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Rodrigues S, Silva P, Vieira R, Duarte A, Escuriet R. Midwives' practices on perineal protection and episiotomy decision-making: A qualitative and descriptive study. Eur J Midwifery 2024; 8:EJM-8-19. [PMID: 38736456 PMCID: PMC11082654 DOI: 10.18332/ejm/174126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 10/09/2023] [Accepted: 11/23/2023] [Indexed: 05/14/2024] Open
Abstract
INTRODUCTION Perineal trauma is associated with both short- and long-term morbidity which in turn relates to the degree of trauma. The objective of this study was to understand midwives' practices regarding perineal protection during the second phase of labor, emphasizing decision-making to perform an episiotomy. METHODS A descriptive and explanatory study was conducted with an intentional sample of twenty-two midwives working in the labor ward of a tertiary hospital in a metropolitan location and in the public service, in Portugal. A semi-open interview was applied to collect the data from 5 to 15 January 2019. The computer software package, NVivo version 10, was used to perform the thematic analysis. RESULTS Four main themes arose from the midwives' data: 1) Factors affecting the application of perineal protection techniques', 2) Birth position, 3) Techniques for perineal protection, and 4) Episiotomy. The reasons for performing an episiotomy were the presence of tense perineum, large weight baby, previous obstetric anal sphincter injury, and Kristeller maneuver. CONCLUSIONS Midwives' practices regarding perineal protection techniques and reasons for performing an episiotomy were not all in line with the evidence. Perineal massage was not mentioned as a perineal protection technique.
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Affiliation(s)
- Silvia Rodrigues
- Biomedical Sciences Institute Abel Salazar, Porto, Portugal
- Hospital of Braga, Braga, Portugal
| | | | | | | | - Ramon Escuriet
- Health and Integrated Care division, Catalan Health Service, Barcelona, Spain
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Dupuis N, Pizzoferrato AC, Garabedian C, Rozenberg P, Kayem G, Harvey T, Mandelbrot L, Doret M, Fuchs F, Azria E, Sénat MV, Ceccaldi PF, Seco A, Chantry A, Le Ray C. Moderate or intensive management of the active phase of second-stage labor and risk of urinary and anal incontinence: results of the PASST randomized controlled trial. Am J Obstet Gynecol 2023; 229:528.e1-528.e17. [PMID: 37499991 DOI: 10.1016/j.ajog.2023.07.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 07/12/2023] [Accepted: 07/20/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Incontinence occurs frequently in the postpartum period. Several theoretical pathophysiological models may underlie the hypothesis that different types of management of the active phase of the second stage of labor have different effects on pelvic floor muscles and thus perhaps affect urinary and anal continence. OBJECTIVE This study aimed to evaluate the impact of "moderate pushing" on the occurrence of urinary or anal incontinence compared with "intensive pushing," and to determine the factors associated with incontinence at 6 months postpartum. STUDY DESIGN This was a planned analysis of secondary objectives of the PASST (Phase Active du Second STade) trial, a multicenter randomized controlled trial. PASST included nulliparous women with singleton term pregnancies and epidural analgesia, who were randomly assigned at 8 cm of dilatation to either the intervention group that used "moderate" pushing (pushing only twice during each contraction, resting regularly for 1 contraction in 5 without pushing, and no time limit on pushing) or the control group following the usual management of "intensive" pushing (pushing 3 times during each contraction, with no contractions without pushing, with an obstetrician called to discuss operative delivery after 30 minutes of pushing). Data about continence were collected with validated self-assessment questionnaires at 6 months postpartum. Urinary incontinence was defined by an ICIQ-UI SF (International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form) score ≥1 and anal incontinence by a Wexner score ≥2. A separate analysis was also performed among the more severely affected women (ICIQ-UI SF ≥6 and Wexner ≥5). Factors associated with incontinence were assessed with univariate and multivariable analyses. RESULTS Among 1618 women initially randomized, 890 (55%) returned the complete questionnaire at 6 months. The rate of urinary incontinence was 36.6% in the "moderate" pushing group vs 38.5% in the "intensive" pushing group (relative risk, 0.95; 95% confidence interval, 0.80-1.13), whereas the rate of anal incontinence was 32.2% vs 34.6% (relative risk, 0.93; 95% confidence interval, 0.77-1.12). None of the obstetrical factors studied related to the second stage of labor influenced the occurrence of urinary or anal incontinence, except operative vaginal delivery, which increased the risk of anal incontinence (adjusted odds ratio, 1.50; 95% confidence interval, 1.04-2.15). CONCLUSION The results of the PASST trial indicate that neither moderate nor intensive pushing efforts affect the risk of urinary or anal incontinence at 6 months postpartum among women who gave birth under epidural analgesia.
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Affiliation(s)
- Ninon Dupuis
- Université Paris Cité, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Institut national de la santé et de la recherche médicale (Inserm), Institut national de recherche pour l'agriculture, l'alimentation et l'environnement (INRAE), Paris, France; Centre hospitalier universitaire (CHU) de Toulouse, Pole de Gynécologie Obstétrique, Hôpital Paule de Viguier, Toulouse, France.
| | | | | | - Patrick Rozenberg
- Service d'Obstétrique et Gynécologie, Centre hospitalier intercommunal de Poissy-Saint-Germain-en-Laye, Poissy, France; Université Paris-Saclay, University of Versailles Saint-Quentin-en-Yvelines, Inserm, Equipe U1018, Epidémiologie clinique, Centre de recherche en Epidémiologie et Santé des Populations (CESP), Montigny-le-Bretonneux, France; Service d'Obstetrique et Gynécologie, Hôpital Américain de Paris, Neuilly-sur-Seine, France
| | - Gilles Kayem
- Université Paris Cité, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Institut national de la santé et de la recherche médicale (Inserm), Institut national de recherche pour l'agriculture, l'alimentation et l'environnement (INRAE), Paris, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Service d'Obstétrique et Gynécologie, Hôpital Armand-Trousseau, Fighting Prematurity University Hospital Federation (FHU PREMA), Paris, France
| | - Thierry Harvey
- Hospital Group Diaconesses Croix Saint-Simon, Paris, France
| | - Laurent Mandelbrot
- AP-HP, Hôpital Louis Mourier, Service de Gynécologie-Obstétrique, Colombes, France
| | - Muriel Doret
- Obstetrics and Gynecology Department, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - Florent Fuchs
- Department of Obstetrics and Gynecology, CHU de Montpellier, Montpellier, France; Inserm, CESP U1018, Reproduction and Child Development Team, Villejuif, France; Desbrest Institute of Epidemiology and Public Health, University of Montpellier, Montpellier, France
| | - Elie Azria
- Université Paris Cité, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Institut national de la santé et de la recherche médicale (Inserm), Institut national de recherche pour l'agriculture, l'alimentation et l'environnement (INRAE), Paris, France; Maternity Unit, Groupe hospitalier Paris Saint Joseph, Paris, France
| | - Marie-Victoire Sénat
- AP-HP, Department of Obstetrics and Gynecology, Bicêtre Hospital, University Paris-Saclay, Le Kremlin-Bicêtre, France
| | | | - Aurélien Seco
- Université Paris Cité, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Institut national de la santé et de la recherche médicale (Inserm), Institut national de recherche pour l'agriculture, l'alimentation et l'environnement (INRAE), Paris, France; Clinical Research Unit Necker-Cochin, AP-HP, Paris, France
| | - Anne Chantry
- Université Paris Cité, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Institut national de la santé et de la recherche médicale (Inserm), Institut national de recherche pour l'agriculture, l'alimentation et l'environnement (INRAE), Paris, France
| | - Camille Le Ray
- Université Paris Cité, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Institut national de la santé et de la recherche médicale (Inserm), Institut national de recherche pour l'agriculture, l'alimentation et l'environnement (INRAE), Paris, France; AP-HP, Maternity Port Royal, FHU PREMA, Paris, France
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