A comparison of the "hands-off" and "hands-on" methods to reduce perineal lacerations: a randomised clinical trial

The influence of the attending midwife on the occurrence of episiotomy: A retrospective cohort study

BACKGROUND

Episiotomy at the time of vaginal birth can result in short- and long-term complications for women. Therefore, it is important to study factors that influence the occurrence of episiotomy.

AIM

To examine to what extent the individual factors of clinical midwives in the same working conditions contribute to variations in episiotomy.

METHODS

A retrospective cohort study was performed at a secondary care hospital in Amsterdam, the Netherlands, using data from women who were assisted by a clinical midwife during birth in 2016. The clinical midwives filled out a questionnaire to determine individual factors. The predictive value of the individual factors of the clinical midwives was examined in a multiple logistic regression model on episiotomy.

RESULTS

A total of 1302 births attended by 27 midwives were included. The mean episiotomy rate was 12.7%, with a range from 3.2% to 30.8% among midwives (p = 0.001). When stratified for parity, within the primipara group there was a significant variation in episiotomy among midwives with a range from 7.9% to 47.8% (p = 0.006). No significant variation was found in the occurrence of third/fourth degree tears or intact perineum. There was a significant difference in episiotomy for maternal indication among midwives (p = 0.041). Predictors for an episiotomy were number of years since graduation and place of bachelor education of the clinical midwife.

CONCLUSION

This study shows that individual factors of clinical midwives influence the rate of episiotomy. Predictors for an episiotomy were the number of years since graduation and place of bachelor education. This shows that continuous training of clinical midwives could contribute to reducing the number of unnecessary episiotomies. Since suspected fetal distress is the only evidence based indication to perform an episiotomy, there is room for improvement given the variation in the number of episiotomies performed for maternal indication.

Effect of the "shoulder-up" bundle on the incidence of spontaneous perineal injury after vaginal delivery: comparison of 2 historic cohorts after propensity score matching

BACKGROUND

Perineal injury following vaginal delivery represents a major cause of long-term maternal morbidity, and its prevention is among the priorities of modern obstetrical practice.

OBJECTIVE

This study aimed to investigate whether the systematic implementation of a bundle of maneuvers to prevent perineal injury (ie, the "shoulder-up" bundle) may reduce the rate of spontaneous perineal tears in women delivering at a single tertiary maternity unit.

STUDY DESIGN

This was a single-center retrospective intervention study including all vaginal deliveries between April 1, 2020 and March 31, 2022. On March 1, 2021, a bundle focused on perineal injury prevention in vaginal deliveries was implemented and introduced as a standard of care. The "shoulder-up" bundle includes the addition of a hands-on technique for the delivery of the posterior shoulder, which is slowly lifted up under the direct visualization of the perineal body, immediately after the disengagement of the anterior shoulder. The labor ward staff underwent dedicated training to acquire expertise on the "shoulder-up" bundle. Little changes in terms of medical and midwifery staffing were recorded during the study period. The incidence of spontaneous second-degree or higher perineal tears was compared between the patients who gave birth before the clinical implementation of the bundle (standard-care group) and those who were delivered following the implementation of the bundle (shoulder-up group). A 1:1 propensity score matching of the 2 groups was done for the variables that proved to be independently associated with the perineal outcome.

RESULTS

From April 1, 2020 to March 31, 2022, 3671 patients had a vaginal birth at our tertiary care unit (1786 in the standard-care group and 1885 in the "shoulder-up" group) and were enrolled in the study population. Of these, 1191 (32.4%) had a spontaneous second-degree or higher perineal tear. At univariate analysis, nulliparity (59.6% vs 39.1%; P<.001), higher gestational age at delivery (39.8±1.28 vs 39.4±1.97 weeks; P<.001), epidural analgesia (40.6% vs 31.2%; P<.001), vacuum-assisted delivery (9.6% vs 4.0%; P<.001), and birthweight >4 kg (11.0% vs 6.3%; P<.001) were independently associated with the perineal outcome. Following propensity score matching for the above cited factors, the 1703 patients of each group were compared. A significant increase in the rate of intact perineum (71.0% vs 64.1%; P=.014) and a reduction in the incidence of second- (27.2% vs 32.9%; P=.006) and third to fourth-degree perineal tears (1.3% vs 3.0%; P<.001) was demonstrated in the "shoulder-up" group. Among the subgroup of patients undergoing vacuum-assisted delivery, a borderline significant reduction in the rate of obstetrical anal sphincter injury (10.4% vs 2.9%; P=.052) was also observed.

CONCLUSION

Our study showed that the clinical implementation of the "shoulder-up" bundle at vaginal delivery is associated with a significant reduction in the incidence of spontaneous second-degree or higher perineal tears.

The effectiveness of interventions in the prevention of perineal trauma in parturients: A systematic review with meta-analysis

AIM

To investigate the effectiveness of interventions to prevent the occurrence of perineal trauma in parturients.

METHODS

A bibliographic search was carried out in Cochrane Library, MEDLINE via PUBMED, LILACS via Virtual Health Library (VHL), Embase, Scopus, CINAHL, Scielo, Web of Science, and PEDro databases. Randomized clinical trials evaluating the effects of any intervention to prevent perineal trauma during pregnancy and/or childbirth were included. There were no temporal or language restrictions. The risk of bias assessment was performed using the Revised Cochrane Risk-of-bias Tool for Randomized Trials.

RESULTS

Fifty studies, with a total of 17,221 participants, were included in this meta-analysis. No intervention during childbirth was effective for the prevention of perineal trauma (RR = 1.07, 95% CI [0.98.1.18], p < 0.01, I² = 83%) when compared to no intervention. However, a lower risk of perineal laceration was verified with techniques performed during pregnancy, when compared to no intervention (RR = 0.81, 95% CI [0.71, 0.93], p = 0.05, I² = 47%). Among them, highlight the effects of perineal massage in preventing lacerations (RR = 0.69, 95% CI [0.54, 0.87], p < 0.01) when compared to no intervention.

CONCLUSIONS

The techniques performed during pregnancy, especially perineal massage, are associated with a lower risk of perineal laceration.

Hands-on vs hands-off for prevention of perineal injury: a randomized clinical trial

OBJECTIVE

To test the hypothesis that in nulliparous women with singleton pregnancies at term, hands-off technique during spontaneous vaginal delivery would reduce the rate of perineal laceration METHODS: Parallel group non-blinded randomized clinical trial. Nulliparous women in spontaneous labor with singleton pregnancies and vertex presentation admitted in labor and delivery room between 37 0/7 - 42 0/7 weeks of gestation were eligible, and were randomized in a 1:1 ratio to receive hands-off technique (intervention group) or hands-on technique during pushing in the second stage of labor. The primary outcome of perineal laceration (any degree). The effect of hands-off technique on each outcome was quantified as the relative risk (RR) with 95% confidence interval (CI).

RESULTS

70 women were enrolled in the trial. Perineal lacerations (any degree) occurred in 15/35 (42.9%) women in the intervention group, and 33/35 (94.3%) in the control group (RR 0.45, 95% CI 0.31 to 0.67). Hands-off technique was also associated with significantly decreased risk in the incidence of episiotomy (RR 0.36, 95% CI 0.14 to 0.88), first-degree (RR 0.41, 95% CI 0.20 to 0.87), and second-degree lacerations (RR 0.43, 95% CI 0.19 to 0.99). There was no significant between-group difference in third- and fourth-degree lacerations, but the trial was not powered for these outcomes.

CONCLUSION

In nulliparous women with singleton pregnancies at term, hands-off technique reduces the rate of perineal lacerations REGISTRATION NUMBER: NCT04860102.

A percepção do cuidado centrado na mulher por enfermeiras obstétricas num centro de parto normal

Resumo Objetivo compreender a percepção da atuação das enfermeiras obstétricas em relação à assistência às mulheres atendidas em um Centro de Parto Normal. Método estudo descritivo, exploratório e de abordagem qualitativa, com a realização de entrevistas semiestruturadas com 11 enfermeiras obstétricas do Centro de Parto Normal Haydeê Pereira Sena, Pará, Brasil. As entrevistas foram realizadas pelo aplicativo WhatsApp®, na função de videochamada e no período de setembro a novembro de 2020, com a gravação utilizando o aplicativo Cube ACR. Os áudios foram transcritos e submetidos à análise de conteúdo na modalidade temática, com o suporte do software ATLAS.ti 8.0. Resultados a percepção do cuidado atribuído à enfermagem obstétrica se fundamenta no campo da humanização do pré-natal e nas ações de cuidado alinhadas às evidências científicas, fisiológicas e de autonomia da mulher no cuidado obstétrico. Conclusão a enfermagem obstétrica possui como foco a humanização centrada nas evidências do parto, o que fomenta um redesenho da assistência obstétrica.

Which elements were significant in reducing obstetric anal sphincter injury? A prospective follow-up study

Background

To examine which elements of an obstetric anal sphincter injury (OASI) care bundle were protective for OASI. Several interventional trials showed that application of a care bundle involving a hands-on approach to perineal protection may reduce the risk of OASI. Previously, we found that only the element “hand on the fetal head” in itself was protective, although the risk of a type 2 error was calculated to be 50%.

Methods

A prospective follow-up study in an obstetric department in Denmark with 3200 deliveries per year. We included a cohort of 10,383 women giving birth vaginally from gestational week 22 + 0 from 2016 through 2019. We documented on a person-level the five elements of the care bundle together with maternal and obstetrical characteristics. The elements were 1) communication, 2) visible perineum, 3) hand on fetal head, 4) perineal support and 5) certification. Regression analysis was used for analysis of associations. The primary outcome measure was OASI.

Results

The total rate of OASI in vaginally delivering women was 1.9%. The incidence was 3.2% in nulliparous women giving birth vaginally. The rate of cesarean section was 16.5% and for episiotomy 2.4%. The reduction in the incidence of OASI was sustained since 2013. Hand on the fetal head and perineal support both were protective factors for OASI. In case of a nulliparous woman with a neonate weighing 3500 g giving birth spontaneously, the relative risk (RR) for OASI was 0.50 (95% CI 0.49- 0.51) with use of hand on the fetal head together with perineal support against no use. Similarly, with a nulliparous woman giving birth to a neonate of 3500 g by vacuum extraction, the RR for OASI was 0.65 (95% CI 0.62-0.68) against no use.

Conclusions

Both hand on the fetal head and perineal support were associated with a reduced risk of OASI.

Practices of midwives working in delivery rooms for protection of perineum during intrapartum period and their feedback on these applications

INTRODUCTION AND HYPOTHESIS

Perineal traumas occurring during labor are undesirable for both the midwives and the woman. Midwives and obstetricians could use different techniques to protect the perineum.

PURPOSE

The aim of this study was to determine the practices of midwives working in the delivery room to protect the perineum during the second stage of labor.

METHODS

This is a prospective observational study regarding practices of midwifes for protection of perineum during intrapartum period. The study was conducted with a total of 20 midwives in a maternity unit of an training and research hospital. The data were collected through the forms prepared by the researchers.

FINDINGS

The average age of the midwives was 34 ± 8.77. The majority of midwives (n: 17, 85%) believed that the need for practices to protect the perineum during labor; 40% of them used perineal protection (hands on) technique to protect perineum and they preferred to perform routine episiotomy in all primiparas.

RESULTS AND CONCLUSIONS

As a result of the study, it was observed that evidence-based practices was not applied sufficiently enough by the midwives although they were knowledgeable and believed that they are beneficial. Studies are needed for the obstacles to these practices to be identified and removed.

A multicentre study on the effect of moderate perineal protection technique: a new technique for perineal management in labour

We conducted a large-sample study in six midwifery centres to estimate the effectiveness of Moderate Perineal Protection technique during spontaneous delivery. 31,249 women accepted the traditional technique were selected as control group, and 57,056 women accepted the Moderate Perineal Protection technique as the observation group. There was no significant difference in demographic characteristics between the two groups. The perineal episiotomy rate decreased (22.913% vs. 32.161%, p < .05), the perineal integrity significantly increased (43.505% vs. 36.384%, p < .05) and perineal trauma reduced in the observation group when compared to the control group (54.630% vs. 61.239% in first degree tears, and 1.826% vs. 2.340% in second degree tears, p < .05). The neonatal asphyxia rate in the observation group was lower than that in the control group (p < .05). The observation group also had a higher rate of total satisfaction, lower VAS score for perineal pain, shorter postpartum hospitalisation days, lower rate of postpartum urinary retention and postpartum incontinence (p < .05). We concluded that the Moderate Perineal Protection technique is safe, effective and worth promoting widely.Impact statementWhat is already known on this subject? In order to reduce the episiotomy rate and reduce perineal injury, some researches have been carried out and some perineal techniques have been evaluated, but there are still many aspects to improve.What the results of this study add? Moderate Perineal Protection technique can effectively reduce episiotomy rate, protect perineal integrity, improve neonatal outcomes and increase maternal satisfaction.What the implications are of these findings for clinical practice and/or further research? The Moderate Perineal Protection technique is an effective and safe technique worth clinical promoting widely. Further research could focus on the long-term effects of Moderate Perineal Protection technique, such as pelvic floor injury and long-term mother-child outcomes.

Hands-on versus hands-off techniques for the prevention of perineal trauma during vaginal delivery: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Perineal trauma at the time of vaginal delivery is common, and when the anal sphincter is included, these injuries can be associated with additional morbidity including incontinence, pelvic pain, and sexual dysfunction.

OBJECTIVE

The aim of this systematic review with meta-analysis was to evaluate whether a hands-on technique during vaginal delivery results in less incidence of perineal trauma than a hands-off technique.

METHODS

Electronic databases were searched from their inception until June 2018. No restrictions for language or geographic location were applied. The reference lists of identified articles were examined to identify studies not captured by electronic searches. Randomized controlled trials comparing a hands-on technique of perineal support during vaginal delivery (i.e. intervention group) with a hands-off technique (i.e. control group) were included in the meta-analysis. Hands-on was defined as involving one hand on the fetal head, applying pressure to control expulsion, with the other hand applying pressure on the maternal perineum. The primary outcome was severe perineal trauma, defined as either third- or fourth-degree lacerations. The meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of relative risk (RR) with 95% confidence interval (CI).

RESULTS

Five trials, including 7287 women, were analyzed. All studies included singleton gestations with cephalic presentation at term undergoing spontaneous vaginal delivery. Women randomized to the hands-on technique had similar incidence of severe perineal trauma (1.5 versus 1.3%; RR 2.00, 95% CI 0.56-7.15). There was no significant between-group difference in the incidence of intact perineum, first-, second- and fourth-degree laceration. Hands-on technique was associated with increased risk of third-degree lacerations (2.6 versus 0.7%; RR 3.41, 95% CI 1.39-8.37) and of episiotomy (13.6 versus 9.8%, RR 1.59, 95% CI 1.14-2.22) compared to the hands-off technique.

CONCLUSIONS

Hands-on technique during spontaneous vaginal delivery of singleton gestations results in similar incidence of several perineal traumas compared to a hands-off technique. The incidence of third-degree lacerations and of episiotomy increases with the hands-on technique. Key Message A hands-on technique during vaginal delivery results in similar incidence of severe lacerations compared to hands-off.

Relation between Epidural Analgesia and severe perineal laceration in childbearing women in Catalonia

OBJECTIVE

Our objectives were to study the association between epidural analgesia and risk of severe perineal laceration (SPL), and identify additional risk factors for SPL. This multicentre study consisted of an analysis of data from the MidconBirth Phase I Database, on the use of EA and perineal results during childbirth. (World Health Organization, International Clinical Trials Registry Platform, 2016: http://apps.who.int/trialsearch/Trial2.aspx?TrialID=ISRCTN17833269).

METHODS

We conducted a prospective study of pregnant women at term between July 2016 and July 2017 in 30 public maternity hospitals in Catalonia, Spain. Inclusion criteria were an uncomplicated singleton pregnancy, in cephalic presentation and vaginal birth. Data was analysed separately for instrumental births and spontaneous vaginal births, as the former is more frequently associated with episiotomy and more perineal lacerations. Risk factors as well as protective factors in each cohort of women (instrumental and spontaneous vaginal birth), were identified. Multivariate logistic regression model was performed to study the association between epidural analgesia and SPL to identify potential confounders. Odds ratios (OR), using 95% confidence intervals (CI) were constructed.

FINDINGS

During the study period, 5497 eligible women gave birth, 77.46% of them received epidural analgesia. SPL occurred in 1.63% of births. The univariate analysis showed births with epidural analgesia had significantly higher rates of inductions, augmentation of labour, lithotomy position for birth and episiotomy. However, this association disappeared when the variable "type of vaginal birth" was introduced. In multivariate logistic regression, nulliparity was the major predictor for SPL (OR: 0.17; CI 95%: 0.08-0.34, p: 0.000).

KEY CONCLUSIONS

Epidural analgesia was not associated with SPL once confounding factors were included. Other interesting factors associated with SPL were identified.

IMPLICATIONS FOR PRACTICE

This paper identifies important practice areas which contribute to SPL and which have the potential to be rectified. It offers evidence on the role that EA plays on pelvic floor injuries and it adds to existing evidence about the disadvantages of using the lithotomy position for birth, especially in relation to SPL. It highlights the need for practice change in Catalonia from what can be considered a medical model of care to one more aligned with the midwifery philosophy of care through the development of clinical guidelines. It also signals the need to provide women with evidence base upon which to make informed choices on the use of EA, specifically in relation to SPL.

Importance of Individual Elements for Perineal Protection in Childbirth: An Interventional, Prospective Trial

Objective  To analyze the association between each element of a hands-on intervention in childbirth and the incidence of obstetric anal sphincter injuries (OASIS). Study Design  We conducted a prospective, interventional quality improvement project and implemented a care bundle with five elements at an obstetric department in Denmark with 3,000 deliveries annually. We aimed at reducing the incidence of OASIS. In the preintervention period, 355 vaginally delivering nulliparous women were included. Similarly, 1,622 nulliparous women were included in the intervention period. The association of each element with the outcome was estimated using a regression analysis. Results  The incidence of OASIS went down from 7.0 to 3.4% among nulliparous women delivering vaginally ( p  = 0.003; relative risk = 0.48; 95% confidence interval [CI]: 0.30-0.76). Number needed to treat was 28. Logistic regression analysis showed that using hand on the head of the child significantly reduced the risk of OASIS (odds ratio = 0.28; 95% CI: 0.14-0.58). Conclusion  Using a quality improvement framework, we documented the individual elements of the intervention. Hand on the infant's head reduced the risk of OASIS.

Perineal techniques during the second stage of labour for reducing perineal trauma

BACKGROUND

Most vaginal births are associated with trauma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including perineal massage, warm or cold compresses, and perineal management techniques have been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011.

OBJECTIVES

To assess the effect of perineal techniques during the second stage of labour on the incidence and morbidity associated with perineal trauma.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (26 September 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Published and unpublished randomised and quasi-randomised controlled trials evaluating perineal techniques during the second stage of labour. Cross-over trials were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. We checked data for accuracy.

MAIN RESULTS

Twenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Overall, trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques.Most studies did not report data on our secondary outcomes. We downgraded evidence for risk of bias, inconsistency, and imprecision for all comparisons. Hands off (or poised) compared to hands onHands on or hands off the perineum made no clear difference in incidence of intact perineum (average risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.12, two studies, Tau² 0.00, I² 37%, 6547 women; moderate-quality evidence), first-degree perineal tears (average RR 1.32, 95% CI 0.99 to 1.77, two studies, 700 women; low-quality evidence), second-degree tears (average RR 0.77, 95% CI 0.47 to 1.28, two studies, 700 women; low-quality evidence), or third- or fourth-degree tears (average RR 0.68, 95% CI 0.21 to 2.26, five studies, Tau² 0.92, I² 72%, 7317 women; very low-quality evidence). Substantial heterogeneity for third- or fourth-degree tears means these data should be interpreted with caution. Episiotomy was more frequent in the hands-on group (average RR 0.58, 95% CI 0.43 to 0.79, Tau² 0.07, I² 74%, four studies, 7247 women; low-quality evidence), but there was considerable heterogeneity between the four included studies.There were no data for perineal trauma requiring suturing. Warm compresses versus control (hands off or no warm compress)A warm compress did not have any clear effect on the incidence of intact perineum (average RR 1.02, 95% CI 0.85 to 1.21; 1799 women; four studies; moderate-quality evidence), perineal trauma requiring suturing (average RR 1.14, 95% CI 0.79 to 1.66; 76 women; one study; very low-quality evidence), second-degree tears (average RR 0.95, 95% CI 0.58 to 1.56; 274 women; two studies; very low-quality evidence), or episiotomy (average RR 0.86, 95% CI 0.60 to 1.23; 1799 women; four studies; low-quality evidence). It is uncertain whether warm compress increases or reduces the incidence of first-degree tears (average RR 1.19, 95% CI 0.38 to 3.79; 274 women; two studies; I² 88%; very low-quality evidence).Fewer third- or fourth-degree perineal tears were reported in the warm-compress group (average RR 0.46, 95% CI 0.27 to 0.79; 1799 women; four studies; moderate-quality evidence). Massage versus control (hands off or routine care)The incidence of intact perineum was increased in the perineal-massage group (average RR 1.74, 95% CI 1.11 to 2.73, six studies, 2618 women; I² 83% low-quality evidence) but there was substantial heterogeneity between studies). This group experienced fewer third- or fourth-degree tears (average RR 0.49, 95% CI 0.25 to 0.94, five studies, 2477 women; moderate-quality evidence).There were no clear differences between groups for perineal trauma requiring suturing (average RR 1.10, 95% CI 0.75 to 1.61, one study, 76 women; very low-quality evidence), first-degree tears (average RR 1.55, 95% CI 0.79 to 3.05, five studies, Tau² 0.47, I² 85%, 537 women; very low-quality evidence), or second-degree tears (average RR 1.08, 95% CI 0.55 to 2.12, five studies, Tau² 0.32, I² 62%, 537 women; very low-quality evidence). Perineal massage may reduce episiotomy although there was considerable uncertainty around the effect estimate (average RR 0.55, 95% CI 0.29 to 1.03, seven studies, Tau² 0.43, I² 92%, 2684 women; very low-quality evidence). Heterogeneity was high for first-degree tear, second-degree tear and for episiotomy - these data should be interpreted with caution. Ritgen's manoeuvre versus standard careOne study (66 women) found that women receiving Ritgen's manoeuvre were less likely to have a first-degree tear (RR 0.32, 95% CI 0.14 to 0.69; very low-quality evidence), more likely to have a second-degree tear (RR 3.25, 95% CI 1.73 to 6.09; very low-quality evidence), and neither more nor less likely to have an intact perineum (RR 0.17, 95% CI 0.02 to 1.31; very low-quality evidence). One larger study reported that Ritgen's manoeuvre did not have an effect on incidence of third- or fourth-degree tears (RR 1.24, 95% CI 0.78 to 1.96,1423 women; low-quality evidence). Episiotomy was not clearly different between groups (RR 0.81, 95% CI 0.63 to 1.03, two studies, 1489 women; low-quality evidence). Other comparisonsThe delivery of posterior versus anterior shoulder first, use of a perineal protection device, different oils/wax, and cold compresses did not show any effects on perineal outcomes. Only one study contributed to each of these comparisons, so data were insufficient to draw conclusions.

AUTHORS' CONCLUSIONS

Moderate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent. Poor-quality evidence suggests hands-off techniques may reduce episiotomy, but this technique had no clear impact on other outcomes. There were insufficient data to show whether other perineal techniques result in improved outcomes.Further research could be performed evaluating perineal techniques, warm compresses and massage, and how different types of oil used during massage affect women and their babies. It is important for any future research to collect information on women's views.

[Implementation methodology of practices based on scientific evidence for assistance in natural delivery: a pilot study]

OBJECTIVE

Presenting methodology for transferring knowledge to improve maternal outcomes in natural delivery based on scientific evidence.

METHOD

An intervention study conducted in the maternity hospital of Itapecerica da Serra, SP, with 50 puerperal women and 102 medical records from July to November 2014. The PACES tool from Joanna Briggs Institute, consisting of pre-clinical audit (phase 1), implementation of best practice (phase 2) and Follow-up Clinical Audit (phase 3) was used. Data were analyzed by comparing results of phases 1 and 3 with Fisher's exact test and a significance level of 5%.

RESULTS

The vertical position was adopted by the majority of puerperal women with statistical difference between phases 1 and 3. A significant increase in bathing/showering, walking and massages for pain relief was found from the medical records. No statistical difference was found in other practices and outcomes. Barriers and difficulties in the implementation of evidence-based practices have been identified. Variables were refined, techniques and data collection instruments were verified, and an intervention proposal was made.

CONCLUSION

The study found possibilities for implementing a methodology of practices based on scientific evidence for assistance in natural delivery.

A retrospective study on perineal lacerations in vaginal delivery and the individual performance of experienced mifwives

BACKGROUND

Medical staff's influence on patient outcomes has become a subject of interest. We evaluated experienced midwives and compared their performance concerning perineal lacerations (PL).

METHODS

In a retrospective cohort study, 1937 women with singleton pregnancies who had delivered spontaneously with a cephalic presentation by experienced midwives in the Medical University of Vienna from January 2009 to April 2014 were included. As predictive parameters, we included basic patient-, pregnancy- and delivery-related characteristics including the individual midwife who delivered the child. The incidence of PL was the main outcome measure.

RESULTS

Overall PL and severe PL were found in 508/1937 (26.2%) and 19/1937 women (1.0%), respectively. In a multivariate analysis for PL of any degree, maternal age (ß = 0.170 ± 0.080), gestational age at delivery (ß = 0.190 ± 0.320), and birth weight (ß = 0.002 ± 0.000) significantly increased the risk, whereas multiparity (ß = -0.379 ± 0.141) and mediolateral episiotomy (ß = -1.514 ± 0.284) decreased it (p < 0.05). In addition, the individual midwife who delivered the child was a significant influencing factor, with ß-values ranging from -0.028 to 0.899 compared to the reference midwife. For severe PL, the midwife was not of significant influence.

CONCLUSIONS

The individual midwife is an independent factor that influences the risk for overall PL, not for severe PL. Other risk factors include maternal age, gestational age at delivery, birth weight, parity and episiotomy.