Psychological consequences of pelvic floor trauma following vaginal birth: a qualitative study from two Australian tertiary maternity units

Could a simple manual technique performed by a midwife reduce the incidence of episiotomy and perineal lacerations? A non-randomized pilot study

INTRODUCTION

Women experience medical interventions, episiotomy, and perineal lacerations during childbirth, impacting their physical, psychological, and sexual well-being. This study compares the perineal status of prospective women who had the midwifery intervention of perineal myofascial release during childbirth, to a matched retrospective control sample of women who received standard care during childbirth.

METHODS

A non-randomized pilot study with prospective data collected for 50 women after informed verbal consent was obtained to having the midwifery intervention of perineal myofascial release during childbirth, and the matched retrospective data for the control group of 49 women were collected from a random sample generated from the medical records. Quantitative analyses included descriptive statistics, independent t-tests, regression, and chi-squared analyses. Retrospective trial registration was granted with The Australian New Zealand Clinical Trials Registry ANZTR.

RESULTS

Women were six times (OR=0.15; 95% CI: 0.0-0.37) less likely to have a non-intact perineum and twice (OR=0.44; 95% CI: 0.35-0.56) less likely to have an episiotomy if they were in the intervention group. Chi-squared analysis found no statistically significant differences between groups for normal vaginal birth and instrumental births, excluding cesareans and waterbirth [χ2(1)= -0.37, p=0.542].

CONCLUSIONS

This study found perineal myofascial release benefits women by reducing perineal trauma and episiotomy. However, there were no significant differences in the duration of the active pushing stage of labor or mode of birth. This study has shown some promise in obtaining data for a larger, definitive, randomized controlled trial.

CLINICAL TRIAL REGISTRATION

The study was registered on the Australian New Zealand Clinical Trials Registry ANZTR.

IDENTIFIER

ID ACTRN12623000807651.

Measuring the psychological burden of women with pelvic floor complaints: The psychometric characteristics of a new instrument

Background

To be able to optimize pelvic healthcare, it would be helpful to specifically assess women's psychological burden with pelvic floor complaints. In the absence of such an instrument, a new instrument was developed to measure this burden in women who seek help. In previous research, a comprehensive overview was yielded of women's restrictions and distress with pelvic floor complaints, and a conceptual model was developed of seven types of distress that were reflected by 33 statements. The present study was performed to investigate the psychometric properties of the new instrument, termed the Pelvic Floor Complaint-related Psychological Burden Inventory (PFC-PBI).

Methods

In an online survey data was collected from women with and without pelvic floor complaints on the 33 statements. The internal consistency of the types of distress was tested using item-total correlation analysis, Principal Component and Confirmatory Factor Analyses were performed, and the convergent and divergent validity of the types of distress was examined against existing questionnaires using the Multi-Trait Multi-Method methodology.

Results

Based on the factor analyses, a 10-item instrument was tested. Outcomes show excellent internal consistency of this instrument, comprising a single component. The PFC-PBI demonstrated satisfactory convergent and divergent validity.

Conclusions

This new measure appears to be a promising tool to inventory the psychological burden of women suffering from pelvic floor complaints. Research into its further development, implementation, and clinical use appears warranted.

Associations of pelvic floor dysfunction and postnatal mental health: a systematic review

BACKGROUND

Postpartum mental health conditions are common and can have devastating effects for both mother and infant. Adverse birth outcomes increase the risk of postnatal mental health conditions. Pelvic floor dysfunction (PFD) is a common adverse pregnancy outcome that may be a risk factor for postnatal mental health conditions. There are many studies reporting associations between PFD and postnatal mental health conditions, but no reports have synthesised the current literature as it relates to pregnancy and the postpartum period.

METHODS

A research librarian conducted systematic literature searches using terms concerning PFD, postnatal mental health conditions, and pregnancy. Searches were conducted within PubMed, Embase, CINAHL, Cochrane, and Scopus. Two reviewers independently rated each study for inclusion and study quality. No studies were excluded based on quality.

RESULTS

A total of 47 studies were included for review. Articles addressed sexual dysfunction (n = 11), incontinence (n = 21), perineal laceration (n = 13), pelvic organ prolapse (n = 2), and general pelvic floor symptoms (n = 2) and associations with postnatal mental health conditions. Two articles addressed more than one type of PFD. The majority (44 studies) reported associations between PFD and adverse postnatal mental health conditions.

DISCUSSION

Most studies included for review found consistent associations between PFD and adverse mental health conditions. Healthcare providers should screen for PFD and postnatal mental health conditions early in the postpartum period. Future research should investigate whether the treatment of PFD can modify the associations between PFD and postnatal mental health conditions.

Psychometric evaluation and cross-cultural adaptation of the Australian Pelvic Floor Questionnaire (APFQ-IR) in Iranian reproductive age women

Pelvic floor disorders (PFDs), as a silent alert, is one of the pervasive debilitating health concerns among women all over the world, such that in developed countries, one in four women, suffers from PFDs. Validity and reliability of the Australian Pelvic Floor Questionnaire (APFQ) has not been determined in Iran, so to determine APFQ's psychometric characteristics, we decided to conduct this study on women of reproductive age in Tabriz city, Iran. This methodological cross-sectional study was intended to determine the psychometric properties of the Persian version of the APFQ-IR in 5 steps including "translation process, content validity, face validity, construct validity (exploratory and confirmatory factor analyses and examination of ceiling and floor effects) and reliability" on 400 reproductive age women referring to health centers in Tabriz city, Iran, with cluster random sampling method in the period between May 2022 to September 2022. The translation process was done based on two approaches, Dual panel, and Beaton et al.'s five steps. Then, in order to evaluate content validity, face validity, and construct validity, 10 instrument and PFDs experts, 10 women from the target group investigated the instrument's items, and 400 eligible women completed the instrument. Finally, to determine the reliability, two internal consistency methods, (Cronbach's alpha and McDonald's omega) and test-retest method (ICC) were used. In the present study, content validity assessment of APFQ-IR, showed a good level of validity (CVR = 0.96, CVI = 0.94). To assess construct validity, exploratory factor analysis results on 36 items, led to the identification of 4 factors including bladder function, bowel function, prolapse symptom and sexual function, which explained 45.53% of the cumulative variance and indicated the sufficiency of the sample size (Kaiser-Meyer-Olkin = 0.750). Implementing confirmatory factor analysis, (RMSEA = 0.08, SRMR = 0.08, TLI = 0.90, CFI = 0.93, χ2/df = 3.52) confirmed the model fit indices. Finally the internal consistency and reliability was high for the entire instrument (Cronbach's alpha = 0.85; McDonald's omega (95% CI) = 0.85 (0.83-0.87) and Intraclass Correlation Coefficient (95% CI) = 0.88 (0.74-0.94)). The Persian version of the APFQ-IR, has a good validity and reliability and has acceptable psychometric properties, thus can be used both for research purposes and for clinical evaluation of pelvic floor disorders symptoms in health centers.

Korean women's perceptions of traumatic childbirth: a qualitative descriptive study

BACKGROUND

Previous studies have established that negative or traumatic childbirth can create childbirth-related post-traumatic stress disorder (CB-PTSD). Because of the negative implications of CB-PTSD for mothers, children, and families, global qualitative research on traumatic or negative childbirth has risen in recent years. However, few studies have been conducted in South Korea. This study aims to explore women's various perceptions of traumatic childbirth in South Korea.

METHODS

This qualitative descriptive study examined nine women who were at high risk of PTSD (IES-R-K > 24) at the time of the interview, between 1 and 11 years after childbirth. Semi-structured interviews were conducted. Interview transcripts were subjected to thematic analysis.

RESULTS

The analysis identified two themes with six subthemes, as follows: (1) person-centred factors (pain, guilt, maternal identity conflict, and damaged femininity); (2) society-centred factors (threatened dignity and disrupted relationships). These findings may be attributed to Korean culture (excessive motherhood and lookism), as well as unbearable pain, disrespectful childbirth environments, lack of spouse's support, loss of their lifestyle, and unrealistic expectations.

CONCLUSIONS

This study demonstrates various negative consequences, ranging from psychological damage to conflict in women's relationships with their spouses, and others. This highlights the various perceptions stemming from traumatic childbirth and emphasizes the significance of clinical intervention. Therefore, healthcare professionals' greater understanding of women's perceptions and increased concern about childbirth and respectful childbirth environments are required. In addition, based on our findings, there is a need to develop interventions that can alleviate CB-PTSD and further improve women's mental health, particularly through women-centred interventions.

Restrictions and distress in daily, social, and sexual functioning, and intimate relationships in women with pelvic floor complaints: A mixed-method study

Women with pelvic floor complaints experience restrictions and distress in their daily, social, and sexual functioning, and their intimate relationships. We interviewed forty-eight women to unravel differences between women receiving and not receiving pelvic physical therapy and between pregnant, parous, and nulliparous women in preparation for theory development. We analyzed data in a mixed-method design using NVivo and Leximancer. Sexual dysfunction, relationship dynamics, the nature and severity of restrictions and distress, and coping strategies appear to vary between women receiving and not receiving therapy. Specific combinations of restrictions and distress are present in pregnant, parous, and nulliparous women, and might influence women's decision to seek help.

Bearing the burden of spill-over effects: Living with a woman affected by symptomatic pelvic organ prolapse after vaginal birth - from a partner's perspective

INTRODUCTION

Symptomatic pelvic organ prolapse (sPOP) can have a negative impact on a woman's health. While research exists about the impact of sPOP on women, little is known about the effect on their partners. Therefore, this study aimed to explore, from the partner's perspective, what it means to live with a woman with symptomatic pelvic organ prolapse after vaginal birth.

METHODS

A qualitative explorative design with a constructed grounded theory approach was taken to analyse the interviews of 13 partners who experienced living with a woman who had sPOP after vaginal birth.

RESULTS

"The theory of bearing the burden of spill-over effects" was constructed based on a core category: "Facing a new restricted life", with related categories "Giving up valued activities"; "Struggling with added demands"; "Changing intimate behaviour" and "Redefining future family planning". The theory also contains factors constraining and enabling adjustment to the new reality. While the shortcomings of healthcare constrained the process of adjustment, getting competent treatment and the feeling of love for the family enabled it.

CONCLUSION

This study demonstrated that women's sPOP had an apparently negative impact on partners' health behaviours, sexual health, relationship harmony, and psychological well-being. The partners indicated they were unprepared for post-birth adversities and distressed by the lack of treatment options. There is a need to develop prenatal information highlighting the potential risks of sPOP which may be accompanied by levator ani muscle injury, implement guidelines for the prevention and management of these conditions, and offer targeted support to partners if needed.

Efficacy of perineal massage during the second stage of labor for the prevention of perineal injury: A systematic review and meta-analysis

BACKGROUND

Numerous interventions to reduce perineal trauma during childbirth have been studied in recent years, including perineal massage.

OBJECTIVE

To determine the efficacy of perineal massage during the second stage of labor to prevent perineal damage.

SEARCH STRATEGY

Systematic search in PubMed, Pedro, Scopus, Web of Science, ScienceDirect, BioMed, SpringerLink, EBSCOhost, CINAHL, and MEDLINE with the terms Massage, Second labor stage, Obstetric delivery, and Parturition.

SELECTION CRITERIA

The articles must have been published in the last 10 years; the perineal massage was administered to the study sample; and the experimental design consisted of randomized controlled trial.

DATA COLLECTION AND ANALYSIS

Tables were used to describe both the studies' characteristics and the extracted data. The PEDro and Jadad scales were used to assess the quality of studies.

MAIN RESULTS

Of the 1172 total results identified, nine were selected. Seven studies were included in the meta-analysis and indicated a statistically significant decreased number of episiotomies in perineal massage.

CONCLUSIONS

Massage during the second stage of labor appears to be effective in preventing episiotomies and reducing the duration of the second stage of labor. However, it does not appear to be effective in reducing the incidence and severity of perineal tears.

Effect of Timing of Second-Stage Pushing on Pelvic Floor Morbidity After Birth

The author describes a recent trial on the effect of the timing of pushing during the second stage of labor on postpartum pelvic floor morbidity.

Disclosure and consent: ensuring the ethical provision of information regarding childbirth

Ethical medical care of pregnant women in Australia should include the real provision of information regarding the risks and benefits of vaginal birth. Routinely obtaining consent for the different ways in which childbirth is commonly intervened on and the assistance involved (such as midwife-led care or a planned caesarean section) and providing sufficient information for women to evaluate the harms and benefits of the care on offer, would not only enable the empowerment of women but would align with the current standard of care as established by Rogers v Whittaker.

Diagnosis of maternal birth trauma by pelvic floor ultrasound

BRIEF SUMMARY

Maternal somatic birth trauma due to vaginal delivery is more common than generally assumed and an important cause of future morbidity. Maternal birth trauma may involve both psychological and somatic morbidity, some of it long-term and permanent. Somatic birth trauma is now understood to encompass not just episiotomy, perineal tears and obstetric anal sphincter injuries (OASI), but also trauma to the levator ani muscle, termed 'avulsion'. This review will focus on recent developments in the imaging diagnosis of maternal birth trauma, discuss the most important risk factors and strategies for primary and secondary prevention. Translabial and exo-anal ultrasound allow the assessment of maternal birth trauma in routine clinical practice and enable the use of levator avulsion and anal sphincter trauma as key performance indicators of maternity services. This is likely to lead to a greater awareness of maternal birth trauma amongst maternity caregivers and improved outcomes for patients, not the least due to an increasing emphasis on patient autonomy and informed consent in antenatal and intrapartum care.

A predictive nomogram model for low anterior resection syndrome after rectal cancer resection

BACKGROUND

The aim of this study was to identify risk factors associated with the low anterior resection syndrome (LARS) and to construct a nomogram capable of predicting the risk of LARS in patients who undergo rectal cancer resection.

METHODS

About 538 patients who had undergone anterior resection were recruited as a development set. In addition, 114 patients with rectal cancer were analysed as a validation set to test the new nomogram. Patients in the development set were grouped into two separate cohorts: those with major LARS and those with minor or no LARS. Multiple logistic regression was conducted to detect risk factors for major LARS.

RESULTS

The prevalence of major LARS was 40.7%, of minor LARS was 28.6% and the proportion with no LARS was 30.7% in the development set. In multivariate analysis, female gender, preoperative chemoradiation, low tumour height, diverting ileostomy, postoperative anastomotic leakage were shown to be independently associated with major LARS occurring in patients after rectal cancer resection. The area under the curve (AUC) values of the nomogram were 0.726 (95% CI: 0.682-0.769) and 0.750 (95% CI: 0.655-0.845) in the development and validation sets, respectively. The calibration curves and Hosmer-Lemeshow goodness of fit tests showed that the model was acceptably accurate.

CONCLUSION

A nomogram model based on risk factors could be valuable as a predictor of the probability of major LARS after rectal cancer surgery, and provides a guide that clinical staff can use to take preventive measures for high-risk patients.

Birthweight difference between deliveries and the risk of obstetric anal sphincter injury in parous women

INTRODUCTION AND HYPOTHESIS

While obstetric anal sphincter injury (OASI) is less frequent in parous compared to nulliparous women, it remains a major concern affecting quality of life of women worldwide. The aim of this study was to evaluate the association between birthweight (BW) difference between deliveries and risk of OASI in parous women.

METHODS

We performed a retrospective case-control study including parous women with at least one previous vaginal delivery who were diagnosed with OASI. The control group consisted of parous women who did not have OASI during vaginal delivery. Controls were matched in a 1:2 ratio by year of birth, maternal age, and parity. Medical history, obstetric background, and current labor-related data were compared. Further univariate and multivariable analyses were performed, assessing for risk factors for OASI.

RESULTS

One hundred eight parous women who had a diagnosis of OASI and a control group of 216 parturients who delivered without OASI were included in the final analysis. Differences between the current BW and the preceding and maximal previous BW were evaluated. There were significantly higher rates of women who had a larger neonate with > 500 g difference between the current and previous BW in the OASI group than in those with no OASI (28.7% vs. 12.30%, respectively; p < 0.001). Following a multivariable analysis for the dependent parameter of OASI, the following parameters were found to be independently associated with OASI outcome: previous operative vaginal delivery, BW ≥ 90th percentile, and current BW ≥ 500 g compared to previous maximal BW.

CONCLUSIONS

In parous women, neonatal BW increase between deliveries of > 500 g is associated with OASI.

Validation and translation of the Hungarian version of the Australian Pelvic Floor Questionnaire (APFQ-H)

INTRODUCTION AND HYPOTHESIS

The aims of the study were the translation, cultural adaptation, and validation of self-administered Australian Pelvic Floor Questionnaire (APFQ) on a Hungarian population.

METHODS

The validation was performed in 294 women over 18 who agreed to answer the Hungarian version of the APFQ. The validation of the questionnaire included evaluation of content/face validity, internal consistency, construct validity, test-retest reproducibility, discriminant validity and convergent validity.

RESULTS

Acceptable and good internal consistency was observed in all four dimensions [McDonald's ω (95% confidence interval) coefficients were > 0.7 for each dimension: bladder 0.888, bowel 0.790, prolapse 0.895 and sexual function 0.738]. Test-retest analyses revealed high reproducibility with intraclass correlation coefficients (bladder 0.83, bowel 0.92, prolapse 0.96 and sexual function 0.87). Prolapse symptom score correlated significantly with Pelvic Organ Prolapse Quantification (POP-Q), and bladder score correlated significantly with the results of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ UI SF) (convergent validity). Scores distinguished between patients with pelvic floor disorders and controls (high discriminant validity).

CONCLUSIONS

Hungarian version of the self-administered APFQ is a reliable and valid instrument for evaluating symptom severity and impact of pelvic floor dysfunction on the quality of life of Hungarian women.

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.

Spanish cross-cultural adaptation and validation of the Australian Pelvic Floor Questionnaire in running women

Pelvic floor dysfunctions are a wide range of disorders in the gynaecological, lower urinary and gastrointestinal tracts that affect the structure and/or function of the pelvic organs. The objective of this study was to carry out a cross-cultural adaptation and a psychometric analysis of the Spanish version of the Australian Pelvic Floor Questionnaire. Observational study divided into two main phases: (1) translation and cross-cultural adaptation and (2) psychometric tests. Women runners from all over the Spanish territory, from different federations, clubs and levels were recruited. Participants: 424 female runners, native Spanish, over 18 years of age and who had been practicing running for more than 6 months. The instruments used in this study were the Australian Pelvic Floor Questionnaire, Female Sexual Function Index, King Health Questionnaire, Quality of Life SF-12 and EuroQoL 5-D. The Spanish version of Australian Pelvic Floor Questionnaire has proven to be an understandable and easy-to-use tool. The general internal consistency of the questionnaire was 0.972 and the intraclass correlation coefficient ranged between ICC 0.596-0.960. The Spanish version of Australian Pelvic Floor Questionnaire is a valid and reliable measure that can be used clinically to assess pelvic floor dysfunctions among the female Spanish population.

2D pelvic floor ultrasound imaging in identifying levator ani muscle trauma agrees highly with 4D ultrasound imaging

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate the agreement between 2D and 4D translabial ultrasound (TLUS) technique in showing levator ani muscle (LAM) states after vaginal birth.

METHODS

In a prospective observational cohort study between March 2017 and April 2019 we evaluated LAM states (intact, hematoma, partial, complete avulsion) of primiparous women having given birth vaginally with singletons in vertex presentation ≥ 36+0 gestational weeks by using 2D and 4D TLUS within 1-4 days postpartum (assessment A1) and again 6-10 weeks postpartum (assessment A2). Cohen's Kappa analysis was performed for each side separately to evaluate the test agreement between the two ultrasound techniques at every assessment period.

RESULTS

A total of 224 women participated at A1 and 213 at A2. The agreement between the two ultrasound techniques was good to very good at A1 (Cohen`s kappa right-sided 0.78, left-sided 0.82) and very good at A2 (Cohen`s kappa both sides 0.88). The agreement was best when assessing an intact LAM or a complete avulsion (Cohen`s kappa between 0.78-0.92 for complete avulsions).

CONCLUSIONS

The comparison between 2D and 4D TLUS showed a good to very good agreement in LAM trauma immediately after birth as well as 6-10 weeks postpartum. Therefore, 2D ultrasound could also be a valuable method for demonstrating a LAM abnormality and could be used in settings where 3D/4D ultrasound equipment is not available.

Perceptions of pelvic floor dysfunction and rehabilitation care amongst women in southeast China after radical hysterectomy: a qualitative study

Objective

To investigate the perceptions of pelvic floor dysfunction (PFD) and rehabilitation care amongst women after radical hysterectomy and to explore ways to improve quality of care.

Methods

Thirty-six women who underwent radical hysterectomy at a hospital in southeast China were enrolled via purposive sampling. Semi-structured in-depth interviews were conducted. The texts were analysed via qualitative content analysis.

Results

Four themes were obtained: serious lack of knowledge, heavy psychological burden, different coping strategies and great eagerness to receive multiparty support on PFD rehabilitation care.

Conclusion

The society and professional staff should strengthen health education on PFD. Professionals should offer education before and after surgery and actively provide rehabilitation consultation to promote the availability of rehabilitation to support women with PFD rehabilitation care. In addition, family-centred care is an important way to support women to return to normal life, and women's need for family support should be more actively expressed. Moreover, knowledge of medical insurance should be popularised, especially in rural areas in China.

Amniotic fluid embolism rescued by venoarterial extracorporeal membrane oxygenation

Background

Amniotic fluid embolism (AFE) is a rare but often catastrophic complication of pregnancy that leads to cardiopulmonary dysfunction and severe disseminated intravascular coagulopathy (DIC). Although few case reports have reported successful use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) with AFE, concerns can be raised about the increased bleeding risks with that device.

Methods

This study included patients with AFE rescued by VA-ECMO hospitalized in two high ECMO volume centers between August 2008 and February 2021. Clinical characteristics, critical care management, in-intensive care unit (ICU) complications, and hospital outcomes were collected. ICU survivors were assessed for health-related quality of life (HRQL) in May 2021.

Results

During that 13-year study period, VA-ECMO was initiated in 54 parturient women in two high ECMO volume centers. Among that population, 10 patients with AFE [median (range) age 33 (24–40), SAPS II at 69 (56–81)] who fulfilled our diagnosis criteria were treated with VA-ECMO. Pregnancy evolved for 36 (30–41) weeks. Seven patients had a cardiac arrest before ECMO and two were cannulated under cardiopulmonary resuscitation. Pre-ECMO hemodynamic was severely impaired with an inotrope score at 370 (55–1530) μg/kg/min, a severe left ventricular ejection fraction measured at 14 (0–40)%, and lactate at 12 (2–30) mmol/L. 70% of these patients were alive at hospital discharge despite an extreme pre-ECMO severity and massive blood product transfusion. However, HRQL was lower than age-matched controls and still profoundly impaired in the role-physical, bodily pain, and general health components after a median of 44 months follow-up.

Conclusion

In this rare per-delivery complication, our results support the use of VA-ECMO despite intense DIC and ongoing bleeding. Future studies should focus on customized, patient-centered, rehabilitation programs that could lead to improved HRQL in this population.

Conceptualization and Inventory of the Sexual and Psychological Burden of Women With Pelvic Floor Complaints; A Mixed-Method Study

Introduction

Despite the fact that the literature reports various restrictions and types of distress in women with pelvic floor complaints, a comprehensive overview of women's sexual and psychological burden emerging from these complaints is lacking, which compromises our ability to assess and grasp the impact to women.

Aim

This study was performed to conceptualize women's sexual and psychological burden and create a more comprehensive overview on this topic from both women's and health care providers’ perspectives. Furthermore, this research intended to identify items to populate a to-be-developed instrument to assess sexual and psychological burden.

Methods

In Group Concept Mapping, 125 statements were used about restrictions and distress that women with pelvic floor complaints experienced. Women with, and health care providers with and without pelvic floor complaints (13 women and 3 men) sorted the statements into comprehensive self-labeled clusters and rated their nature and severity. Multidimensional scaling and hierarchical cluster analyses were performed to identify a conceptual model of coherent clusters of statements. Item-total correlations of severity scores were calculated to identify statements that can be used in future research to represent women's sexual and psychological burden.

Main Outcome Measure

A conceptual model emerged, and outcomes of item-total correlations were then examined again using the conceptual model.

Results

Seven distress clusters were identified, namely, loss of control, sexual distress, feeling insecure, feeling wronged, feeling helpless, feeling angry, and feeling disappointed. Feeling insecure appeared more pervasive than other distresses. Furthermore, 33 statements were identified that can be used in future research to develop an instrument to assess sexual and psychological burden representing both women's and health care providers’ perspectives.

Conclusion

The conceptual model and list of statements may concisely represent the sexual and psychological burden of women with pelvic floor complaints from both women's and health care providers’ perspectives on this topic.

Brand AM, Rosas S, Waterink W, et al. Conceptualization and Inventory of the Sexual and Psychological Burden of Women With Pelvic Floor Complaints; A Mixed-Method Study. Sex Med 2022;10:100504.

Informed consent and birth preparedness/complication readiness: A qualitative study at two tertiary maternity units

BACKGROUND

Informed consent in obstetrics should involve full disclosure of risks, benefits and alternative interventions. However, we have found no evidence of a formal informed consent process before an attempt at vaginal delivery in published policy or practice. The idea of informed consent in vaginal birth has attracted controversy and has been the subject of some debate.

AIM

To explore the perspectives and experiences of informed consent and birth preparedness/complication readiness for birthing women in a high resource setting.

MATERIALS AND METHODS

Qualitative study using semi-structured interviews to examine experiences and perspectives of women following birth.

RESULTS

Forty telephone interviews were concluded. Eight statement categories were identified: (i) no issues of consent, (ii) absent/inadequate informed consent, (iii) adequate birth preparedness/complication readiness, (iv) inadequate birth preparedness/complication readiness, (v) desire to forfeit decision making to a trusted and accountable health professional, (vi) belief that informed consent is not realistic in birth under some circumstances, (vii) negative feelings related to birth and (viii) poor postnatal follow-up.

CONCLUSIONS

When complications arose during birth, 20% of participants felt that informed consent was absent/inadequate, 25% of participants suggested policy change in favour of a formal informed consent process and 55% of participants suggested policy change in favour of increased birth preparedness/complication readiness. Our study suggests that informed consent for vaginal birth and formal birth preparedness/complication readiness should form part of routine antenatal care. Women's preferences for decision-making and informed consent should be established before birth.

Recognition and Management of Pelvic Floor Disorders in Pregnancy and the Postpartum Period

Often considered a condition of aging women, pelvic floor disorders may initially present in pregnancy and postpartum, having a negative impact on quality of life during this important time in a woman's life. This review outlines the clinical approach to implementing pelvic health into obstetric care through education and promotion of pelvic health in pregnancy, screening for pelvic floor disorders routinely, and providing support through resources, treatment, and referrals if pelvic floor disorders develop during pregnancy and postpartum.

Should we inform women about the recognised risks of childbirth?

BACKGROUND

At present in Australia women are not routinely, systematically informed of the risks of childbirth.

AIMS

It is hoped this presentation of the perspective of some women who suffer unexpected obstetric complications will encourage change.

MATERIALS AND METHODS

The experience of women involved in obstetric medicolegal reports prepared by a colorectal surgeon over ten years is analysed.

RESULTS

Twenty women were identified. Sixteen had vaginal deliveries. All 16 suffered third or fourth-degree tears, six developed rectovaginal fistulae, six required stomas and 11 developed faecal incontinence. Of the four women who delivered by caesarean section, there were two post-operative caecal perforations, one unrecognised small bowel enterotomy, and one patient developed sepsis due to an infected haematoma. Seventeen of the 20 women were noted to suffer psychological sequalae. None of the women recollected being warned of the complication they suffered, and there was no record of such warnings in their medical records.

CONCLUSION

Informed written 'consent' for natural vaginal delivery is, understandably, a contentious topic. Although learning from medicolegal cases may go against the grain, as medical professionals it is very difficult to ethically justify the status quo, where women are not routinely simply informed of the risks of childbirth. This is not fair. Even if informing women does not decrease the incidence of complications, the women who subsequently suffer these complications may well handle them much better, recognising they could occur.

Women's experiences of the OASI Care Bundle; a package of care to reduce severe perineal trauma

INTRODUCTION AND HYPOTHESIS

Obstetric anal sphincter injury (OASI) is a severe form of perineal trauma that can occur during vaginal birth. Long-term morbidities include anal incontinence and psychosocial disorders. To reduce these injuries within England, Scotland and Wales, the OASI Care Bundle was introduced to 16 maternity units (January 2017-March 2018). The OASI Care Bundle comprises four elements: (1) antenatal information, (2) manual perineal protection, (3) medio-lateral episiotomy (when indicated) and 4) recognition and diagnosis of tears. As part of the project evaluation, a qualitative study was conducted to explore women's experiences of the OASI Care Bundle.

METHODS

Semi-structured interviews were conducted with women (n = 19) who received the OASI Care Bundle as part of their maternity care. This was to explore their experience of each element. A thematic analysis of the interview data was performed.

RESULTS

Three themes were identified: (1) memories of touch, whereby women reported that a 'hands-on' approach to perineal protection was a positive experience; (2) midwife as a supportive guide, where women reported that good communication facilitated a calm birth and post-birth diagnosis; (3) education: women need more information about perineal trauma.

CONCLUSION

This study contributes to the literature through its exploration of women's experiences of perineal protection techniques and diagnosis of perineal trauma. Interviewed women indicated that they did not experience any of the care bundle elements as an intrusion of their physical integrity. Additionally, an urgent need was identified for more information about perineal trauma in terms of risk, prevention and recovery.

Ultrasound imaging of maternal birth trauma

INTRODUCTION AND HYPOTHESIS

The term 'maternal birth trauma' has undergone substantial changes in meaning over the last 2 decades. Leaving aside psychological morbidity, somatic trauma is now understood to encompass not just episiotomy, perineal tears and obstetric anal sphincter injuries (OASI), but also trauma to the levator ani muscle. This review covers diagnosis of maternal birth trauma by translabial ultrasound imaging.

METHODS

Narrative review.

RESULTS

Tomographic imaging of pelvic structures with the help of 4D ultrasound, used since 2007, has allowed international standardization and seems to be highly reproducible and valid for the diagnosis of OASI and levator avulsion.

CONCLUSIONS

Translabial and exo-anal ultrasound allows the assessment of maternal birth trauma in routine clinical practice and the utilization of avulsion and sphincter trauma as key performance indicators of maternity services. It is hoped that this will lead to a greater awareness of maternal birth trauma among maternity caregivers and improved outcomes for patients, both in the short term and in the decades to come.

Association between the side of levator Ani muscle trauma and fetal position at birth - a prospective observational study

INTRODUCTION

Trauma of the levator ani muscle (LAM) is common after vaginal birth and can most reliably be diagnosed by 3-dimensional (3D) translabial ultrasound (TLUS). Multiple risk factors are known in general, but not in association to a specific side of the body. Therefore, our aim was to evaluate different impact factors which cause LAM trauma on either side of the body or bilateral by focusing on the fetal position at birth.

MATERIAL AND METHODS

As part of a prospective cohort study between 3/2017 and 4/2019, we analyzed vaginal births of nulliparous women with singletons in vertex presentation≥36+0 gestational weeks. We evaluated their pelvic floor for hematomas, partial and complete LAM avulsions by 3D TLUS 2-4 days postpartum and searched for an association between the affected body side and different fetal, maternal and obstetrical factors.

RESULTS

71 out of 213 women (33.3%) suffered from LAM trauma - 17 (23.9%) on the right side, 20 (28.2%) on the left side and 34 (47.9%) bilateral. No association between the different evaluated factors and the affected body side could be identified, except for the quality of fetal heart rate tracing.

CONCLUSIONS

No significant impact factors of LAM trauma could be associated with a specific side of the body. Other possible mechanisms need investigation in the future, such as the time of the birth canal and the fetus to adapt to each other, including adequate time for the tissue to stretch and the fetus to rotate into the ideal position within the LAM hiatus.

EINLEITUNG

Levatormuskelverletzungen sind häufig nach Vaginalgeburten und können zuverlässig mittels translabialem 3D-Ultraschall diagnostiziert werden. Diverse Risikofaktoren sind hierfür bekannt, allerdings keine hinsichtlich der Assoziation zu einer der beiden Körperseiten. Daher war das Ziel dieser Arbeit, verschiedene Einflussfaktoren im Rahmen vaginaler Geburten zu evaluieren, welche eine Levatorverletzung auf einer der beiden Körperseiten bzw. beidseitig begünstigen, v. a. hinsichtlich der Kindsposition im Geburtskanal.

MATERIAL UND METHODIK

In einer prospektiven Kohortenstudie analysierten wir von 3/2017-4/2019 Erstgebärende mit vaginalen Einlingsgeburten aus Schädellage≥36+0 SSW. Wir evaluierten 2-4 Tage postpartal ihren Beckenboden mittels 3D-Ultraschall hinsichtlich Hämatomen sowie partiellen und kompletten Levatoravulsionen und suchten nach Assoziationen zwischen der betroffenen Körperseite und fetalen, maternalen und geburtshilflichen Einflussfaktoren.

ERGEBNISSE

Von 213 Frauen erlitten 71 (33.3%) eine Levatorverletzung - 17 (23.9%) rechtsseitig, 20 (28.2%) linksseitig und 34 (47.9%) beidseitig. Es wurden keine Assoziationen zwischen den untersuchten Einflussfaktoren und der betroffenen Körperseite gefunden, bis auf die Qualität der fetalen Herzfrequenz.

DISKUSSION

Es konnten keine signifikanten Einflussfaktoren für das Auftreten einer Levatorverletzung einer spezifischen Körperseite eruiert werden. Daher bedarf es in Zukunft der Untersuchung weiterer Mechanismen, wie der Adaptationsvorgänge von Geburtskanal und Fet und der adäquaten Zeit für das Gewebe zur notwendigen Dehnung, v. a. im Bereich der Levatoröffnung.

Association between sexual dysfunction and avulsion of the levator ani muscle after instrumental vaginal delivery

INTRODUCTION

The effects of levator ani muscle (LAM) avulsion after instrumental delivery on the sexual function of patients are currently unknown. Therefore, the objective of our study was to use a validated questionnaire, namely, the Female Sexual Function Index (FSFI), to compare the sexual function in patients with and without LAM avulsion after instrumental vaginal delivery.

MATERIAL AND METHODS

This was a prospective observational study of 112 primiparous women after instrumental (vacuum or forceps) vaginal delivery. The obstetric and general characteristics of the population were studied. At 6 months postpartum, the contraceptive method used and the occurrence of LAM avulsion (using four-dimensional transperineal ultrasound) were determined, and the FSFI was administered.

RESULTS

A total of 100 patients (62 without avulsion and 38 with avulsion) completed the study. Thirty-eight (38%) were diagnosed with avulsion (42.1% after Kielland forceps delivery, 57.9% after Malmström vacuum delivery; P = .837). Women with LAM avulsion had significantly lower scores for desire (2.9 ± 1.2 vs 3.4 ± 1.1; P = .049), arousal (2.8 ± 1.7 vs 3.6 ± 1.4; P = .014), lubrication (2.3 ± 1.4 vs 3.0 ± 1.2; P = .011), orgasm (2.6 ± 1.6 vs 3.3 ± 1.2; P = .006) and satisfaction (3.1 ± 1.8 vs 3.9 ± 1.5; P = .051) than did women without LAM avulsion. The overall FSFI score was lower in patients with avulsion (16.7 ± 8.9 vs 20.7 ± 6.9, P = .033). These results were obtained after controlling for confounders (delivery mode, induced labor, birthweight, perineal tears, avulsion degree, contraceptive method and group assignment for the parent study) in the multivariate analysis (F = 4.974, P = .001).

CONCLUSIONS

Patients with LAM avulsion present a higher degree of sexual dysfunction compared wiith patients without avulsion at 6 months after instrumental vaginal delivery.

Can postpartum pelvic floor muscle training reduce urinary and anal incontinence?: An assessor-blinded randomized controlled trial

BACKGROUND

Pelvic floor dysfunction, including urinary and anal incontinence, is a common postpartum complaint and likely to reduce quality of life.

OBJECTIVE

To study the effects of individualized physical therapist-guided pelvic floor muscle training in the early postpartum period on urinary and anal incontinence and related bother, as well as pelvic floor muscle strength and endurance.

MATERIALS AND METHODS

This was an assessor-blinded, parallel-group, randomized controlled trial evaluating effects of pelvic floor muscle training by a physical therapist on the rate of urinary and/or anal leakage (primary outcomes); related bother and muscle strength and endurance in the pelvic floor were secondary outcomes. Between 2016 and 2017, primiparous women giving birth at Landspitali University Hospital in Reykjavik, Iceland, were screened for eligibilty 6-10 weeks after childbirth. Of those identified as urinary incontinent, 95 were invited to participate, of whom 84 agreed. The intervention, starting at ∼9 weeks postpartum consisted of 12 weekly sessions with a physical therapist, after which the main outcomes were assessed (endpoint, ∼6 months postpartum). Additional follow-up was conducted at ∼12 months postpartum. The control group received no instructions after the initial assessment. The Fisher exact test was used to test differences in the proportion of women with urinary and anal incontinence between the intervention and control groups, and independent-sample t tests were used for mean differences in muscle strength and endurance. Significance levels were set as α = 0.05.

RESULTS

A total of 41 and 43 women were randomized to the intervention and control groups, respectively. Three participants and 1 participant withdrew from these respective groups. Measurement variables and main delivery outcomes were not different at recruitment. At the endpoint, urinary incontinence was less frequent in the intervention group, with 21 participants (57%) still symptomatic, compared to 31 controls (82%) (P = .03), as was bladder-related bother with 10 participants (27%) in the intervention vs 23 (60%) in the control group (P = .005). Anal incontinence was not influenced by pelvic floor muscle training (P = .33), nor was bowel-related bother (P = .82). The mean differences between groups in measured pelvic floor muscle strength changes at endpoint was 5 hPa (95% confidence interval, 2-8; P = .003), and for pelvic floor muscle endurance changes, 50 hPa/s (95% confidence interval, 23-77; P = .001), both in favor of the intervention group. The mean between-group differences for anal sphincter strength changes was 10 hPa (95% confidence interval, 2-18; P = .01) and for anal sphincter endurance changes 95 hPa/s (95% confidence interval, 16-173; P = .02), both in favor of the intervention. At the follow-up visit 12 months postpartum, no differences were observed between the groups regarding rates of urinary and anal incontinence and related bother. Pelvic floor- and anal muscle strength and endurance favoring the intervention group were maintained.

CONCLUSION

Postpartum pelvic floor mucle training decreased the rate of urinary incontinence and related bother 6 months postpartum and increased muscle strength and endurance.

Validation of the Australian Pelvic Floor Questionnaire in Chinese pregnant and postpartum women

OBJECTIVES

To test the psychometric properties of the culturally adapted Chinese version of the self-administered Australian Pelvic Floor Questionnaire (APFQ) in pregnant and postpartum women.

STUDY DESIGN

Between November 2018 and December 2018, a total of 316 pregnant women who met the inclusion criteria in an outpatient setting were enrolled. The participants completed the questionnaire during the third trimester and twice after delivery. The test for validity was composed of face/content validity and construct validity. Reliability testing included internal consistency and test-retest reliability. The degree of responsiveness was assessed using effect size (ES) and standardized response mean (SRM).

RESULTS

Two hundred and seventy-four women completed all questionnaires. Content validity, missing data did not exceed 4 % for any questions in the Chinese version of the self-administered APFQ. Construct validity, there was statistically significant difference in the symptoms scores of women with and without subjective suffering bothersome symptoms in bladder function, bowel function, prolapse and sexual function during pregnancy and postpartum periods. Reliability, the total Cronbach's alpha coefficients of the questionnaire in pregnancy and postpartum periods were 0.8, 0.9 and 0.9, respectively, and the intraclass correlation coefficient (ICC) of the total questionnaire was 0.8 during the test-retest. Responsiveness, the Chinese version of APFQ can track changes in bladder function domain and bowel function domain for the women with standardized response mean equal to 0.6 and 0.2, respectively.

CONCLUSIONS

The Chinese version of the self-administered APFQ had satisfactory reliability and validity, and can longitudinally monitor changes in pelvic floor symptoms during pregnancy and postpartum periods.

Online reported women's experiences of symptomatic pelvic organ prolapse after vaginal birth

Background

Pelvic organ prolapse (POP) is a major public health problem with a relative high lifetime risk of surgery. The main risk factor for developing POP is vaginal birth. Many women become symptomatic later in life and most of the existing research on symptomatic pelvic organ prolapse (sPOP) predominantly concentrates on the effects of the condition on postmenopausal women. However bothersome symptoms of POP can be reported as early as in women’s 20s and may occur shortly after vaginal birth. Limited studies provide an insight into daily life of fertile women with sPOP. Thus, we aimed to explore fertile women’s experiences of symptomatic pelvic organ (sPOP) after vaginal birth.

Methods

An inductive, text-driven approach was taken by selecting thread posts from an internet forum written by 33 Swedish fertile women who had experienced sPOP after vaginal birth.

Results

The overarching theme “being irreparably damaged” was identified as representing an experience of being disabled by sPOP after vaginal birth. The fertile women experienced that their lives were ruined because of physical and psychological limitations caused by this unexpected, unfamiliar and unexplained condition. Living with sPOP impinged on sexual health, restricted daily and sports activities and affected the women’s ability to fulfill everyday parental duties. This in turn compromised women’s psychological health. In addition, the negligence of healthcare professionals who tended to trivialize and normalize the symptoms led to the belief that there were no sustainable treatments and that women would have to live with bothersome symptoms of POP for rest of their lives.

Conclusions

This study found that sPOP had a significant negative impact on fertile women’s lives. The women indicated that they had not had the opportunity to voice their concerns and had not been taken seriously by healthcare professionals. It is of the utmost importance to acknowledge this problem and develop guidelines for prevention and management of sPOP to improve the quality of life for women.

Factors Influencing Couples' Sexuality in the Puerperium: A Systematic Review

INTRODUCTION

The puerperium is a period of adaptation in which various transformations take place in the lives of women and men on their way to becoming mothers and fathers. These changes can also have repercussions on their sexual relations. How the couple deals with this transition is crucial to the well-being of the couple and affects how parents relate to the baby.

AIM

This study aimed to explore the factors that influence sexuality in both women and men during postpartum.

METHODS

We conducted a bibliographic review of 236 articles found on the PubMed database and published from 2008 to January 2019.

MAIN OUTCOME MEASURE

The main outcome measure was the impact of various physical, psychological, and sociocultural factors on couples' sexual functioning during postpartum.

RESULTS

The main problems that couples face after childbirth can be classified as (i) psychological changes, such as loss of a sense of self, transitioning to parenthood, taking on the new roles of mother and father, and feelings of abandonment among men; (ii) body changes in women that affect their self-image and perineal trauma; (iii) hormonal changes in women and men that can lead to reduced sexual desire in both and vaginal dryness or dyspareunia in women; (iv) changes in the marital relationship, including changes in each other's roles, taking time for intimacy, and initiating sexual intercourse; (v) sociocultural influences, such as social support, culturally expected roles, and beliefs regarding when to resume sex; and (vi) lifestyle changes, especially with regard to baby care.

CONCLUSION

Sexuality during postpartum is influenced by multiple factors: physical, psychological, and sociocultural. Our findings offer a deeper understanding of how the transition to parenthood affects sexual relationships during the postpartum period. Implications regarding caring for and promoting the sexual health of individuals and couples after childbirth are discussed, and some medical recommendations for parents are offered. Serrano Drozdowskyj E, Gimeno Castro E, Trigo López E, et al. Factors Influencing Couples' Sexuality in the Puerperium: A Systematic Review. Sex Med Rev 2020;8:38-47.

Synthesis of Mixed Research on Posttraumatic Stress Related to Traumatic Birth

OBJECTIVE

To synthesize mixed-research results (quantitative and qualitative) on posttraumatic stress in women who experienced traumatic births.

DATA SOURCES

PubMed, Scopus, and PsycINFO databases.

STUDY SELECTION

Quantitative and qualitative studies were included if they were published in English from January 1, 2009, through December 31, 2018, and focused on posttraumatic stress in the postpartum period related to traumatic childbirth.

DATA EXTRACTION

The final sample consisted of 59 studies: 4 qualitative and 55 quantitative. Both authors independently appraised each study using the Critical Appraisal Skills Programme. Quantitative studies were synthesized by narrative synthesis and vote counting, and qualitative studies were synthesized by content analysis.

DATA SYNTHESIS

In the included studies, prevalence rates of elevated posttraumatic stress ranged from 0.8% to 26%. Significant predictors of posttraumatic stress that occurred before childbirth and those that were birth related were identified. Reports of six intervention studies to decrease posttraumatic stress symptoms after traumatic births were included. These interventions focused on postnatal debriefing, expressive writing, online cognitive behavioral therapy, a brief cognitive intervention, and the implementation of the nine instinctive stages of the infant during the first hour after birth. We created four themes from the findings of the qualitative studies: Distressing Symptoms, Detrimental Effect of Posttraumatic Stress on Women's Relationships With Their Infants and Partners, Critical Influence ofSupport, and Debriefing.

CONCLUSION

When a woman experiences posttraumatic stress related to a traumatic birth, the entire family unit is vulnerable. Findings from quantitative predictor studies can be used to develop an instrument to screen women for risk factors for posttraumatic stress related to birth trauma. Primary interventions are needed to prevent women from experiencing traumatic births.