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

Conservative management versus systematic suture of isolated vaginal or first-degree perineal tears after delivery: A preliminary randomized efficacy trial

BACKGROUND

The objective of this study was to assess the preliminary efficacy and safety of conservative management compared with systematic suture in isolated vaginal or first-degree perineal tears after birth.

METHODS

We conducted a preliminary efficacy, open-label, randomized, controlled, and prospective trial. This study implemented Simon's 2-step plan (interim analysis and final analysis) to test the success rate of the digital compression strategy group. Primiparous women aged ≥18 years with isolated vaginal or first-degree perineal tears after spontaneous vaginal birth of a cephalic presenting term (≥37 weeks) neonate were randomly allocated to the conservative management (CM) group (digital compression if bleeding followed by suture if persistent bleeding) or a systematic suture (SS) group. The primary outcome was the success of the intervention 10 days after delivery, defined by pain as evaluated using a visual analog scale < 3, satisfactory healing defined by a REEDA score ≤ 2, and no bleeding or infection. Sexual well-being was assessed at 2 and 6 months postpartum.

RESULTS

Among 861/2209 eligible women, 143 consenting women with a superficial perineal tear were randomized: 72 in the systematic suture group and 71 in the conservative management group. Success rate was 87.8% (90% CI [70.5-93.54]) (42/55) in the systematic suture group vs 90% (90% CI [78.3-93.8]) (53/61) in the conservative management group. The REEDA score was significantly higher in the systematic suture group (1.4 vs 0.9; P = 0.036). Perineal pain was significantly higher at day 1 in the systematic suture group (2.38 vs 1.69; P = 0.034). For the Female Sexual Functional Index score, no significant difference was found between the two groups at inclusion or at 2 and 6 months postpartum.

CONCLUSIONS

Conservative management of superficial perineal tears shows an efficacy rate ≥90%. Women in the conservative management group had less pain at the 1st day follow-up and lower REEDA scores at the 10th day follow-up.

The Skin Antiseptic agents at Vaginal dElivery (SAVE) trial: study protocol for a randomized controlled trial

BACKGROUND

Cleansing of the vulva and perineum is recommended during preparation for vaginal delivery, and special attention is paid to cleansing before episiotomy because episiotomy is known to increase the risk of perineal wound infection and/or dehiscence. However, the optimal method of perineal cleansing has not been established, including the choice of antiseptic agent. To address this issue, we designed a randomized controlled trial to examine whether skin preparation with chlorhexidine-alcohol is superior to povidone-iodine for the prevention of perineal wound infection after vaginal delivery.

METHODS

In this multicenter randomized controlled trial, term pregnant women who plan to deliver vaginally after episiotomy will be enrolled. The participants will be randomly assigned to use antiseptic agents for perineal cleansing (povidone-iodine or chlorhexidine-alcohol). The primary outcome is superficial or deep perineal wound infection within 30 days after vaginal delivery. The secondary outcomes are the length of hospital stay, physician office visits, or hospital readmission for infection-related complications, endometritis, skin irritations, and allergic reactions.

DISCUSSION

This study will be the first randomized controlled trial aiming to determine the optimal antiseptic agent for the prevention of perineal wound infections after vaginal delivery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05122169. First submitted date on 8 November 2021. First posted date on 16 November 2021.

Application of Honey to Reduce Perineal Laceration Pain during the Postpartum Period: A Randomized Controlled Trial

Perineal lacerations affect between 35 and 85% of women during childbirth and may be responsible for postpartum pain. Honey has been demonstrated to have interesting properties that can promote wound healing. The aim was to evaluate the effectiveness of the application of honey to the perineum to reduce perineal pain during the early postpartum period. A randomized controlled trial including 68 women was conducted. In the intervention group, honey was applied to perineal lacerations for four days, in addition to standard care. The control group received only standard care. The primary outcome was pain intensity using the Visual Analog Scale and pain perception using the McGill Pain Questionnaire (QDSA). The secondary outcomes were a burning sensation, the use of a pain killer, and the women’s satisfaction with the honey application. The intensity of pain was not significantly different between the groups on Day 1 (VAS 3.38 in the control group versus 3.34 in the intervention group, p = 0.65) or on Day 4 (VAS 2.28 versus 1.41, respectively, p = 0.09). There was no significant difference regarding the perception of pain with the QDSA. Despite this, most of the women in the intervention group (93%) were satisfied or very satisfied with the use of honey on their perineum.

A one-stop perineal clinic: our eleven-year experience

Introduction and hypothesis

The perineal clinic is a dedicated setting offering assessment for various childbirth-related presentations including obstetric anal sphincter injuries (OASIs), perineal wound complications, pelvic floor dysfunction and other conditions such as female genital mutilation(FGM). We describe the clinical presentation and outcomes of women from a tertiary perineal clinic based on data collected over an 11-year period.

Methods

This is a retrospective observational study. A one-stop outpatient service was offered to all women who sustained OASIs (postnatally and antenatally in a subsequent pregnancy), perineal complications (within 16 weeks postpartum), FGM and/or peripartum symptoms of urinary/anal incontinence or prolapse. Assessment included history with validated questionnaires, examination and anal manometry and endoanal ultrasound when appropriate. Outcomes were compared among different grades of OASIs. Management of each type of presentation was reported with outcomes.

Results

There were 3254 first attendance episodes between 2006 and 2016. The majority (58.1%) were for OASIs, followed by perineal wound complications. Compared to the lower grades, the higher grades of OASI were associated with poorer outcomes in terms of symptoms, investigations and complications. Women with OASIs had unrelated symptoms such as urinary incontinence, perineal pain and wound infections that needed further intervention. A high proportion(42%) of wound complications required further specialist management.

Conclusion

We describe a dedicated, one-stop perineal clinic model for antenatal and postnatal women for management of perineal and pelvic floor disorders. This comprehensive and novel data will enable clinicians to better counsel women regarding of outcomes after OASI and focus training to minimize risks of morbidities.

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

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

Randomized Trial of 3 Techniques of Perineal Skin Closure During Second-Degree Perineal Laceration Repair

INTRODUCTION

Perineal lacerations during childbirth are common, and suturing the perineal skin during repair has been associated with increased postpartum pain. This study sought to test the hypothesis that no difference in postpartum perineal pain exists between 3 methods of skin closure for second-degree repair: suture, no suture, and surgical glue.

METHODS

A single-blind randomized controlled trial of women after vaginal birth who had a second-degree perineal laceration was conducted at a tertiary care teaching hospital from August 2014 to April 2017. Women were randomized to perineal skin closure with suture, no suture, or surgical glue using a 1:1:1 allocation. Pain was assessed using the short-form McGill Pain Questionnaire, a 100-mm visual analog scale (VAS), and Present Pain Index (PPI) at one day, 2 weeks, 6 weeks, and 3 months postpartum. Wound healing was assessed at 6 weeks using the Redness, Edema, Ecchymosis, Drainage, Approximation (REEDA) scale. Pain scores were compared across groups using a chi-square test, Mann-Whitney U test, or analysis of variance where appropriate.

RESULTS

A total of 35 women were randomized: 14 received suture, 11 had no suture, and 10 received surgical glue for perineal skin repair. Demographic characteristics were similar between groups. At 2 weeks postpartum, women with suture had higher median pain scores on the short-form McGill Pain Questionnaire (15.0 suture vs 2.0 glue vs 2.0 no suture, P = .03) and VAS (50.0 suture vs 3.0 glue vs 7.0 no suture, P = .02). Significant differences in pain were not seen on the PPI. At 3 months, women in the suture group had higher median pain scores on the short-form McGill Pain Questionnaire compared with surgical glue (1.0 vs 0, P = .04). Wound healing was similar across groups (REEDA score: 0 suture vs 1.0 no suture, vs 0 surgical glue, P = .24).

DISCUSSION

Compared with no suture and surgical glue, suturing the perineal skin was associated with the highest postpartum pain scores.

Investigating the Efficacy of Anatomical Silicone Models Developed from a 3D Printed Mold for Perineal Repair Suturing Simulation

There is a scarcity of affordable, validated, standardized and anatomically correct silicone perineum models for the rehearsal of postpartum laceration repair. The purpose of this technical report is to describe and validate evidence for a silicone, perineal repair model created from a 3D printed mold for medical resident training and clinical skills maintenance. A pre-existing model from an open-source royalty-free website was purchased and converted using Fusion360TM (Autodesk Inc., San Rafael, CA, USA) into a stereolithography (.stl) file and altered to produce a negative mold. Using a spatula, a fine silicone layer was first applied inside the mold, followed by a small piece of flesh-colored mesh netting material within the perineal surface area, fitting the width of the mold. The mesh was pressed into the thin layer of silicone, which was meant to provide anatomical structure to prevent the sutures from tearing through the silicone. The remainder of the silicone mix was then poured into the mold, which required three hours to fully set before being removed from the mold. Twelve silicone models were produced and used during a one-hour workshop at the Rural and Remote Conference by 16 obstetrics and gynecology residents and practicing rural physicians, and four facilitators. At the end of the workshop, the participants were provided with a qualitative survey and asked to rate the perceived realism and educational effectiveness of the silicone perineum model as compared to pre-existing simulation models that they have used previously. The overall workshop participant feedback was positive, noting that the models provided more realistic visualization for the suturing simulation of first- and second-degree perineal injuries. The silicone models were considered to be useful in simulation training when attempting first- and second-degreeperineum suturing techniques within a confined space. The overall feedback was positive, noting that they provided more realistic visualization experience compared to pre-existing simulation models, such as beef tongues and synthetic sponges. The feedback from the participants and facilitators included thoughts about how to add additional mesh to the silicone model so the subcutaneous and vaginal plane sutures would hold, as well as increase the size of the vaginal canal size to more accurately represent a postpartum repair. There were also suggestions to alter the colour of the model to be flesh-toned as opposed to pink, to more accurately simulate human tissue. Silicone perineum models, created from a 3D printed mold, are an economical training tool as compared to commercially available, cost prohibitive models. They also provide anatomically accurate simulation training opportunities for residents to learn and maintain clinical skills in perineal repair, as compared to beef tongues and synthetic sponges, which have previously been used in obstetrics and gynecology simulation-based medical education.

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.

Implementation of care practices to prevent and repair perineal trauma in childbirth

Objective

To implement care practices for perineal trauma prevention and repairing in normal birth.

Method

Quasi-experimental study conducted at Hospital da Mulher Mãe-Luzia, in Macapá, AP, Brazil. Seventy-four (74) nurses and obstetricians and 70 post-partum women were interviewed and the records of 555 patients were analyzed. The study was conducted in three stages: pre-audit and baseline audit (phase 1); educational intervention and implementation of best practices (phase 2); post-implementation audit (phase 3). Data was analyzed by comparison of the results of phases 1 and 3.

Results

Following the educational intervention, a lower number of health professionals encouraged directed pushing, performed episiotomies and repaired first-degree lacerations; more women reported lithotomy position; more patient records indicated the use of Vicryl™ to suture the perineal mucosa and skin.

Conclusion

The educational intervention improved birth care and perineal outcomes. Nevertheless, gaps were identified in the implementation of evidence, as well as inappropriate perineal care management.

Single-knot versus multiple-knot technique of perineal repair: a randomised controlled trial

PURPOSE

An important factor influencing the outcome of perineal repair is the repair technique. This study was done to determine if there is a difference in post perineal repair pain scores following the use of the standard multiple-knot technique (MKT) of perineal repair and a single-knot technique (SKT).

METHODS

We randomised 260 women who sustained a second-degree perineal tear at the University of Benin Teaching Hospital, Benin City, Nigeria and had perineal repair using either a SKT or a MKT between 1 July 2014 and 28 February 2015. Primary outcome measure was pain assessed with a numerical rating scale (0 = no pain, 10 = worst imaginable pain) on day two, day 10 and at 3 months. Secondary outcome measures were pain scores during basic activities of daily living, analgesia use, dyspareunia and patient satisfaction.

RESULTS

Mean pain scores were significantly lower in the SKT group on day two (2.8 versus 5.6; P < 0.001) and day 10 (1.8 versus 3.3; P < 0.001). Significantly fewer women in the SKT group reported pain on day two (90/126, 71.4 % versus 122/128, 95.3 %; Relative Risk [RR] 0.6, 95 % Confidence Interval [CI] 0.6-0.8; P < 0.001), and day 10 (69/126, 54.8 % versus 107/128, 83.6 %; RR 0.7, 95 % CI 0.5-0.7; P < 0.001)]. Women in the SKT group were more likely to be satisfied with outcome of repair at three months (RR 1.4, 95 % CI 1.2-1.5; P < 0.001). No difference in pain scores and dyspareunia at 3 months.

CONCLUSIONS

SKT of perineal repair is associated with significantly less pain in the first 10 days postdelivery and a higher patient satisfaction rate at 3 months.

Incidence of and risk factors for perineal trauma: a prospective observational study

BACKGROUND

Our aim was to describe the range of perineal trauma in women with a singleton vaginal birth and estimate the effect of maternal and obstetric characteristics on the incidence of perineal tears.

METHODS

We conducted a prospective observational study on all women with a planned singleton vaginal delivery between May and September 2006 in one obstetric unit, three freestanding midwifery-led units and home settings in South East England. Data on maternal and obstetric characteristics were collected prospectively and analysed using univariable and multivariable logistic regression. The outcome measures were incidence of perineal trauma, type of perineal trauma and whether it was sutured or not.

RESULTS

The proportion of women with an intact perineum at delivery was 9.6% (125/1,302) in nulliparae, and 31.2% (453/1,452) in multiparae, with a higher incidence in the community (freestanding midwifery-led units and home settings). Multivariable analysis showed multiparity (OR 0.52; 95% CI: 0.30-0.90) was associated with reduced odds of obstetric anal sphincter injuries (OASIS), whilst forceps (OR 4.43; 95% CI: 2.02-9.71), longer duration of second stage of labour (OR 1.49; 95% CI: 1.13-1.98), and heavier birthweight (OR 1.001; 95% CI: 1.001-1.001), were associated with increased odds. Adjusted ORs for spontaneous perineal truama were: multiparity (OR 0.42; 95% CI: 0.32-0.56); hospital delivery (OR 1.48; 95% CI: 1.01-2.17); forceps delivery (OR 2.61; 95% CI: 1.22-5.56); longer duration of second stage labour (OR 1.45; 95% CI: 1.28-1.63); and heavier birthweight (OR 1.001; 95% CI: 1.000-1.001).

CONCLUSIONS

This large prospective study found no evidence for an association between many factors related to midwifery practice such as use of a birthing pool, digital perineal stretching in the second stage, hands off delivery technique, or maternal birth position with incidence of OASIS or spontaneous perineal trauma. We also found a low overall incidence of OASIS, and fewer second degree tears were sutured in the community than in the hospital settings. This study confirms previous findings of overall high incidence of perineal trauma following vaginal delivery, and a strong association between forceps delivery and perineal trauma.