trials Registry Platform (ICTRP) (8th September 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) which referred to all formal methods of antenatal education and addressed care of a potential perineal wound as a result of a tear or episiotomy, which was experienced by pregnant women who planned to give birth within a hospital setting.Trials using a cluster-RCT and a quasi-randomised design would have been eligible for inclusion in this review but none were identified. Cross-over trials were not eligible for inclusion in this review. Studies published in abstract form would have been eligible for inclusion in this review, but none were identified.We planned to consider all formal methods of antenatal education which addressed care of a perineal wound. We also planned to consider all contact points where there was an opportunity for formal education, including midwifery appointments, antenatal education classes, obstetrician appointments, general practitioner appointments and physiotherapist appointments.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed titles and abstracts of the studies identified by the search strategy for their eligibility.

MAIN RESULTS

No studies met the inclusion criteria for this review. We excluded one study and one other study is ongoing.

AUTHORS' CONCLUSIONS

We set out to evaluate the RCT evidence pertaining to the impact of antenatal education on perineal wound healing in postnatal women who have birthed in a hospital setting, and who experienced a break in the skin of the perineum as a result of a tear or episiotomy, or both. However, no studies met the inclusion criteria. There is a lack of evidence concerning whether or not antenatal education relating to perineal wound healing in this cohort of women will change the outcome for these women in relation to wound healing, infection rate, re-attendance or re-admission to hospital, pain, health-related quality of life, maternal bonding, and negative emotional experiences. Further study is warranted in this area given the significant physical, psychological and economic impact of perineal wounds, and the large proportion of childbearing women who have experienced a postnatal wound. The benefits of any future research in this field would be maximised by incorporating women in a range of socio-economic groups, and with a range of healthcare options. This research could take both a qualitative and a quantitative approach and examine the outcomes identified in this review in order to assess fully the potential benefits of a tailored antenatal package, and to make recommendations for future practice. There is currently no evidence to inform practice in this regard.

Feasibility of a Smartphone website to support antenatal Perineal massage in pregnant women

Background

In Japan, 85% of pregnant women do not practice antenatal perineal massage. Therefore, we developed a smartphone website to support the practice of antenatal perineal massage. The purpose of the present study was to evaluate the feasibility of our smartphone website.

Methods

Pregnant women were recruited at five hospitals or clinics in Tokyo, Japan. Participants assigned to the smartphone website group (n = 74) were asked to register on the smartphone website. After completing registration, they could login and use all the contents of the website. After giving birth, participants completed a 5-item questionnaire evaluating the acceptability of the smartphone website. Participants assigned to the leaflet group (n = 71) received a leaflet on antenatal perineal massage and completed a similar 4-item questionnaire evaluating the leaflet. Data were collected from April 2014 to November 2014. Data analysis was performed using chi-square and t-tests to analyze responses to close-ended questions, and content analysis was conducted to analyze responses of open-ended questions.

Results

In the smartphone website group, 9 women (12.2%) did not register on the smartphone website. Approximately 80% of the women who responded indicated that the smartphone site was easy to understand and useful for practicing antenatal perineal massage. In the smartphone website group, the reply rate for reporting the frequency of massage was 43.6%. Although the ratings and frequency at which the material was accessed tended to be higher in the smartphone website group than in the leaflet group, there were no significant differences.

Conclusions

Most pregnant women in the smartphone website group provided a favorable evaluation for the smartphone website. However, some participants had suggestions for improvement, which need to be incorporated in a revised version of the website. Therefore, the present study’s results demonstrate the feasibility of a smartphone website to support the practice of antenatal perineal massage, and they may aid in the development of similar web-based educational material for pregnant women.

Trial registration

This trial was registered with the UMIN Clinical Trials Registry (UMIN000013979) on May 16, 2014.

Active delivery of the anterior arm and incidence of second-degree perineal tears: a clinical practice evaluation

BACKGROUND

Evaluate the feasibility of active delivery of the anterior arm during spontaneous delivery. This maneuver could decrease incidence of second-degree perineal tears because it reduces fetal biacromial diameter.

METHODS

An observational comparative prospective study was conducted at our teaching maternity from July 2012 to March 2013. The study included 199 nulliparous women ≥18 years, who met the following criteria: singleton pregnancy, vaginal delivery with occiput anterior presentation, on epidural analgesia, from 37 weeks of gestation onward. The distribution of rate and type of perineal tears were compared between two groups: a non-exposed group and a group exposed to the maneuver.

RESULTS

A total of 101 patients were exposed to Couder's maneuver (CM) and 98 patients were not exposed. In the intervention group, 3 failures of the maneuver were reported. The maneuver was considered easy in 80% of cases, moderately easy in 12% and difficult in 8% of cases. There was a significant difference (p = 0.03) in the distribution of perineal tears between the two groups. There was a significant reduction (p < 0.001) in the number of second-degree perineal tears in the patients exposed to CM. There was no significant difference in the rate of anterior perineal trauma between the exposed and non-exposed arms.

CONCLUSIONS

CM in primiparous women at term is feasible with a low failure rate and influences the distribution of perineal tears by lowering second-degree perineal tears in a highly significant manner (p <0.01).

Does meperidine analgesia affect the incidence of obstetric lacerations at vaginal delivery?

PURPOSE

To study whether meperidine analgesia affects the incidence of obstetric lacerations at normal vaginal deliveries.

MATERIALS AND METHODS

A retrospective cohort study of all women with term vertex singleton pregnancies, who underwent normal vaginal deliveries, in a single tertiary hospital, between 2011 and 2015, was performed. The incidence of various obstetric lacerations was compared between deliveries with meperidine analgesia and deliveries with no analgesia. Deliveries with epidural analgesia and instrumental deliveries were excluded. An intravenous infusion of 75 mg of meperidine was administered together with 25 mg of promethazine. A multivariate logistic regression analysis was performed to assess the association between meperidine analgesia and obstetric lacerations, after controlling for confounders.

RESULTS

Overall, 5227 (91.8%) deliveries with no analgesia and 466 (8.1%) deliveries with meperidine analgesia were included. Meperidine analgesia was associated with a decreased risk of first- and second-degree perineal lacerations (adjusted OR = 0.63, 95% CI = 0.49-0.81), and a decreased risk of any suturing (adjusted OR = 0.73, 95% CI = 0.59-0.91), after controlling for confounders. Meperidine analgesia did not affect the risk of severe perineal lacerations or episiotomies.

CONCLUSION

Meperidine analgesia may have a protective effect against first- and second-degree perineal lacerations.

Aspirin (single dose) for perineal pain in the early postpartum period

BACKGROUND

Perineal trauma (due to spontaneous tears, surgical incision (episiotomy) or in association with operative vaginal birth) is common after vaginal birth, and is often associated with postpartum perineal pain. Birth over an intact perineum may also lead to perineal pain. There are adverse health consequences associated with perineal pain for the women and their babies in the short- and long-term, and the pain may interfere with newborn care and the establishment of breastfeeding. Aspirin has been used in the management of postpartum perineal pain and its effectiveness and safety should be assessed.

OBJECTIVES

To determine the efficacy of a single dose of aspirin (acetylsalicylic acid), including at different doses, in the relief of acute postpartum perineal pain.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (30 August 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (31 May 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) assessing single dose aspirin compared with placebo, no treatment, a different dose of aspirin, or single dose paracetamol/acetaminophen for women with perineal pain in the early postpartum period. We planned to include cluster-RCTs but none were identified. Quasi-RCTs and cross-over studies were not eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of the included RCTs. Data were checked for accuracy. The quality of the evidence for the main comparison (aspirin versus placebo) was assessed using the GRADE approach.

MAIN RESULTS

We included 17 RCTs, with 16 involving 1132 women randomised to aspirin or placebo (one RCT did not report numbers of women). Two RCTs (of 16) did not contribute data to review meta-analyses. All women had perineal pain post-episiotomy, and were not breastfeeding. Studies were published between 1967 and 1997, and the risk of bias was often unclear due to poor reporting.We included four comparisons: aspirin versus placebo (data from 15 RCTs); 300 mg versus 600 mg aspirin (1 RCT); 600 mg versus 1200 mg aspirin (2 RCTs); and 300 mg versus 1200 mg aspirin (1 RCT). Primary outcomes Aspirin versus placeboMore women who received aspirin experienced adequate pain relief compared with women who received placebo over four to eight hours after administration (risk ratio (RR) 2.03, 95% confidence intervals (CI) 1.69 to 2.42; 13 RCTs, 1001 women; low-quality evidence). Women who received aspirin were less likely to need additional pain relief over four to eight hours after administration (RR 0.25, 95% CI 0.17 to 0.37; 10 RCTs, 744 women; very low-quality evidence). There was no difference in maternal adverse effects over four to eight hours post-administration (RR 1.08, 95% CI 0.57 to 2.06; 14 RCTs, 1067 women; very low-quality evidence). Subgroup analyses based on dose did not reveal any clear subgroup differences.There was no clear difference over four hours after administration between 300 mg and 600 mg aspirin for adequate pain relief (RR 0.82, 95% CI 0.36 to 1.86; 1 RCT, 81 women) or need for additional pain relief (RR 0.68, 95% CI 0.12 to 3.88; 1 RCT, 81 women). There were no maternal adverse effects in either aspirin group.There was no clear difference over four to eight hours after administration between 600 mg and 1200 mg aspirin for adequate pain relief (RR 0.85, 95% CI 0.52 to 1.39; 2 RCTs, 121 women), need for additional pain relief (RR 1.32, 95% CI 0.30 to 5.68; 2 RCTs, 121 women), or maternal adverse effects (RR 3.00, 95% CI 0.13 to 69.52; 2 RCTs, 121 women).There was no clear difference over four hours after administration between 300 mg and 1200 mg aspirin for adequate pain relief (RR 0.62, 95% CI 0.29 to 1.32; 1 RCT, 80 women) or need for additional pain relief (RR 2.00, 95% CI 0.19 to 21.18; 1 RCT, 80 women). There were no maternal adverse effects in either aspirin group.None of the included RCTs reported on neonatal adverse effects. Secondary outcomesNo studies reported on secondary review outcomes: prolonged hospitalisation due to perineal pain; re-hospitalisation due to perineal pain; fully breastfeeding at discharge; mixed feeding at discharge; fully breastfeeding at six weeks; mixed feeding at six weeks; perineal pain at six weeks; maternal views; maternal postpartum depression.

AUTHORS' CONCLUSIONS

We found low-quality evidence to suggest that single dose aspirin compared with placebo can increase pain relief in women with perineal pain post-episiotomy. Very low-quality evidence also suggested that aspirin can reduce the need for additional analgesia, without increasing maternal adverse effects. Evidence was downgraded based on study limitations (risk of bias), imprecision, and publication bias or both. RCTs excluded breastfeeding women so there is no evidence to assess the effects of aspirin on neonatal adverse effects or breastfeeding.With international guidance recommending mothers initiate breastfeeding within one hour of birth, and exclusively breastfeed for the first six months, the evidence from this review is not applicable to current recommended best practice. Aspirin may be considered for use in non-breastfeeding women with post-episiotomy perineal pain. Although formal assessment was beyond the remit of this review, current guidance suggests that other analgesic drugs (including paracetamol) should be considered first for postpartum perineal pain. Such agents are the focus of other reviews in this series on drugs for perineal pain in the early postpartum period. It is considered most likely that if RCTs are conducted in the future they could compare aspirin with other pain relievers. Future RCTs should be designed to ensure high methodological quality, and address gaps in the evidence, such as the secondary outcomes established for this review. Current research has focused on women with post-episiotomy pain, future RCTs could be extended to women with perineal pain associated with spontaneous tears or operative birth.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction

INTRODUCTION AND HYPOTHESIS

There has been an increasing need for the terminology on the conservative management of female pelvic floor dysfunction to be collated in a clinically based consensus report.

METHODS

This Report combines the input of members and elected nominees of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by many external referees. An extensive process of nine rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Before opening up for comments on the webpages of ICS and IUGA, five experts from physiotherapy, neurology, urology, urogynecology, and nursing were invited to comment on the paper.

RESULTS

A Terminology Report on the conservative management of female pelvic floor dysfunction, encompassing over 200 separate definitions, has been developed. It is clinically based, with the most common symptoms, signs, assessments, diagnoses, and treatments defined. Clarity and ease of use have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Ongoing review is not only anticipated, but will be required to keep the document updated and as widely acceptable as possible.

CONCLUSION

A consensus-based terminology report for the conservative management of female pelvic floor dysfunction has been produced, aimed at being a significant aid to clinical practice and a stimulus for research.

The Effect of Perineal Lacerations on Pelvic Floor Function and Anatomy at 6 Months Postpartum in a Prospective Cohort of Nulliparous Women

OBJECTIVE

To determine the effect of perineal lacerations on pelvic floor outcomes, including urinary and anal incontinence, sexual function, and perineal pain in a nulliparous cohort with low incidence of episiotomy.

METHODS

Nulliparous women were prospectively recruited from a midwifery practice. Pelvic floor symptoms were assessed with validated questionnaires, physical examination, and objective measures in pregnancy and 6 months postpartum. Two trauma groups were compared, those with an intact perineum or only 1st degree lacerations and those with second-, third-, or fourth-degree lacerations.

RESULTS

Four hundred and forty-eight women had vaginal deliveries. One hundred and fifty-one sustained second-degree or deeper perineal trauma and 297 had an intact perineum or minor trauma. Three hundred and thirty-six (74.8%) presented for 6-month follow-up. Perineal trauma was not associated with urinary or fecal incontinence, decreased sexual activity, perineal pain, or pelvic organ prolapse. Women with trauma had similar rates of sexual activity; however, they had slightly lower sexual function scores (27.3 vs 29.1). Objective measures of pelvic floor strength, rectal tone, urinary incontinence, and perineal anatomy were equivalent. The subgroup of women with deeper (> 2 centimeter) perineal trauma demonstrated increased likelihood of perineal pain (15.5% vs 6.2%) and weaker pelvic floor muscle strength (61.0% vs 44.3%) compared with women with more superficial trauma.

CONCLUSION

Women having second-degree lacerations are not at increased risk for pelvic floor dysfunction other than increased pain, and slightly lower sexual function scores at 6 months postpartum.

A Geometric Capacity-Demand Analysis of Maternal Levator Muscle Stretch Required for Vaginal Delivery

Because levator ani (LA) muscle injuries occur in approximately 13% of all vaginal births, insights are needed to better prevent them. In Part I of this paper, we conducted an analysis of the bony and soft tissue factors contributing to the geometric "capacity" of the maternal pelvis and pelvic floor to deliver a fetal head without incurring stretch injury of the maternal soft tissue. In Part II, we quantified the range in demand, represented by the variation in fetal head size and shape, placed on the maternal pelvic floor. In Part III, we analyzed the capacity-to-demand geometric ratio, g, in order to determine whether a mother can deliver a head of given size without stretch injury. The results of a Part I sensitivity analysis showed that initial soft tissue loop length (SL) had the greatest effect on maternal capacity, followed by the length of the soft tissue loop above the inferior pubic rami at ultimate crowning, then subpubic arch angle (SPAA) and head size, and finally the levator origin separation distance. We found the more caudal origin of the puborectal portion of the levator muscle helps to protect it from the stretch injuries commonly observed in the pubovisceral portion. Part II fetal head molding index (MI) and fetal head size revealed fetal head circumference values ranging from 253 to 351 mm, which would increase up to 11 mm upon face presentation. The Part III capacity-demand analysis of g revealed that, based on geometry alone, the 10th percentile maternal capacity predicted injury for all head sizes, the 25th percentile maternal capacity could deliver half of all head sizes, while the 50th percentile maternal capacity could deliver a head of any size without injury. If ultrasound imaging could be operationalized to make measurements of ratio g, it might be used to usefully inform women on their level of risk for levator injury during vaginal birth.

Prevention of pelvic floor disorders: international urogynecological association research and development committee opinion

INTRODUCTION AND HYPOTHESIS

Pelvic floor disorders (PFD), including urinary incontinence, anal incontinence, and pelvic organ prolapse, are common and have a negative effect on the quality of life of women. Treatment is associated with morbidity and may not be totally satisfactory. Prevention of PFDs, when possible, should be a primary goal. The purpose of this paper is to summarise the current literature and give an evidence-based review of the prevention of PFDs METHODS: A working subcommittee from the International Urogynecological Association (IUGA) Research and Development (R&D) Committee was formed. An initial document addressing the prevention of PFDs was drafted, based on a review of the English-language literature. After evaluation by the entire IUGA R&D Committee, revisions were made. The final document represents the IUGA R&D Committee Opinion on the prevention of PFDs.

RESULTS

This R&D Committee Opinion reviews the literature on the prevention of PFDs and summarises the findings with evidence-based recommendations.

CONCLUSIONS

Pelvic floor disorders have a long latency, and may go through periods of remission, thus making causality difficult to confirm. Nevertheless, prevention strategies targeting modifiable risk factors should be incorporated into clinical practice before the absence of symptomatology.

A cross-sectional survey of policies guiding second stage labor in urban Japanese hospitals, clinics and midwifery birth centers

Background

The Japan Academy of Midwifery developed and disseminated the ‘2012 Evidence-based Guidelines for Midwifery Care (Guidelines for Midwives)’ for low-risk births to achieve a more uniform standard of care during childbirth in Japan. The objective of this study was to cross-sectional survey policy implementation regarding care during the second stage of labor at Japanese hospitals, clinics, and midwifery birth centers, and to compare those policies with the recommendations in Guidelines for Midwives.

Methods

This study was conducted in the four major urbanized areas (e.g. Tokyo) of the Kanto region of Japan. Respondents were chiefs of the institutions (obstetricians/midwives), nurse administrators (including midwives) of the obstetrical departments, or other nurse/midwives who were well versed in the routine care of the targeted institutions. The Guidelines implementation questionnaire comprised 12 items. Data was collected from October 2010 to July 2011.

Results

The overall response was 255 of the 684 institutions (37 %). Of the total responses 46 % were hospitals, 26 % were clinics and 28 % were midwifery birth centers. Few institutions reported perineal massage education for ‘almost all cases’. Using ‘active birth’ were all midwifery birth centers, 56 % hospitals and 32 % clinics. Few institutions used water births. The majority of hospitals (73 %) and clinics (80 %) but a minority (39 %) of midwifery birth centers reported ‘not implemented’ about applying warm compress to the perineum. Few midwifery birth centers (10 %) and more hospitals (38 %) and clinics (50 %) had a policy for valsalva as routine care. Many hospitals (90 %) and clinics (88 %) and fewer midwifery birth centers (54 %) offered hands-on technique to provide perineal support during birth. A majority of institutions used antiseptic solution for perineal disinfection. Few institutions routinely used episiotomies for multiparas, however routine use for primiparas was slightly more in hospitals (21 %) and clinics (25 %). All respondents used fundal pressure as consistent with guidelines. Not many institutions implemented the hands and knees position for correcting fetal abnormal rotation.

Conclusions

This survey has provided new information about the policies instituted in three types of institutions guiding second stage labor in four metropolitan areas of Japan. There existed considerable differences among institutions’ practice. There were also many gaps between reported policies and evidence-based Guidelines for Midwives, therefore new strategies are needed in Japan to realign institution’s care policies with evidenced based guidelines.

Obstetric anal sphincter injuries: review of anatomical factors and modifiable second stage interventions

INTRODUCTION AND HYPOTHESIS

Obstetric anal sphincter injuries (OASIs) are the leading cause of anal incontinence in women. Modification of various risk factors and anatomical considerations have been reported to reduce the rate of OASI.

METHODS

A PubMed search (1989-2014) of studies and systematic reviews on risk factors for OASI.

RESULTS

Perineal distension (stretching) of 170 % in the transverse direction and 40 % in the vertical direction occurs at crowning, leading to significant differences (15-30°) between episiotomy incision angles and suture angles. Episiotomies incised at 60° achieve suture angles of 43-50°; those incised at 40° result in a suture angle of 22°. Episiotomies with suture angles too acute (<30°) and too lateral (>60°) are associated with an increased risk of OASI. Suture angles of 40-60° are in the safe zone. Clinicians are poor at correctly estimating episiotomy angles on paper and in patients. Sutured episiotomies originating 10 mm away from the midline are associated with a lower rate of OASIs. Compared to spontaneous tears, episiotomies appear to be associated with a reduction in OASI risk by 40-50 %, whereas shorter perineal lengths, perineal oedema and instrumental deliveries are associated with a higher risk. Instrumental deliveries with mediolateral episiotomies are associated with a significantly lower OASI risk. Other preventative measures include warm perineal compresses and controlled delivery of the head.

CONCLUSIONS

Relieving pressure on the central posterior perineum by an episiotomy and/or controlled delivery of the head should be important considerations in reducing the risk of OASI. Episiotomies should be performed 60° from the midline. Prospective studies should evaluate elective episiotomies in women with a short perineal length and application of standardised digital perineal support.

Antibiotic prophylaxis for third- and fourth-degree perineal tear during vaginal birth

BACKGROUND

One to eight per cent of women suffer third-degree perineal tear (anal sphincter injury) and fourth-degree perineal tear (rectal mucosa injury) during vaginal birth, and these tears are more common after forceps delivery (28%) and midline episiotomies. Third- and fourth-degree tears can become contaminated with bacteria from the rectum and this significantly increases in the chance of perineal wound infection. Prophylactic antibiotics might have a role in preventing this infection.

OBJECTIVES

To assess the effectiveness of antibiotic prophylaxis for reducing maternal morbidity and side effects in third- and fourth-degree perineal tear during vaginal birth.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014) and the reference lists of retrieved articles.

SELECTION CRITERIA

Randomised controlled trials comparing outcomes of prophylactic antibiotics versus placebo or no antibiotics in third- and fourth-degree perineal tear during vaginal birth.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the trial reports for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We identified and included one trial (147 women from a pre-planned sample size of 310 women) that compared the effect of prophylactic antibiotic (single-dose, second-generation cephalosporin - cefotetan or cefoxitin, 1 g intravenously) on postpartum perineal wound complications in third- or fourth-degree perineal tears compared with placebo. Perineal wound complications (wound disruption and purulent discharge) at the two-week postpartum check up were 8.20% and 24.10% in the treatment and the control groups respectively (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.12 to 0.96). However, the high failed-appointment rate may limit the generalisability of the results. The overall risk of bias was low except for incomplete outcome data. The quality of the evidence using GRADE was moderate for infection rate at two weeks' postpartum, and low for infection rate at six weeks' postpartum.

AUTHORS' CONCLUSIONS

Although the data suggest that prophylactic antibiotics help to prevent perineal wound complications following third- or fourth-degree perineal tear, loss to follow-up was very high. The results should be interpreted with caution as they are based on one small trial.

Hyaluronidase for reducing perineal trauma

BACKGROUND

Perineal hyaluronidase (HAase) injection was widely used to reduce the occurrence of perineal trauma, pain and need for episiotomy in the 1950s to 1960s. Reports suggested that the administration of HAase was a simple, low risk, low cost and effective way to decrease perineal trauma without adverse effects.

OBJECTIVES

The objective of this review was to assess the effectiveness and safety of perineal HAase injection for reducing spontaneous perineal trauma, episiotomy and perineal pain in vaginal deliveries.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2013), the International Clinical Trials Registry Platform (ICTRP) and the Networked Digital Library of Theses and Dissertations (both on 1 April 2013), and reference lists of retrieved studies. We also contacted relevant organisations.

SELECTION CRITERIA

Published and unpublished randomised and quasi-randomised controlled trials comparing perineal HAase injection with placebo injection or no intervention in vaginal deliveries.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. Data were checked for accuracy.

MAIN RESULTS

The search strategy identified six potentially eligible studies. Two studies were excluded. We included four randomised controlled trials that randomised a total of 599 women (data were available for 595 women).Two trials (283 women) compared the effects of perineal HAase injection during the second stage of labour with placebo injection and were at low risk of bias. Three trials (one three-armed trial was analysed twice) (373 women) compared the effects of perineal HAase injection during second stage of labour with no intervention and two out of the three trials were at high risk of bias. Data from four trials involving 599 women suggested that perineal HAase injection during second stage of labour had a lower incidence of perineal trauma (average risk ratio (RR) 0.69, 95% confidence interval (CI) 0.50 to 0.95,Tau² = 0.08, I² = 82% compared with women in the control group, but there was no clear evidence of a reduction in the incidence of episiotomy (average RR 0.74, 95% CI 0.43 to 1.29, Tau² = 0.17, I² = 66%), first and second degree perineal lacerations (average RR 0.54, 95% CI 0.38 to 1.33, Tau² = 0.30 , I² = 85%) and third and fourth degree perineal lacerations (RR 0.12, 95% CI 0.01 to 2.13). Data from two trials involving 283 women indicated that there was no clear evidence of a reduction in the incidence of perineal trauma (RR 0.90, 95% CI 0.77 to 1.06, Tau²=1.07, I² = 7%), episiotomy (RR 0.77, 95% CI 0.32 to 1.89, Tau² = 0.27, I² = 54%), first and second degree perineal lacerations (RR 1.08, 95% CI 0.83 to 1.40, Tau² = 1.11, I² = 10%) and third and fourth degree perineal lacerations (RR 0.12, 95% CI 0.01 to 2.13) with perineal HAase injection. Data from three trials involving 373 women suggested that perineal HAase injection during second stage of labour had a lower incidence of perineal trauma (RR 0.61, 95% CI 0.42 to 0.88, Tau² = 0.08, I² = 78%) compared with no intervention, but had no clear effect on in the incidence of episiotomy (RR 0.79, 95% CI 0.44 to 1.42, Tau² = 0.16, I² = 70%) and first and second degree perineal lacerations (RR 0.58, 95% CI 0.31 to 1.10, Tau² = 0.18, I² = 59%). No side effects were reported in the included trials.No included trials reported on perineal pain and other pre-specified secondary outcomes: perineal trauma requiring suturing; blood loss; dyspareunia; urinary incontinence; faecal incontinence; assisted delivery rate; women's satisfaction; Apgar score less than seven at five minutes and need for admission to special care baby unit.

AUTHORS' CONCLUSIONS

Perineal HAase injection during second stage of labour had a lower incidence of perineal trauma compared with control or no intervention, but there was no clear evidence of benefit compared with placebo injection. The difference in incidence of perineal trauma may probably be due to bias and confounding in the non-placebo controlled comparison, this result should be interpreted cautiously. The potential use of perineal HAase injection as a method to reduce perineal trauma were yet to be determined as there was no appropriate established dose for HAase, no evidence of follow up, and the number of high-quality trials and outcomes reported were too limited to draw conclusions on its effectiveness and safety. Further rigorous randomised controlled trials are required to evaluate the role of perineal HAase injection in vaginal deliveries.